CHIEF COMPLAINT: LLE Erythema/Hypotension

PRESENT ILLNESS: The patient is a [**Age over 90 **]yoM with a history of HTN, atrial fib/flutter
s/p pacemaker, and multiple DVTs on lifelong coumadin who
presents with right lower leg erythema, swelling, and pain that
began earlier this evening. He was in his usual state of health
until this subacute pain began, and he later described an
intense cold feeling as well as trembling.  This prompted an ED
visit.
.
He immediately triggered on admission to the ED with a BP of
63/38, though he was otherwise afebrile with tachycarida to 100.
His BP was checked several times in the left arm, yielding
60s/30s on each of these assays.  He states that he's had
similar swelling and pain before, and that he had to do "shots
in the belly."  He maintained normal mentation throughout. Labs
were notable for bandemia to 19%, lactate to 2.9, [**Last Name (un) **] to cr 1.6,
and an INR of 3.6.  Trauma ultrasound revealed no bleed.  CTA
chest revealed no massive PE, and no intraabdominal acute
pathology.  CVL was placed and he was resuscitated with 4LNS.
Got one gram vancomycin. Placed on low dose norepinephrine with
bolstering of pressure to mid-90s systolic prior to transfer.
.
Upon arrival to the MICU, his initial vitals were T:96.3
BP:99/43 P:78 R:22 O2: 99RA. He is currently in no pain and has
no complaints.  He claims to have been asymptomatic during his
hypotension, though his wife found him to be more confused than
usual.  With regard to his RLE erythema, he denies previous
episodes of cellulitis.  He has baseline edema without erythema
or pain bilaterally.  He also mentioned urinary frequency over
the preceding 4-5 days without dysuria or hematuria.

MEDICAL HISTORY: 1.  Hypertension.
2.  Osteoarthritis.
3.  Benign prostatic hypertrophy status post transurethral
resection of the prostate.
4.  Status post hernia repair.
5.  History of depression.

MEDICATION ON ADMISSION: BUPROPION HCL - 75 mg Tablet - 1 Tablet(s) by mouth once a day
DIAZEPAM - (Prescribed by Other Provider; takes PRN only) - 10
mg Tablet - 1 Tablet(s) by mouth once a day as needed for only
PRN
DORZOLAMIDE-TIMOLOL [COSOPT] - 0.5 %-2 % Drops - 1 ggts od twice
a day
DOXAZOSIN - 2 mg Tablet - 2 Tablet(s) by mouth at bedtime
FOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth once a day
HYDROCHLOROTHIAZIDE - 12.5 mg Tablet - 1 Tablet(s) by mouth once
a day dispense tablet only
LATANOPROST [XALATAN] - (Prescribed by Other Provider) - 0.005 %
Drops - 1 gtt once a day
LISINOPRIL - 10 mg Tablet - 0.5 (One half) Tablet(s) by mouth
once a day
SIMVASTATIN - 10 mg Tablet - 1 Tablet(s) by mouth once a day
WARFARIN [JANTOVEN] - 4 mg Tablet - 1 Tablet(s) by mouth once a
day extra [**12-12**] tab 3 days per week

ALLERGIES: Penicillins

PHYSICAL EXAM: Vitals: T:96.3 BP:99/43 P:78 R:22 O2: 99RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, no LAD, no JVD appreciated
CV: Regular rate and rhythm, normal S1 + S2, 2/6 SEM at the
right 2nd ICS
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: +foley
Ext: diffuse erythema and warmth encompassing the right leg from
ankle to tibial tuberosity.  Tender to touch. Neuro: CNII-XII
intact, 5/5 strength upper/lower extremities, grossly normal
sensation, 2+ reflexes bilaterally, gait deferred,
finger-to-nose intact

FAMILY HISTORY: NC

SOCIAL HISTORY: Lives at [**Hospital3 537**] with hiswife.  Former 30 pack year
smoker, quit 40 years ago.  Occasional alcohol.  No drugs.
Married and lives with wife.  Retired accountant.
Unspecified septicemia,Septic shock,Cellulitis and abscess of leg, except foot,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Severe sepsis,Long-term (current) use of anticoagulants,Coronary atherosclerosis of native coronary artery,Dysthymic disorder
Septicemia NOS,Septic shock,Cellulitis of leg,Acute kidney failure NOS,Urin tract infection NOS,Severe sepsis,Long-term use anticoagul,Crnry athrscl natve vssl,Dysthymic disorder
Admission Date:  [**2129-11-5**]              Discharge Date:   [**2129-11-12**]


Service: MEDICINE

Allergies:
Penicillins

Attending:[**First Name3 (LF) 30**]
Chief Complaint:
LLE Erythema/Hypotension


Major Surgical or Invasive Procedure:
R IJ central line placement

History of Present Illness:
The patient is a [**Age over 90 **]yoM with a history of HTN, atrial fib/flutter
s/p pacemaker, and multiple DVTs on lifelong coumadin who
presents with right lower leg erythema, swelling, and pain that
began earlier this evening. He was in his usual state of health
until this subacute pain began, and he later described an
intense cold feeling as well as trembling.  This prompted an ED
visit.
.
He immediately triggered on admission to the ED with a BP of
63/38, though he was otherwise afebrile with tachycarida to 100.
His BP was checked several times in the left arm, yielding
60s/30s on each of these assays.  He states that he's had
similar swelling and pain before, and that he had to do "shots
in the belly."  He maintained normal mentation throughout. Labs
were notable for bandemia to 19%, lactate to 2.9, [**Last Name (un) **] to cr 1.6,
and an INR of 3.6.  Trauma ultrasound revealed no bleed.  CTA
chest revealed no massive PE, and no intraabdominal acute
pathology.  CVL was placed and he was resuscitated with 4LNS.
Got one gram vancomycin. Placed on low dose norepinephrine with
bolstering of pressure to mid-90s systolic prior to transfer.
.
Upon arrival to the MICU, his initial vitals were T:96.3
BP:99/43 P:78 R:22 O2: 99RA. He is currently in no pain and has
no complaints.  He claims to have been asymptomatic during his
hypotension, though his wife found him to be more confused than
usual.  With regard to his RLE erythema, he denies previous
episodes of cellulitis.  He has baseline edema without erythema
or pain bilaterally.  He also mentioned urinary frequency over
the preceding 4-5 days without dysuria or hematuria.


Past Medical History:
1.  Hypertension.
2.  Osteoarthritis.
3.  Benign prostatic hypertrophy status post transurethral
resection of the prostate.
4.  Status post hernia repair.
5.  History of depression.


Social History:
Lives at [**Hospital3 537**] with hiswife.  Former 30 pack year
smoker, quit 40 years ago.  Occasional alcohol.  No drugs.
Married and lives with wife.  Retired accountant.


Family History:
NC


Physical Exam:
Vitals: T:96.3 BP:99/43 P:78 R:22 O2: 99RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, no LAD, no JVD appreciated
CV: Regular rate and rhythm, normal S1 + S2, 2/6 SEM at the
right 2nd ICS
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: +foley
Ext: diffuse erythema and warmth encompassing the right leg from
ankle to tibial tuberosity.  Tender to touch. Neuro: CNII-XII
intact, 5/5 strength upper/lower extremities, grossly normal
sensation, 2+ reflexes bilaterally, gait deferred,
finger-to-nose intact


Pertinent Results:
Labs on admission and dc:

[**2129-11-5**] 12:54AM BLOOD WBC-8.2 RBC-4.30* Hgb-13.4* Hct-38.1*
MCV-89 MCH-31.2 MCHC-35.2* RDW-14.1 Plt Ct-136*
[**2129-11-5**] 12:54AM BLOOD Neuts-74* Bands-19 Lymphs-1 Monos-4 Eos-0
Baso-0 Atyps-1 Metas-1 Myelos-0
[**2129-11-11**] 08:05AM BLOOD WBC-5.9 RBC-3.92* Hgb-11.8* Hct-37.0*
MCV-94 MCH-30.1 MCHC-31.8 RDW-13.9 Plt Ct-228#

[**2129-11-5**] 12:54AM BLOOD PT-35.8* PTT-29.7 INR(PT)-3.6*
[**2129-11-11**] 08:05AM BLOOD PT-18.9* PTT-30.9 INR(PT)-1.8*

[**2129-11-5**] 12:54AM BLOOD Glucose-218* UreaN-32* Creat-1.6* Na-136
K-3.2* Cl-102 HCO3-23 AnGap-14
[**2129-11-11**] 08:05AM BLOOD Glucose-258* UreaN-28* Creat-1.2 Na-139
K-4.5 Cl-99 HCO3-32 AnGap-13

[**2129-11-5**] 03:56      Red Clear 1.034
DIPSTICK URINALYSIS Blood Nitrite Protein Glucose Ketone Bilirub
Urobiln pH Leuks
[**2129-11-5**] 03:56    LG NEG TR NEG TR NEG NEG 5.0 TR
MICROSCOPIC URINE EXAMINATION RBC WBC Bacteri Yeast Epi TransE
RenalEp
[**2129-11-5**] 03:56    >182* 112* FEW NONE 1

Imaging:

TTE [**11-5**]:

There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The aortic root is mildly dilated at the sinus level. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion. There are no echocardiographic signs of
tamponade.

IMPRESSION: Normal regional and global biventricular systolic
function. No significant valvular abnormality seen. Anterior
echo-lucent space may be due to a loculated pleural effusion or
a pericardial cyst. No evidence of tamponade.

CTA [**11-5**]:

IMPRESSION:
1. Suboptimal contrast bolus with mixing artifact limits
evaluation for PE.
Within this limitation, there is no evidence of central
pulmonary embolism.
2. No acute aortic injury.
3. Approximate 9.3 cm x 3.2 cm x 7.5 cm anterior mediastinal
cystic lesion
without enhancement and with fluid density and extending to the
base of the
heart. This is most consistent with a pericardial cyst.
4. Right adrenal lesion, previously characterized as myelolipoma
or adenoma,
is unchanged since [**2123**].
5. Uncinate process small cystic lesions as above, unchanged
since prior
examination, likely represents a small focus of side branch
IPMN.
6. Persistent cholelithiasis.
7. Unchanged fat-containing left inguinal hernia.
8. Unchanged enlarged prostate.
9. Small hiatal hernia.

LENI [**11-9**]:
IMPRESSION: No right lower extremity DVT.


Brief Hospital Course:
Assessment and Plan:  Mr. [**Known lastname **] is a [**Age over 90 **]yoM with afib/flutter,
and ?previous DVTs who presents with RLL pain/erythema and who
was found to be profoundly hypotensive with bandemia and [**Last Name (un) **].

# SEPTIC SHOCK:  Felt to be due to cellulitis and possible UTI.
Received ~ 8 liters NS for fluid resuscitation and was on
norepinephrine briefly.  Started on vanc/cefepime for cellulitis
and presumed UTI. Urine culture was negative, but tx for seved
days with Ciprofloxacin as culture was obtained after antibiotic
administration.  He remained in intensive care unit overnight
only.

# Cellulitis.  Initially well responded to vancomycin, however
given negatie nasal swab and no evicence of abcess, was changed
to Ancef IV. LENI was negative.
Slow but steady improvement in erytheme and induration was made
and he was transition to PO Keflext on [**2129-11-11**].  He was diuresed
with lasix for lower extremity edema and was discharged on a
week's course of lasix.  ACE bandages are to be applied on daily
basis at time of discharge.

# ACUTE KIDNEY INJURY: due to hypoperfusion.  Improved to 1.2
(baseline 1.1 with IVF).  Lisinopril was held at discharge until
patient completes course of lasix at which point it can be
reinstituted.  HCTZ was likewise held at discharge.

# ATRIAL ARRHYTHMIA:  has both atrial flutter and fibrillation
patterns in previous EKGs/telemetry.  According to cards notes,
spends about 35% time in atrial arrhythmia.  During his ICU
stay, he remained often in atrial fibrillation although
occasionally was atrial paced or venticular paced. As patient
was diuresed his rate normalized and he remained in SR vast
majority of the time.

Multiple indicental findings on CTA:
 MEDIASTINAL MASS: seen on CTA, pericardial cyst (benign).
 ADRENAL NODULE: unchanged from prior exam
 PROSTATIC ENLARGEMENT: stable

Transition issues:
- PO diuretics for 1 week with lab follow up
- Resumption of home lisinopril and potentially HCTZ pending
above
- Cellulitis f/u with Dr. [**Last Name (STitle) **].

Medications on Admission:
BUPROPION HCL - 75 mg Tablet - 1 Tablet(s) by mouth once a day
DIAZEPAM - (Prescribed by Other Provider; takes PRN only) - 10
mg Tablet - 1 Tablet(s) by mouth once a day as needed for only
PRN
DORZOLAMIDE-TIMOLOL [COSOPT] - 0.5 %-2 % Drops - 1 ggts od twice
a day
DOXAZOSIN - 2 mg Tablet - 2 Tablet(s) by mouth at bedtime
FOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth once a day
HYDROCHLOROTHIAZIDE - 12.5 mg Tablet - 1 Tablet(s) by mouth once
a day dispense tablet only
LATANOPROST [XALATAN] - (Prescribed by Other Provider) - 0.005 %
Drops - 1 gtt once a day
LISINOPRIL - 10 mg Tablet - 0.5 (One half) Tablet(s) by mouth
once a day
SIMVASTATIN - 10 mg Tablet - 1 Tablet(s) by mouth once a day
WARFARIN [JANTOVEN] - 4 mg Tablet - 1 Tablet(s) by mouth once a
day extra [**12-12**] tab 3 days per week

Discharge Medications:
1. bupropion HCl 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
5. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. doxazosin 2 mg Tablet Sig: Two (2) Tablet PO once a day.
7. diazepam 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for anxiety.
8. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
9. Keflex 500 mg Capsule Sig: One (1) Capsule PO three times a
day for 7 days.
Disp:*21 Capsule(s)* Refills:*0*
10. warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day.
11. warfarin 2 mg Tablet Sig: One (1) Tablet PO Tuesday Thursday
Saturday: in addition to 4mg tablet for total of 6mg.
12. Outpatient Lab Work
CBC, INR and Chem 7 on [**2129-11-14**] and results to be faxed to
[**Last Name (LF) 1413**],[**First Name3 (LF) 1412**] W.
Phone: [**Telephone/Fax (1) 457**]
Fax: [**Telephone/Fax (1) 1419**]

13. potassium chloride 20 mEq Packet Sig: One (1)  PO once a day
for 7 days.
Disp:*7 packets* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services

Discharge Diagnosis:
Primary: Septic shock due to cellulitis and urinary tract
infection


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
You were admitted to the hospital with severe infection of your
leg and urine.  You were treated in the intensive care unit
followed by treatmet for cellulitis (infection of the leg).
With antibiotics your symptoms improved although significant
amount of swelling and redness in your leg persisted.

You were given water pills to help get rid of some of the water
in your legs.  In addition, you required wrapping of your legs
with ACE bandages to help get rid of the fluid.

The following changes were made to your medications.
STARTED:
- Furosemide 20mg daily for one week
- Keflex 500mg three times daily
- Potassium 20  meq daily for one week

STOPPED:
- Hydrochlorothiazide
- Lisinopril (until you complete your furosemide)

Please ensure that you elevate your legs daily and wrap them
with ACE bandage.

Should you develop any symptoms concerning to you, please call
Dr. [**Last Name (STitle) **] (PCP, [**Telephone/Fax (1) 457**]) or go to the emergency room.
You have an appointment with Dr. [**Last Name (STitle) **] at the end of
[**Month (only) 1096**], but his office will contact you to set up a follow up
within the next week.  If you don't hear from him by middle of
next week, please call his office.

Please also obtain labs to check your coumadin level next week.


Followup Instructions:
Department: INFECTIOUS DISEASE
When: WEDNESDAY [**2129-12-7**] at 1:30 PM
With: [**Doctor First Name 1412**] [**Name Initial (MD) **] [**Name8 (MD) 1413**], M.D. [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: CARDIAC SERVICES
When: MONDAY [**2129-12-19**] at 1:30 PM
With:  DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: CARDIAC SERVICES
When: MONDAY [**2129-12-19**] at 2:20 PM
With: [**Doctor First Name 900**] [**Name8 (MD) 901**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage



Completed by:[**2129-11-13**]
{'Unspecified septicemia,Septic shock,Cellulitis and abscess of leg, except foot,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Severe sepsis,Long-term (current) use of anticoagulants,Coronary atherosclerosis of native coronary artery,Dysthymic disorder'}


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: LLE Erythema/Hypotension

PRESENT ILLNESS: The patient is a [**Age over 90 **]yoM with a history of HTN, atrial fib/flutter
s/p pacemaker, and multiple DVTs on lifelong coumadin who
presents with right lower leg erythema, swelling, and pain that
began earlier this evening. He was in his usual state of health
until this subacute pain began, and he later described an
intense cold feeling as well as trembling.  This prompted an ED
visit.
.
He immediately triggered on admission to the ED with a BP of
63/38, though he was otherwise afebrile with tachycarida to 100.
His BP was checked several times in the left arm, yielding
60s/30s on each of these assays.  He states that he's had
similar swelling and pain before, and that he had to do "shots
in the belly."  He maintained normal mentation throughout. Labs
were notable for bandemia to 19%, lactate to 2.9, [**Last Name (un) **] to cr 1.6,
and an INR of 3.6.  Trauma ultrasound revealed no bleed.  CTA
chest revealed no massive PE, and no intraabdominal acute
pathology.  CVL was placed and he was resuscitated with 4LNS.
Got one gram vancomycin. Placed on low dose norepinephrine with
bolstering of pressure to mid-90s systolic prior to transfer.
.
Upon arrival to the MICU, his initial vitals were T:96.3
BP:99/43 P:78 R:22 O2: 99RA. He is currently in no pain and has
no complaints.  He claims to have been asymptomatic during his
hypotension, though his wife found him to be more confused than
usual.  With regard to his RLE erythema, he denies previous
episodes of cellulitis.  He has baseline edema without erythema
or pain bilaterally.  He also mentioned urinary frequency over
the preceding 4-5 days without dysuria or hematuria.

MEDICAL HISTORY: 1.  Hypertension.
2.  Osteoarthritis.
3.  Benign prostatic hypertrophy status post transurethral
resection of the prostate.
4.  Status post hernia repair.
5.  History of depression.

MEDICATION ON ADMISSION: BUPROPION HCL - 75 mg Tablet - 1 Tablet(s) by mouth once a day
DIAZEPAM - (Prescribed by Other Provider; takes PRN only) - 10
mg Tablet - 1 Tablet(s) by mouth once a day as needed for only
PRN
DORZOLAMIDE-TIMOLOL [COSOPT] - 0.5 %-2 % Drops - 1 ggts od twice
a day
DOXAZOSIN - 2 mg Tablet - 2 Tablet(s) by mouth at bedtime
FOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth once a day
HYDROCHLOROTHIAZIDE - 12.5 mg Tablet - 1 Tablet(s) by mouth once
a day dispense tablet only
LATANOPROST [XALATAN] - (Prescribed by Other Provider) - 0.005 %
Drops - 1 gtt once a day
LISINOPRIL - 10 mg Tablet - 0.5 (One half) Tablet(s) by mouth
once a day
SIMVASTATIN - 10 mg Tablet - 1 Tablet(s) by mouth once a day
WARFARIN [JANTOVEN] - 4 mg Tablet - 1 Tablet(s) by mouth once a
day extra [**12-12**] tab 3 days per week

ALLERGIES: Penicillins

PHYSICAL EXAM: Vitals: T:96.3 BP:99/43 P:78 R:22 O2: 99RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, no LAD, no JVD appreciated
CV: Regular rate and rhythm, normal S1 + S2, 2/6 SEM at the
right 2nd ICS
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: +foley
Ext: diffuse erythema and warmth encompassing the right leg from
ankle to tibial tuberosity.  Tender to touch. Neuro: CNII-XII
intact, 5/5 strength upper/lower extremities, grossly normal
sensation, 2+ reflexes bilaterally, gait deferred,
finger-to-nose intact

FAMILY HISTORY: NC

SOCIAL HISTORY: Lives at [**Hospital3 537**] with hiswife.  Former 30 pack year
smoker, quit 40 years ago.  Occasional alcohol.  No drugs.
Married and lives with wife.  Retired accountant. 

### Response:
{'Unspecified septicemia,Septic shock,Cellulitis and abscess of leg, except foot,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Severe sepsis,Long-term (current) use of anticoagulants,Coronary atherosclerosis of native coronary artery,Dysthymic disorder'}
