CHIEF COMPLAINT: Hypotension/cellulitis

PRESENT ILLNESS: 76 yo F with AF, CAD s/p CABG, h/o cellultis, who presents from
home with worsening R leg infection. On [**Name (NI) 2974**], pt noticed a
swelling on her right lateral leg with redness. this progressed
over the next few days followed by pain in the last two days.
Denies fevers, but has some chills. No N/V, few loose BM's/day
over last few days. No cough/SOB. Also noted [**Month (only) **] UOP with ok
fluid intake but poor appetite.
.
Seen at OSH today where she was noted to have a large
cellulitis. Her BP was 80's without sxs. She was started on
levofed after being given 2.5 L IVF. A CVL was placed. She was
given clinda/vanc and a surgery consult was called which r/o
necrotizing fascitis. She was sent to [**Hospital1 **] for further care.
.
In the ED, VS 97.3, 80, 80/42, 16, 98%. Exam with 10-20 cm right
erythema to thigh, no skin breakdown. Vascular consult who
reccomended f/u cultures and monitoring exam of leg. Given add'l
clinda/vancomycin in the ED. UO notd to be poor--20 cc total. On
50 mcg of levofed on transfer.
.
Admitted to the ICU for sepsis.
.
In the MICU, surgery consult ruled out necr. fascitis. In the
unit required levophed for hypotension, echo with preserved EF
and severe TR. Mildly elevated LFTs, and CT abdomen with 4X 4 cm
AAA. (per PCP 3.5 cm AAA 3 yeras ago in '[**96**]). Vascular
following. Leg improved. Lateral leg ruptured bullae so Derm
followed. Initially on vanc/clinda for 3 days with some
improvement but due to leucocytosis so started unasysn. failed
[**Last Name (un) 104**] stiim got steroids for 5 days. This AM went into rapid a.
fib (given 5 mg iv lopressor). Started on metoprolol 25 (outpt
dose 75).

MEDICAL HISTORY: HTN
CAD
PVD
Afib
diverticulosis
h/o ARF
h/o coagulopathy
CHF
h/o cellulitis/sepsis- at BIDN on [**11-19**]; wound grew coag-neg
staph, txt w/ vanco

MEDICATION ON ADMISSION: Benicar 20, Lopressor 75'', Crestor 30', Coumadin 2.5', HCTZ
25', Lasix 120', MVI, vit E, zetia

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Tm 96.8 Tc 95.6 BP 104/58 (95-130/60-70)--off levophed since [**04**]
AM [**1-9**].
HR 76 (76-138) RR 20 O2 98% RA
I/O 1212/900

FAMILY HISTORY: NC

SOCIAL HISTORY: lives in [**Location 620**] with husband, former [**Name2 (NI) 1818**] (quite 25 years
ago), occ ETOH, no drugs
Unspecified septicemia,Cellulitis and abscess of leg, except foot,Congestive heart failure, unspecified,Atrial fibrillation,Acute kidney failure with lesion of tubular necrosis,Mitral valve disorders,Diseases of tricuspid valve,Pressure ulcer, buttock,Severe sepsis,Abdominal aneurysm without mention of rupture,Venous (peripheral) insufficiency, unspecified,Diverticulosis of colon (without mention of hemorrhage),Unspecified essential hypertension,Long-term (current) use of anticoagulants,Aortocoronary bypass status
Septicemia NOS,Cellulitis of leg,CHF NOS,Atrial fibrillation,Ac kidny fail, tubr necr,Mitral valve disorder,Tricuspid valve disease,Pressure ulcer, buttock,Severe sepsis,Abdom aortic aneurysm,Venous insufficiency NOS,Dvrtclo colon w/o hmrhg,Hypertension NOS,Long-term use anticoagul,Aortocoronary bypass
Admission Date:  [**2199-6-4**]              Discharge Date:   [**2199-6-13**]

Date of Birth:  [**2122-9-19**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 9240**]
Chief Complaint:
Hypotension/cellulitis

Major Surgical or Invasive Procedure:
Left internal jugular line placement

History of Present Illness:
76 yo F with AF, CAD s/p CABG, h/o cellultis, who presents from
home with worsening R leg infection. On [**Name (NI) 2974**], pt noticed a
swelling on her right lateral leg with redness. this progressed
over the next few days followed by pain in the last two days.
Denies fevers, but has some chills. No N/V, few loose BM's/day
over last few days. No cough/SOB. Also noted [**Month (only) **] UOP with ok
fluid intake but poor appetite.
.
Seen at OSH today where she was noted to have a large
cellulitis. Her BP was 80's without sxs. She was started on
levofed after being given 2.5 L IVF. A CVL was placed. She was
given clinda/vanc and a surgery consult was called which r/o
necrotizing fascitis. She was sent to [**Hospital1 **] for further care.
.
In the ED, VS 97.3, 80, 80/42, 16, 98%. Exam with 10-20 cm right
erythema to thigh, no skin breakdown. Vascular consult who
reccomended f/u cultures and monitoring exam of leg. Given add'l
clinda/vancomycin in the ED. UO notd to be poor--20 cc total. On
50 mcg of levofed on transfer.
.
Admitted to the ICU for sepsis.
.
In the MICU, surgery consult ruled out necr. fascitis. In the
unit required levophed for hypotension, echo with preserved EF
and severe TR. Mildly elevated LFTs, and CT abdomen with 4X 4 cm
AAA. (per PCP 3.5 cm AAA 3 yeras ago in '[**96**]). Vascular
following. Leg improved. Lateral leg ruptured bullae so Derm
followed. Initially on vanc/clinda for 3 days with some
improvement but due to leucocytosis so started unasysn. failed
[**Last Name (un) 104**] stiim got steroids for 5 days. This AM went into rapid a.
fib (given 5 mg iv lopressor). Started on metoprolol 25 (outpt
dose 75).


Past Medical History:
HTN
CAD
PVD
Afib
diverticulosis
h/o ARF
h/o coagulopathy
CHF
h/o cellulitis/sepsis- at BIDN on [**11-19**]; wound grew coag-neg
staph, txt w/ vanco


Social History:
lives in [**Location 620**] with husband, former [**Name2 (NI) 1818**] (quite 25 years
ago), occ ETOH, no drugs

Family History:
NC

Physical Exam:
Tm 96.8 Tc 95.6 BP 104/58 (95-130/60-70)--off levophed since [**04**]
AM [**1-9**].
HR 76 (76-138) RR 20 O2 98% RA
I/O 1212/900

well, lying comfortablly in bed, NAD, o x 3
EOMI, PEERLA, anicteric, mouth-dry
L IJ in place
RRR, nl s1, nl s2, mild holosystolic murmur
CTA anteriorly
soft NT/D BS, no R/G, nl liver span, mid line surgical scar
LLE: some distal LE brany erythema and discoloation, +2+ edmea
RLE: large confluent areas of red macular ertyhema and warmth
with swelling, outlined, some areas around knee and medial thigh
spared, small areas of skin breakdown on buttock, areas extend
to buttock and over to right flank


Pertinent Results:
Admission Labs:
[**2199-6-4**] 11:12PM   LACTATE-1.6
[**2199-6-4**] 10:16PM   WBC-13.1* RBC-3.01* HGB-10.6* HCT-31.4*
MCV-104* MCH-35.2* MCHC-33.7 RDW-17.5*
[**2199-6-4**] 08:20PM   GLUCOSE-101 UREA N-67* CREAT-2.7* SODIUM-131*
POTASSIUM-3.3 CHLORIDE-94* TOTAL CO2-24 ANION GAP-16
[**2199-6-4**] 08:20PM   CALCIUM-8.2* PHOSPHATE-4.9* MAGNESIUM-2.4
[**2199-6-4**] 04:20PM URINE  COLOR-Amber APPEAR-Cloudy SP [**Last Name (un) 155**]-1.015
[**2199-6-4**] 04:20PM URINE  BLOOD-SM NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2199-6-4**] 04:20PM URINE  RBC-[**3-18**]* WBC-[**6-23**]* BACTERIA-MOD
YEAST-NONE EPI-0-2
[**2199-6-4**] 04:15PM   CK(CPK)-25*
[**2199-6-4**] 04:15PM   cTropnT-<0.01
[**2199-6-4**] 04:15PM   CK-MB-NotDone
.
IMAGING:
CXR: FINDINGS: Consistent with the given history, a left
internal jugular approach central line has been placed. The
distal tip lies in the brachiocephalic vein proximal to the
junction with the superior vena cava. There is evidence of prior
median sternotomy and CABG. Consistent with the prior report,
there is massive cardiomegaly and chamber enlargement. A double
density is noted with splaying of the carina consistent with
left atrial enlargement in particular. There is no focal
consolidation. No significant cephalization is evident although
there is interlobular septal thickening noted in the periphery.
No pleural effusion or pneumothorax is evident.

IMPRESSION: Left internal jugular approach central line as above
with no pneumothorax. Massive cardiomegaly. Interlobular septal
thickening of indeterminate acuity. Regardless, there is no
evidence to suggest significant volume overload.
.
LENIs: FINDINGS: Ultrasound evaluation of the right and left
lower extremity deep venous system using grayscale, color, and
pulse wave Doppler demonstrates the veins to be fully
compressible with normal Doppler waveforms, augmentation, and
respiratory variation in flow.

IMPRESSION: No evidence of DVT involving the right or left lower
extremities.
.
ECHO: Conclusions:
The left atrium is dilated. The right atrium is markedly
dilated. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
appears dilated. Right ventricular systolic function is normal.
[Intrinsic right ventricular systolic function is likely more
depressed given the severity of tricuspid regurgitation.] There
is abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic regurgitation. The mitral valve leaflets are mildly
thickened. There is moderate/severe mitral valve prolapse.
Moderate (2+) mitral regurgitation is seen. The mitral
regurgitation jet is eccentric.  The tricuspid valve leaflets
are mildly thickened. Moderate [2+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
.
Abdominal Ultrasound: FINDINGS: The liver is normal in
echotexture without evidence of focal lesion. There is a
questionable tiny hyperechogenic focus in the gallbladder neck
that could represent a small gallstone vs. polyp. No evidence of
cholecystitis. No evidence of intra or extrahepatic biliary
ductal dilatation and the common duct measures 5 mm. Main portal
vein is patent with antegrade flow. The pancreas appears normal.
The aorta demonstrates a fusiform aneurysm on its mid portion
measuring 4.2 x 3.9 cm. The right kidney measures 10.8 cm and
the left 11.8 cm. The renal parenchymal thickness is normal.
There is a 9 mm non-obstructive stone in the left kidney. No
evidence of hydronephrosis. No evidence of free fluid.
IMPRESSION:
1) 4.2 cm infrarenal aortic aneurysm.
2) 9 mm non-obstructive left renal stone.
3) Small hyperechogenic focus within the gallbladder neck could
represent a small stone vs. a polyp. No evidence of
cholecystitis
.
MICRO:
URINE CULTURE: NEGATIVE
.
BLOOD CULTURE: NGTD

Brief Hospital Course:
ICU course: Patient was admitted to the ICU for pressor support
from her persistent hypotension.  She was given Levophed
successfully through her left IJ CVL which was placed in the ED.
 She was initially treated with empiric Vancomycin/Clindamycin.
Vascular surgery was consulted and followed the patient in
house.  She did respond to these  antibiotics, but her
Clindamycin was stopped in favor of Unasyn for better GNR
coverage.  Her urine culture was negative, and her blood
cultures were NGTD on transfer from the MICU.  Moreover, given
the extensive nature of her cellulitis, dermatology was
consulted.  They felt her primary insult was likely a stasis
dermatitis.  She was thus treated with clobetasol cream and
bactroban.  LENIs was also performed and was negative for DVT.
Throughout her ICU course her cellulitis continued to improve.
Moreover, she was successfully weaned off Levophed on [**6-9**].  Her
steroids (which were started for possible adrenal insufficiency)
were quickly weaned and discontinued.

Regarding her mild transaminitis, abdominal ultrasound was
performed which showed a polyp vs. gallstone without evidence of
cholecystitis or ductal dilatation.  She remained asymptomatic
and her LFTs remained stable.

Ultrasound did show an infrarenal aortic aneurysm which will
need follow up.

With regards to her afib, she was initially supratherapeutic on
her anticoagulation and her coumadin was held.  There was no
evidence of bleeding.  Her beta blocker was held due to her
hypotension.  She did have [**2-16**] brief episodes of RVR requiring
IV metoprolol which she responded well to.  On the day of her
transfer out of the ICU, her beta blocker was re-started at a
lower dosage to be uptitrated as tolerated by the floor team.

While on the floor, the hypotension and sepsis were resolved and
BP was stable.  She was given hydrocortisone in the ICU but did
not require further steroids on the floor.  Antbiotics were
continued with Day 1 [**6-4**] of IV Vancomycin, but unasyn started
[**6-7**]. Will continue for full 14 day course of Unasyn to finish
[**6-20**].

- Statis dermatitis/ cellulitis- Evaluated by dermatology and
recommended to apply clobetasol ointment to erythematous areas
on thighs/legs. Bactroban to open erosions. The cellulitis
appears to be in the distribution of her previous herpes zoster
and is likely the nidus for the infection.  She will have to
have a completion of antibiotics as above and follow up with
dermatology if the areas do not heal.

- Infrarenal aortic aneurysm - Noted on CT and per outpatient
PCP this is old and given lack of positive blood cultures, doubt
this is a mycotic aneurysm.

- Renal failure: Given lytes likely ATN [**2-15**] hypotension.
Currently improving, with Cr of 1.1  Haved dosed meds for CrCl
of 55.

- Atrial Fibrillation: rate controlled on admission. has had
brief episodes of RVR. As outpt on BB and coumadin.  She was
restarted on metoprolol 25 [**Hospital1 **] on [**6-9**] (outpt dose 75),
increased to TID on [**6-11**] and 50 mg TID on [**6-12**]
Initially held coumadin with elevated INR, but restarted at home
dose of 2.5mg on [**6-10**]  (received 5 mg on [**6-12**] to increase
INR).  This should be rechecked at least q week with the first
check occurring 2-3 days after discharge.

- CHF: slightly volume overloaded on admission, but currently
euvolemic. EF 55-60% on echo here. Restarted benicar 20 mg qday
on [**6-13**].  Her outpatient diuretics were not restarted as the
patient was autodiuresing after ATN, but it should be restarted
as an outpatient as the BP allows (lasix, hctz).

- Early decub ulcers: bactroban to erosions as well as zinc
oxide paste to erythematous areas. wound care consult for skin
breakdown on buttocks. Started on zinc, vitamin C.  As well the
patient should have movement to prevent further stasis.

- Elevated LFTs/pancreatic enzymes: unclear if there is a
clinical significance. But may be secondary to hypotensive and
inadequate perfusion during septic phase. Will no longer trend
as no clinical correlation

- Elevated finger sticks: no known diagnosis of DM. Was recently
on steroids.  Should be followed as an outpatient.

- Hx of loose stool: f/u c. diff cultures negative. Symptoms
improved.


Medications on Admission:
Benicar 20, Lopressor 75'', Crestor 30', Coumadin 2.5', HCTZ
25', Lasix 120', MVI, vit E, zetia

Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: per ss
Injection ASDIR (AS DIRECTED).
2. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for pain.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. Clobetasol 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day): until wounds heal.
7. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day): until wounds heal.
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. Zinc Sulfate 220 (50) mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
10. Olmesartan 20 mg Tablet Sig: One (1) Tablet PO Qday ().
11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
12. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Please check INR weekly and adjust dose appropriately.
13. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
14. Vancomycin 1000 mg IV Q 24H
D#1 [**6-4**] FINISHES approx [**2107-6-20**]. Ampicillin-Sulbactam 3 gm IV Q8H FINISHES [**2108-6-20**]. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN.  Inspect site every shift.


Discharge Disposition:
Extended Care

Facility:
[**Location (un) 582**] Of [**Location (un) 620**]

Discharge Diagnosis:
sepsis secodary to cellulitis
hypertension, CAD, PVD, atrial fibrillation, diverticulosis,
history of acute renal failure, CHF


Discharge Condition:
Improved infection, stable vitals


Discharge Instructions:
You were admitted for a severe infection.  You were treated with
antibiotics and improved.
Please follow up with your PCP upon discharge from rehab.

Followup Instructions:
Please follow up with your PCP upon discharge from Rehab by
calling: [**Last Name (LF) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 17753**]
{'Unspecified septicemia,Cellulitis and abscess of leg, except foot,Congestive heart failure, unspecified,Atrial fibrillation,Acute kidney failure with lesion of tubular necrosis,Mitral valve disorders,Diseases of tricuspid valve,Pressure ulcer, buttock,Severe sepsis,Abdominal aneurysm without mention of rupture,Venous (peripheral) insufficiency, unspecified,Diverticulosis of colon (without mention of hemorrhage),Unspecified essential hypertension,Long-term (current) use of anticoagulants,Aortocoronary bypass status'}


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: Hypotension/cellulitis

PRESENT ILLNESS: 76 yo F with AF, CAD s/p CABG, h/o cellultis, who presents from
home with worsening R leg infection. On [**Name (NI) 2974**], pt noticed a
swelling on her right lateral leg with redness. this progressed
over the next few days followed by pain in the last two days.
Denies fevers, but has some chills. No N/V, few loose BM's/day
over last few days. No cough/SOB. Also noted [**Month (only) **] UOP with ok
fluid intake but poor appetite.
.
Seen at OSH today where she was noted to have a large
cellulitis. Her BP was 80's without sxs. She was started on
levofed after being given 2.5 L IVF. A CVL was placed. She was
given clinda/vanc and a surgery consult was called which r/o
necrotizing fascitis. She was sent to [**Hospital1 **] for further care.
.
In the ED, VS 97.3, 80, 80/42, 16, 98%. Exam with 10-20 cm right
erythema to thigh, no skin breakdown. Vascular consult who
reccomended f/u cultures and monitoring exam of leg. Given add'l
clinda/vancomycin in the ED. UO notd to be poor--20 cc total. On
50 mcg of levofed on transfer.
.
Admitted to the ICU for sepsis.
.
In the MICU, surgery consult ruled out necr. fascitis. In the
unit required levophed for hypotension, echo with preserved EF
and severe TR. Mildly elevated LFTs, and CT abdomen with 4X 4 cm
AAA. (per PCP 3.5 cm AAA 3 yeras ago in '[**96**]). Vascular
following. Leg improved. Lateral leg ruptured bullae so Derm
followed. Initially on vanc/clinda for 3 days with some
improvement but due to leucocytosis so started unasysn. failed
[**Last Name (un) 104**] stiim got steroids for 5 days. This AM went into rapid a.
fib (given 5 mg iv lopressor). Started on metoprolol 25 (outpt
dose 75).

MEDICAL HISTORY: HTN
CAD
PVD
Afib
diverticulosis
h/o ARF
h/o coagulopathy
CHF
h/o cellulitis/sepsis- at BIDN on [**11-19**]; wound grew coag-neg
staph, txt w/ vanco

MEDICATION ON ADMISSION: Benicar 20, Lopressor 75'', Crestor 30', Coumadin 2.5', HCTZ
25', Lasix 120', MVI, vit E, zetia

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Tm 96.8 Tc 95.6 BP 104/58 (95-130/60-70)--off levophed since [**04**]
AM [**1-9**].
HR 76 (76-138) RR 20 O2 98% RA
I/O 1212/900

FAMILY HISTORY: NC

SOCIAL HISTORY: lives in [**Location 620**] with husband, former [**Name2 (NI) 1818**] (quite 25 years
ago), occ ETOH, no drugs 

### Response:
{'Unspecified septicemia,Cellulitis and abscess of leg, except foot,Congestive heart failure, unspecified,Atrial fibrillation,Acute kidney failure with lesion of tubular necrosis,Mitral valve disorders,Diseases of tricuspid valve,Pressure ulcer, buttock,Severe sepsis,Abdominal aneurysm without mention of rupture,Venous (peripheral) insufficiency, unspecified,Diverticulosis of colon (without mention of hemorrhage),Unspecified essential hypertension,Long-term (current) use of anticoagulants,Aortocoronary bypass status'}
