CHIEF COMPLAINT: foot ulcer

PRESENT ILLNESS: Story per record as patient is intubated
63 M with IDDM 2, hx of L foot ulcer, who presents with
worsening L foot pain and swelling, and three days of chills.
He saw his podiatrist who recommended he go to the ED for
admission.
Denies N/V, diarrhea, CP, SOB, Abd pain.

MEDICAL HISTORY: diabetes-with peripheral neuorpathy-on insulin
obstructive sleep apnea,
elevated cholesterol,
depression.
He had a broken neck at age 13 with C1-C2 repair.
He also has some cognitive decline for which she is seeing a
behavioral neurology, Dr. [**First Name (STitle) 6817**].
L index finger pain-s/p steroid injections by Dr.[**First Name (STitle) **]

MEDICATION ON ADMISSION: Ibuprofen PRN
amlodipine 5 mg PO BID
buproprion 150 mg PO TID
Rosuvastin calcium 40 PO QD
Gabapentin 800 mg PO BID
Gabapentin 1200 PO QHS
venlafaxine 150 mg PO BID
insulin SS and glargine 48 U qhs
trazadone 50-150 po QHS
lisinopril 40 PO QD
.

ALLERGIES: Penicillins / Cephalosporins / Aztreonam / Latex

PHYSICAL EXAM: VS: 97.4 80/53 75 19 100%
HEENT: intubated
Gen: intubated, sedated
CV: RRR, heart sounds distant
Resp: CTA on ant exam
Abd: soft, NT/ND, (+)BS, soft mobile mass in LRQ
Ext: + 2 pulse in R, L with c/d/i dressings, large area of
erythema and warmth from edge of dressings to knee on ant
surface of leg
NEURO: intubated, sedated

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: (+) tobacco use x40 years, quit, patient denies past etoh abuse,
although OMR notes indicate past chronic alcohol use.  Denies
illicit drug use.  Married.
Unspecified septicemia,Acute respiratory failure,Septic shock,Pneumonitis due to inhalation of food or vomitus,Ulcer of heel and midfoot,Cellulitis and abscess of foot, except toes,Acute osteomyelitis, ankle and foot,Pyogenic arthritis, ankle and foot,Gas gangrene,Acute posthemorrhagic anemia,Severe sepsis,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Other bone involvement in diseases classified elsewhere,Obstructive sleep apnea (adult)(pediatric),Pure hypercholesterolemia
Septicemia NOS,Acute respiratry failure,Septic shock,Food/vomit pneumonitis,Ulcer of heel & midfoot,Cellulitis of foot,Ac osteomyelitis-ankle,Pyogen arthritis-ankle,Gas gangrene,Ac posthemorrhag anemia,Severe sepsis,DMII oth nt st uncntrld,Neuropathy in diabetes,Bone involv in oth dis,Obstructive sleep apnea,Pure hypercholesterolem
Admission Date:  [**2188-3-21**]              Discharge Date:   [**2188-3-27**]

Date of Birth:  [**2125-1-31**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins / Cephalosporins / Aztreonam / Latex

Attending:[**Doctor Last Name 10493**]
Chief Complaint:
foot ulcer

Major Surgical or Invasive Procedure:
I&D
I&D with toe amputation
RIJ placed and removal
PICC


History of Present Illness:
Story per record as patient is intubated
63 M with IDDM 2, hx of L foot ulcer, who presents with
worsening L foot pain and swelling, and three days of chills.
He saw his podiatrist who recommended he go to the ED for
admission.
Denies N/V, diarrhea, CP, SOB, Abd pain.

In the ED patient was initially stable, but near midnight was
noted to be more confused, spiked a fever to 101, and became
diaphoretic.  He was seen by podiatry who found gas in the
tissues of his foot and decided to take him for emergent
surgery.  While he was getting his pre-op CXR, his oxygen
saturations dropped, he started agonal breathing, became blue,
and may have been transiently apneic, and possibly pulseless.  A
Code Blue was called.  The timing is unclear but he soon began
breathing again on his own, with good femoral pulses.  He was
intubated for airway protection and since he was due to go to
the OR.  He went to the OR for an I & D and debridement of his L
foot.
.
Patient received 3 liters of NS, Vanco, Clinda, Flagyl, levo.
His lactate was 4.5 so patient was transferred from the OR to
MICU for sepsis.


Past Medical History:
diabetes-with peripheral neuorpathy-on insulin
obstructive sleep apnea,
elevated cholesterol,
depression.
He had a broken neck at age 13 with C1-C2 repair.
He also has some cognitive decline for which she is seeing a
behavioral neurology, Dr. [**First Name (STitle) 6817**].
L index finger pain-s/p steroid injections by Dr.[**First Name (STitle) **]

Social History:
(+) tobacco use x40 years, quit, patient denies past etoh abuse,
although OMR notes indicate past chronic alcohol use.  Denies
illicit drug use.  Married.

Family History:
non-contributory

Physical Exam:
VS: 97.4 80/53 75 19 100%
HEENT: intubated
Gen: intubated, sedated
CV: RRR, heart sounds distant
Resp: CTA on ant exam
Abd: soft, NT/ND, (+)BS, soft mobile mass in LRQ
Ext: + 2 pulse in R, L with c/d/i dressings, large area of
erythema and warmth from edge of dressings to knee on ant
surface of leg
NEURO: intubated, sedated


Pertinent Results:
Labs:
[**2188-3-20**] 10:20PM BLOOD WBC-10.4 RBC-3.00* Hgb-10.3* Hct-29.4*
MCV-98 MCH-34.2* MCHC-34.9 RDW-13.2 Plt Ct-272
[**2188-3-20**] 10:20PM BLOOD Neuts-80.0* Lymphs-9.5* Monos-8.0 Eos-1.9
Baso-0.5
[**2188-3-27**] 05:39AM BLOOD ESR-84*
[**2188-3-20**] 10:20PM BLOOD Glucose-82 UreaN-17 Creat-0.9 Na-137
K-4.6 Cl-98 HCO3-26 AnGap-18
[**2188-3-21**] 01:00AM BLOOD CK(CPK)-204*
[**2188-3-21**] 01:00AM BLOOD CK-MB-5 cTropnT-<0.01
[**2188-3-27**] 05:39AM BLOOD CRP-52.8*
[**2188-3-21**] 01:05AM BLOOD Lactate-4.5*
.
Foot x-ray [**2188-3-20**]
Large ulcer with extensive subcutaneous gas. Findings are highly
concerning for a gas-forming organism infection. No definite
radiographic evidence of osteomyelitis at this time.
.
CT LOW EXT W/O C LEFT  [**2188-3-20**] 11:38 PM
Markedly abnormal appearance to the plantar soft tissues, with
deep ulcer reaching bone in the region of the fourth metatarsal
head. There is extensive subcutaneous emphysema, which may
relate to the reported recent probing and irrigation (noted in
the preliminary report). However, the extensive gas bubbles at
its dorsal aspect, removed from the ulcer, as well as the
intramedullary gas within the fourth metatarsal head are highly
suspicious for osteomyelitis, perhaps with gas-forming organism.
No focal fluid collection is identified.
.
Pathology submittede [**2188-3-21**], report [**2188-3-25**]
SPECIMEN SUBMITTED: LEFT INFECTED 4 METATARSAL AND INFECTED 4
PHRALNAN SPACE 4.
DIAGNOSIS:
Fourth metatarsal:  Acute osteomyelitis.
.
Foot x-ray [**2188-3-22**]
There has been an interval osteotomy involving the fourth tarsal
metatarsal joint with soft tissue removal in that region.
Post-surgical changes are again evident in the second and third
metatarsals. The third metatarsal proximal phalanx cortical
margin is not well defined and infection cannot be excluded in
this region.
IMPRESSION: Postoperative changes. Acute osteomyelitis of the
surrounding bones cannot be totally excluded due to osteopenia
in these regions. Recommend followup.
.
Pathology:
Tissue: 4TH TOE (1) PENDING


Brief Hospital Course:
A/P: 63 M with IDDM 2, hx of L foot ulcer, who presents with
worsening L foot pain and swelling, chills, now with elevated
lactate and s/p Code Blue in ED, s/p I & D in OR, MICU admission
for sepsis, repeat I&D with toe amputation on long course of
antibiotics.
.
# Sepsis/foot infection: Most obvious source is his L foot
abscess. Patient off pressors since [**3-21**] in am. Lactate improved
from 4.5 to 1.2 SvO2 77%. Per surgeon, the infection was quite
severe, requiring deep debridement and removal of infected bone.
 Pathology of first I&D was consistent with acute osteomyelitis.
 A second I&D was performed this time with toe amputation and
pathology is still pending at the time of discharge.  The
patient has a history of MRSA and has grown out organisms
resistant to clinda in the past. Blood cx (-) so far.  Bone
biopsies were not sent for culture so the patient was treated
with broad coverage antibiotics.  ID receommended vanco,
levofloxacin, flagyl for 4-6 weeks.  Swab cultures growing out
MSSA, however given allergy to PCN, treated with vancomycin.
Physical therapy recommended home with PT vs rehab and based on
the patient's desire to go home plus good support at home,
patient was discharge with follow up and VNA services.
.
# Resp Failure: Patient intubated after being agonal prior to
arriving in OR.  It is unclear whether this was sepsis induced
respiratory failure, fatigue  or new PNA. CXR report with
evolving right lower lung field airspace consolidation,
worrisome for pneumonia versus aspiration and also with volume
overload.  The patient's antibiotic regimen included vancomycin,
levoquin and flagyl as above.  Good response to diuresis.  The
patient was extubated without complication, insentive spirometry
was encouraged. O2 was gradually weaned.
.
#Anemia: Low HCT after surgical procedure but stable and vital
signs stable. No need for transfusion.  Guaiac negative.  Iron
studies consistent with ACD.  Patient given iron supplement.
.
#T2 DM: Patient on Lantus and HISS.
.
#CAD: MIBI in [**2184**] no ischemia.
-ASA, statin
.
# Access: PIVs, RIJ. RIJ removed. PICC line in place at time of
discharge.




Medications on Admission:
Ibuprofen PRN
amlodipine 5 mg PO BID
buproprion 150 mg PO TID
Rosuvastin calcium 40 PO QD
Gabapentin 800 mg PO BID
Gabapentin 1200 PO QHS
venlafaxine 150 mg PO BID
insulin SS and glargine 48 U qhs
trazadone 50-150 po QHS
lisinopril 40 PO QD
.


Discharge Medications:
1. Venlafaxine 75 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
2. Bupropion 75 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
3. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
4. Gabapentin 400 mg Capsule Sig: Three (3) Capsule PO HS (at
bedtime).
5. Trazodone 50 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as
needed.
6. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Insulin Glargine 100 unit/mL Solution Sig: As directed As
directed Subcutaneous at bedtime.
8. Insulin Lispro (Human) 100 unit/mL Solution Sig: As directed
As directed Subcutaneous As directed.
9. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

10. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
gram Intravenous Q 12H (Every 12 Hours) for 5 weeks: Please draw
trough once weekly.
Disp:*70 gram* Refills:*0*
11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 5 weeks.
Disp:*105 Tablet(s)* Refills:*0*
12. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24 () for
5 weeks.
Disp:*840 Tablet(s)* Refills:*0*
13. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours): Do not drive or operate heavy
machinery while taking this medication.  .
Disp:*10 Patch 72 hr(s)* Refills:*0*
14. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every [**3-28**]
hours as needed for pain: Do not drive or operate heavy
machinery while taking this medicaiton.
Disp:*45 Tablet(s)* Refills:*0*
15. Saline Flush 0.9 % Syringe Sig: One (1) syringe Injection
once a day as needed for for line flushes as needed: Saline
flushes .
Disp:*60 units* Refills:*0*
16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
17. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO twice a day as
needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
18. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

19. Outpatient Lab Work
Vancomycin trough once weekly.  Fax results to Dr. [**First Name (STitle) **] at
[**Telephone/Fax (1) 432**]
20. Outpatient Lab Work
First week of [**2188-4-22**], check CBC, BUN, Creatinine, LFTs and
send results to PCP and fax to Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 432**]
21. Heparin Flush 100 unit/mL Kit Sig: Two (2) units Intravenous
once a day: 10 ml NS followed by 2 ml of 100 Units/ml heparin
(200 units heparin) each lumen Daily and PRN. Inspect site every
shift.
.
Disp:*5 week supply* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
Primary diagnosis:
- Sepsis
- Osteomyelitis
.
Secondary diagnosis:
- Diabetes mellitus type 2
- Peripheral neuropathy
- Obstructive sleep apnea
- Hypercholesterolemia


Discharge Condition:
Stable, ambulatory with assistance


Discharge Instructions:
You were admitted with a foot ulcer/infection and found to have
sepsis.  While in the hospital you had 2 podiatry surgeries and
received antibiotics for the infection.  You will need to
continue to receive antibiotics for a total of 6 weeks.

Please take all medications as directed.  You will be taking
vancomycin IV twice daily to complete a 6 week course.  You will
also take flagyl and levofloxacin as directed for 6 weeks.

You have also been prescribed pain medicaiton.  A fentanyl patch
to be replaced every 3 days.  Also, percocet as needed for
breakthrough pain.  Do not drive or operate heavy machinery
while taking these medications.

If you develop fever, chills, shortness of breath, chest pain,
or any other symptom that concerns you, call your doctor or if
unavailable, go to the emergency room.

Please attend all follow up appointments.

Continue to check your blood sugar regularly and administer
insulin as directed by your doctor.  If your blood sugar is less
than 60 or greater than 350, call your doctor.

Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Doctor Last Name **], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2188-4-1**] 11:40

Provider: [**Name Initial (NameIs) **] Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2188-4-16**] 3:30

Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2188-5-5**] 10:00
You will need weekly vanco trough, CBC, LFTs, BUN/Cr faxed to
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 432**]


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**] MD, [**MD Number(3) 10495**]
{'Unspecified septicemia,Acute respiratory failure,Septic shock,Pneumonitis due to inhalation of food or vomitus,Ulcer of heel and midfoot,Cellulitis and abscess of foot, except toes,Acute osteomyelitis, ankle and foot,Pyogenic arthritis, ankle and foot,Gas gangrene,Acute posthemorrhagic anemia,Severe sepsis,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Other bone involvement in diseases classified elsewhere,Obstructive sleep apnea (adult)(pediatric),Pure hypercholesterolemia'}


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: foot ulcer

PRESENT ILLNESS: Story per record as patient is intubated
63 M with IDDM 2, hx of L foot ulcer, who presents with
worsening L foot pain and swelling, and three days of chills.
He saw his podiatrist who recommended he go to the ED for
admission.
Denies N/V, diarrhea, CP, SOB, Abd pain.

MEDICAL HISTORY: diabetes-with peripheral neuorpathy-on insulin
obstructive sleep apnea,
elevated cholesterol,
depression.
He had a broken neck at age 13 with C1-C2 repair.
He also has some cognitive decline for which she is seeing a
behavioral neurology, Dr. [**First Name (STitle) 6817**].
L index finger pain-s/p steroid injections by Dr.[**First Name (STitle) **]

MEDICATION ON ADMISSION: Ibuprofen PRN
amlodipine 5 mg PO BID
buproprion 150 mg PO TID
Rosuvastin calcium 40 PO QD
Gabapentin 800 mg PO BID
Gabapentin 1200 PO QHS
venlafaxine 150 mg PO BID
insulin SS and glargine 48 U qhs
trazadone 50-150 po QHS
lisinopril 40 PO QD
.

ALLERGIES: Penicillins / Cephalosporins / Aztreonam / Latex

PHYSICAL EXAM: VS: 97.4 80/53 75 19 100%
HEENT: intubated
Gen: intubated, sedated
CV: RRR, heart sounds distant
Resp: CTA on ant exam
Abd: soft, NT/ND, (+)BS, soft mobile mass in LRQ
Ext: + 2 pulse in R, L with c/d/i dressings, large area of
erythema and warmth from edge of dressings to knee on ant
surface of leg
NEURO: intubated, sedated

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: (+) tobacco use x40 years, quit, patient denies past etoh abuse,
although OMR notes indicate past chronic alcohol use.  Denies
illicit drug use.  Married. 

### Response:
{'Unspecified septicemia,Acute respiratory failure,Septic shock,Pneumonitis due to inhalation of food or vomitus,Ulcer of heel and midfoot,Cellulitis and abscess of foot, except toes,Acute osteomyelitis, ankle and foot,Pyogenic arthritis, ankle and foot,Gas gangrene,Acute posthemorrhagic anemia,Severe sepsis,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Other bone involvement in diseases classified elsewhere,Obstructive sleep apnea (adult)(pediatric),Pure hypercholesterolemia'}
