CHIEF COMPLAINT: Transfer from [**Hospital3 628**] for infectious disease and
neurosurgical evaluation of epidural abscess with MRSA

PRESENT ILLNESS: This is an 87 y.o. female s/p Right Hip ORIF in [**2142-2-4**]
who presented to [**Hospital3 628**] on [**2142-7-11**] after her daughter
tripped on her and she fell, sustaining a Left Hip Fracture.
She underwent a Left Hip ORIF on [**2142-7-13**].  (She was
anticoagulated with coumadin given a heparin allergy).  Her
hospital course was complicated by a temp spike to 101 on [**7-14**]
with 2/4 bottles + for MRSA.  (per her family she had been
febrile for several weeks prior).  A TEE on [**7-17**] was (-) for SBE
and a PICC line was placed for 6 weeks of vancomycin.
Surveillance cx on [**7-18**] grew [**4-8**] MRSA and the PICC line was
d/c'd.  On  [**7-24**] surveillance cultures were (-) and another PICC
line was placed.  On the same day the patient complained of back
pain and a CT T-L Spine demonstrated multiple compression
fractures and an MRI on [**7-27**] demonstrated L2-3 diskitis and a
small epidural abscess (w/o evidence of cord compression).  She
was transferred to [**Hospital1 18**] on [**2142-7-30**] for neurosurgical and
infectious disease evaluation.

MEDICAL HISTORY: 1) Hypertension
2) GERD
3) CVA [**2140**] (residual short-term memory loss and diminished
vision b/l)
4) Right Hip Fracture s/p ORIF by Dr. [**Last Name (STitle) 28272**] in [**2-7**]
5) Hypothyroidism
6) Asthma

MEDICATION ON ADMISSION: (Medications on transfer from [**Location (un) 620**] to [**Hospital1 18**])
Vanco 1.5 qd, Rifampin 300 [**Hospital1 **], Lumigan eye gtts, advair,
lexapro, protonix, norvasc 2.5, fosamax qweek, coumadin 3,
tylenol, oxycodone [**5-14**] prn

ALLERGIES: Penicillins / Sulfa (Sulfonamides) / Aspirin / Heparin Agents

PHYSICAL EXAM: T:99.3, BP:140/70,  HR:102, RR:22, O2:99% 2L
Gen: NAD.  A/O x 3
HEENT: Small ulcer on hard palate.  No LAD, supple neck
CV: II/VI SM at RUSB
Pulm: CTA B/L.
ABD: S/NT/ND
Ext:Swollen left LE with TTP.  Trace PT.
Erythematous Papules in diaper area, under breasts, eythema at
Right PICC line site.
Neuro: CN II-XII GI.  MAEW.  Sensation GI

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: No Tob/EtOH.  Independent prior to 1st hip fracture.  Close with
daughters [**Name (NI) **] (Healthcare proxy) and [**Name (NI) **].
Bacteremia,Infection and inflammatory reaction due to internal joint prosthesis,Intraspinal abscess,Acute kidney failure with lesion of tubular necrosis,Other specified conduction disorders,Acute posthemorrhagic anemia,Hyposmolality and/or hyponatremia,Congestive heart failure, unspecified
Bacteremia,React-inter joint prost,Intraspinal abscess,Ac kidny fail, tubr necr,Conduction disorder NEC,Ac posthemorrhag anemia,Hyposmolality,CHF NOS
Admission Date:  [**2142-7-30**]              Discharge Date:   [**2142-9-4**]


Service: MED

Allergies:
Penicillins / Sulfa (Sulfonamides) / Aspirin / Heparin Agents

Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Transfer from [**Hospital3 628**] for infectious disease and
neurosurgical evaluation of epidural abscess with MRSA

Major Surgical or Invasive Procedure:
Multiple VAC Dressing Changes in the Operating [**Apartment Address(1) 41332**]/204: "Incision and drainage of postoperative
wound which was treated elsewhere."
[**2142-8-16**]:"Incision and drainage of the
osteomyelitis, incision and drainage of the postoperative
wound, and exchange nailing using Synthes, subtrochanteric
nail."
[**2142-8-30**]: Closure of Wound with irrigation and drainage


History of Present Illness:
This is an 87 y.o. female s/p Right Hip ORIF in [**2142-2-4**]
who presented to [**Hospital3 628**] on [**2142-7-11**] after her daughter
tripped on her and she fell, sustaining a Left Hip Fracture.
She underwent a Left Hip ORIF on [**2142-7-13**].  (She was
anticoagulated with coumadin given a heparin allergy).  Her
hospital course was complicated by a temp spike to 101 on [**7-14**]
with 2/4 bottles + for MRSA.  (per her family she had been
febrile for several weeks prior).  A TEE on [**7-17**] was (-) for SBE
and a PICC line was placed for 6 weeks of vancomycin.
Surveillance cx on [**7-18**] grew [**4-8**] MRSA and the PICC line was
d/c'd.  On  [**7-24**] surveillance cultures were (-) and another PICC
line was placed.  On the same day the patient complained of back
pain and a CT T-L Spine demonstrated multiple compression
fractures and an MRI on [**7-27**] demonstrated L2-3 diskitis and a
small epidural abscess (w/o evidence of cord compression).  She
was transferred to [**Hospital1 18**] on [**2142-7-30**] for neurosurgical and
infectious disease evaluation.

Past Medical History:
1) Hypertension
2) GERD
3) CVA [**2140**] (residual short-term memory loss and diminished
vision b/l)
4) Right Hip Fracture s/p ORIF by Dr. [**Last Name (STitle) 28272**] in [**2-7**]
5) Hypothyroidism
6) Asthma

Social History:
No Tob/EtOH.  Independent prior to 1st hip fracture.  Close with
daughters [**Name (NI) **] (Healthcare proxy) and [**Name (NI) **].

Family History:
non-contributory

Physical Exam:
T:99.3, BP:140/70,  HR:102, RR:22, O2:99% 2L
Gen: NAD.  A/O x 3
HEENT: Small ulcer on hard palate.  No LAD, supple neck
CV: II/VI SM at RUSB
Pulm: CTA B/L.
ABD: S/NT/ND
Ext:Swollen left LE with TTP.  Trace PT.
Erythematous Papules in diaper area, under breasts, eythema at
Right PICC line site.
Neuro: CN II-XII GI.  MAEW.  Sensation GI

Pertinent Results:
WBC:12.3
Hct:31.5
Plt:636
Na:132
K:3.4
Cl:91
HCO3:31.6
BUN:9
Cr:0.7
Gluc:91
Ca:8.2

CXR: PICC line well positioned w/o CHF/infiltrates
MRI: L2-3 diskitis, possible small epidural abscess, no cord
compression

Brief Hospital Course:
The patient had a long and complicated hospital course as
follows by issue:

1) ID:(ID Service--[**Doctor First Name **] [**Doctor Last Name **]--following) (also see ortho
below)
She spiked a temp to 101 on [**7-14**] and blood cx drew [**2-7**] MRSA and
vancomycin was started.
[**7-16**] - repeat cx no growth
[**7-17**]- no growth, picc line placed.  TTE negative
[**7-18**] spiked temp and cultures at that time grew [**4-8**] mrsa
[**7-19**] continued to be febrile -- picc line d/c'd (picc tip cx
grew staph coag negative NOT MRSA), gent added for synergy
(duration 4 days)
abdominal CT negative for abscess
[**7-20**] TEE negative for evidence of endocarditis
[**Date range (1) 9435**] surveillence cultures negative
[**7-22**] LOST IV ACCESS therefore no IV abx for 2 days
[**2058-7-22**] -- spiked temp, surviellence cx negative
[**7-25**] PICC placed, then cx from [**7-24**] [**1-7**] MRSA
[**7-26**] pt c/o back pain, plain films negative, rifampin added, ESR
66
[**7-27**] underwent MRI L2-L3 diskitis, small epidural abcess, no
cord compression

When initially evaluated by ID the following recommendations
were made:
-Dose of vanco (begun on [**7-14**]) was changed to [**Hospital1 **] with trough
checks q72 hours
-Rifampin (begun on [**7-28**]) was continued with LFT checks qweek.


[**8-1**] and [**8-5**]: left knee was tapped with no growth
[**8-3**]: Repeat MRI with L2-3 epidural abscess without cord
compression
[**2142-8-5**]: Vanco changed to q8 hours
[**2142-8-6**]: Ortho hardware removal with Deep tissue (from hip)
Culture + for Enterobacter resistant to all organisms save
meropenem, bactrim and cefepime.  Given possibility of inducible
resistance,
Meropenem begun after desensitization in the MICU (given h/o
cefepime allergy)
[**2142-8-7**]: Spiked to 102.4 on [**8-14**].  CXR with ? LLL infiltrate
[**2142-8-16**]: Left hip hardware exchange performed with I+D.
[**2142-8-20**]: Given persistent low-grade fevers and +yeast in tissue
cx and urine, started Fluconazole on [**8-20**].

D/C Antibiotic Plan as follows:
-Vanco/Rifampin until [**2142-9-17**] for treatment of epidural abscess
and left hip, then po doxycycline 100 po BID indefinitely (given
sensitivity of MRSA and Enterobacter to doxycycline)
-Meropenem for enterobacter soft issue infectionuntil [**2142-9-27**]
-Fluconazole until [**2142-9-2**]
-LFTs, CBC and Chem-7 followed at rehab
-F/U with [**Doctor First Name **] [**Doctor Last Name 9404**] in [**Hospital **] clinic in [**10-8**]

2) EPIDURAL ABCESS
    Dr [**Last Name (STitle) 1338**] (neurology) consulted. He advised medical
management, neurologically intact.
    [**8-2**]: incontinence of stool, ? decreased rectal tone
therefore repeated MRI ---> stable epidural abcess, no cord
compression

3) ORTHO: Intertrochanteric fx of Left Hip s/p orif
   ortho following (Dr. [**First Name (STitle) 1022**].
    [**8-1**]: knee tap negative for septic joint
    [**8-5**]: Ct guided aspiration of left hip -- cx ngtd
    [**8-6**]: ortho took to or and removed hardware, took cx from hip
 tissue and placed new hardware as joint unstable
     ++ Enterobacter
   [**8-10**]: increased pain in left knee, lenis negative (except
could not visualize popliteal), ortho retapped knee, cx NTD.
   [**8-12**] LENI (repeated given LLE edema) (-).
  [**8-16**] to OR to replace hardware.  Gross drainage of pus.
       ***POST-OP with SBP in 80s w/o tachycardia, bolused with
1L NS with normalization of pressure.  O2 sat remained>92% on
RA.
       Urine output was minimal but slowly picked up (to
~20-25cc/hour) with boluses and lasix (thought to be ATN)
   >>to OR [**8-20**] for sterile VAC DSG change
   >>to OR [**8-24**] for sterile VAC DSG Change
   >>to OR [**8-27**] for sterile VAC DSG Change
   >> Wound Closed with 2 JP drains placed on [**8-30**] with plans
for aggressive rehab with PWB on LLE.
   >>JP drain #2 pulled after no output x 24 hours.
   >>Per ortho recs, the remaining JP drain should be pulled
(one suture in place) after no output for 24 hours.  Patient
will follow-up with Dr. [**First Name (STitle) 1022**] in 3 weeks.


4. HEPARIN ALLERGY
 -consulted allergy --> NO HEPARIN PRODUCTS.

5. SVT/ A TACH -- occasional burst of SVT in 160s w/o sx,
evaluated by EP on [**8-4**]  and recommended metoprolol. underwent
CTA (given not adequately anticoagulated -- use of coumadin and
possible surgery) but NEGATIVE for PE.

6. ATN (by muddy brown cast on [**8-8**]) and oliguria s/p surgeries
on [**8-6**] and [**8-16**] in the setting of transient hypotension.
-- at dischargee resolved with CrCL >80.

7. ?CAD
See SVT above.
EF by ECHO on [**7-8**] was 75%.

8. Anticoag: Given heparin allergy, she was placed on coumadin
with INR goal of 1.5-2.0.

9. Code Status/Goals of Care: Discussed with daughter [**Name (NI) **] (HCP)
on [**8-13**].  [**Telephone/Fax (1) 41333**].   Changed to DNR/DNI status on [**8-19**].  She
would, however, want pressors and all other aggressive measures
short of defibrillation and intubation.  She provided us with
the health care proxy form indicating that her daughter [**Name (NI) **] will
make all decisions for her should she not be able to make
decisions for herself.  She values her function and would want
all measures that would allow a reasonable chance of retaining
her physical and mental function.  She found comfort in prayer.


Medications on Admission:
(Medications on transfer from [**Location (un) 620**] to [**Hospital1 18**])
Vanco 1.5 qd, Rifampin 300 [**Hospital1 **], Lumigan eye gtts, advair,
lexapro, protonix, norvasc 2.5, fosamax qweek, coumadin 3,
tylenol, oxycodone [**5-14**] prn


Discharge Medications:
1. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
twice a day: START on [**2142-9-17**].
2. Outpatient Lab Work
LFTs, CBC, Chem-7 qweek
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).

4. Escitalopram Oxalate 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
5. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
6. Bimatoprost 0.03 % Drops Sig: One (1) drop Ophthalmic  qd ().

7. Rifampin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours) for 2 weeks: LAST DOSE ON [**2142-9-17**]
Please follow LFTs qweek.
8. Alendronate Sodium 70 mg Tablet Sig: One (1) Tablet PO QWED
(every Wednesday).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
10. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
11. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
12. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
treatment Inhalation Q6H (every 6 hours) as needed.
14. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer
treatment Inhalation Q6H (every 6 hours) as needed.
15. Levothyroxine Sodium 175 mcg Tablet Sig: One (1) Tablet PO
QD (once a day).
16. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
17. Hydralazine HCl 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
18. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
19. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 1 days: LAST DOSE on [**2142-9-2**].
20. Furosemide 20 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
21. Multivitamin     Capsule Sig: One (1) Cap PO QD (once a
day).
22. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical  TID
(3 times a day) as needed.
23. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: One
(1) Packet PO BID (2 times a day).
24. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
25. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
26. Warfarin Sodium 2 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime): Titrate to INR 1.5-2.0 for DVT Prophylaxis given
heparin allergy.
27. Morphine Sulfate 1-3 mg IV Q4H:PRN
hold for sedation, or RR <12
28. Meropenem 1 g Recon Soln Sig: One (1) gram Intravenous
three times a day for 2 weeks: Last dose on [**2142-9-17**].
29. Vancomycin HCl 1,000 mg Recon Soln Sig: One (1) gram
Intravenous  once a day for 2 weeks: LAST DOSE ON [**2142-9-17**]
.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]

Discharge Diagnosis:
Congestive Heart Failure
Right Hip Fracture s/p ORIF
Left Hip Fracture s/p ORIF and hardware exchanges
Hypertension
Hypothyroidism


Discharge Condition:
stable

Discharge Instructions:
Please notify your [**Location (un) 2449**] or doctors of chest [**Name5 (PTitle) **], shortness of
breath, palpitations, swelling, weakness, numbness, fevers,
chills, dysuria, constipation, diarrhea, rashes or any other
symptoms of concern.  You will take meropenem until [**2142-9-17**] and
then begin taking doxycycline.  Please follow-up (see below)
with Dr. [**First Name (STitle) **] [**Name (STitle) 9404**].

Notify your doctors [**First Name (Titles) **] [**Last Name (Titles) 2449**] of weight gain (>3 pounds).  Limit
fluid intake to less than 1.5 L per day and salt intake to less
than 2g/day.

Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 9406**], MD Where: LM [**Hospital Unit Name 4337**]
DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2142-10-8**] 11:30

Please call [**First Name8 (NamePattern2) **] [**Name8 (MD) 1022**], MD (orthopedics) to be seen in 2 weeks
Phone: [**Telephone/Fax (1) 5499**]

                             [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
{'Bacteremia,Infection and inflammatory reaction due to internal joint prosthesis,Intraspinal abscess,Acute kidney failure with lesion of tubular necrosis,Other specified conduction disorders,Acute posthemorrhagic anemia,Hyposmolality and/or hyponatremia,Congestive heart failure, 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: Transfer from [**Hospital3 628**] for infectious disease and
neurosurgical evaluation of epidural abscess with MRSA

PRESENT ILLNESS: This is an 87 y.o. female s/p Right Hip ORIF in [**2142-2-4**]
who presented to [**Hospital3 628**] on [**2142-7-11**] after her daughter
tripped on her and she fell, sustaining a Left Hip Fracture.
She underwent a Left Hip ORIF on [**2142-7-13**].  (She was
anticoagulated with coumadin given a heparin allergy).  Her
hospital course was complicated by a temp spike to 101 on [**7-14**]
with 2/4 bottles + for MRSA.  (per her family she had been
febrile for several weeks prior).  A TEE on [**7-17**] was (-) for SBE
and a PICC line was placed for 6 weeks of vancomycin.
Surveillance cx on [**7-18**] grew [**4-8**] MRSA and the PICC line was
d/c'd.  On  [**7-24**] surveillance cultures were (-) and another PICC
line was placed.  On the same day the patient complained of back
pain and a CT T-L Spine demonstrated multiple compression
fractures and an MRI on [**7-27**] demonstrated L2-3 diskitis and a
small epidural abscess (w/o evidence of cord compression).  She
was transferred to [**Hospital1 18**] on [**2142-7-30**] for neurosurgical and
infectious disease evaluation.

MEDICAL HISTORY: 1) Hypertension
2) GERD
3) CVA [**2140**] (residual short-term memory loss and diminished
vision b/l)
4) Right Hip Fracture s/p ORIF by Dr. [**Last Name (STitle) 28272**] in [**2-7**]
5) Hypothyroidism
6) Asthma

MEDICATION ON ADMISSION: (Medications on transfer from [**Location (un) 620**] to [**Hospital1 18**])
Vanco 1.5 qd, Rifampin 300 [**Hospital1 **], Lumigan eye gtts, advair,
lexapro, protonix, norvasc 2.5, fosamax qweek, coumadin 3,
tylenol, oxycodone [**5-14**] prn

ALLERGIES: Penicillins / Sulfa (Sulfonamides) / Aspirin / Heparin Agents

PHYSICAL EXAM: T:99.3, BP:140/70,  HR:102, RR:22, O2:99% 2L
Gen: NAD.  A/O x 3
HEENT: Small ulcer on hard palate.  No LAD, supple neck
CV: II/VI SM at RUSB
Pulm: CTA B/L.
ABD: S/NT/ND
Ext:Swollen left LE with TTP.  Trace PT.
Erythematous Papules in diaper area, under breasts, eythema at
Right PICC line site.
Neuro: CN II-XII GI.  MAEW.  Sensation GI

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: No Tob/EtOH.  Independent prior to 1st hip fracture.  Close with
daughters [**Name (NI) **] (Healthcare proxy) and [**Name (NI) **]. 

### Response:
{'Bacteremia,Infection and inflammatory reaction due to internal joint prosthesis,Intraspinal abscess,Acute kidney failure with lesion of tubular necrosis,Other specified conduction disorders,Acute posthemorrhagic anemia,Hyposmolality and/or hyponatremia,Congestive heart failure, unspecified'}
