CHIEF COMPLAINT: Nectrotizing Fascitis of the LLE and groin.

PRESENT ILLNESS: 62M transfered from outside hospital with nectrotizing
fascitis. Patient was seen at OSH two days ago with "boil" on
left leg and was discharged home (unknown whether he was treated
with Abx). Patient reports the erythema has spread over last two
days and has become painful. Patient presented to OSH ED today
secondary to shortness of breath and dysnea. Upon arrival to OSH
patient was found to be hypotensive and a soft tissue skin
infection was apparent on the left leg. Patient was given Zosyn
and Clindamycin, started on Levophed and transferred to [**Hospital1 18**].

MEDICAL HISTORY: PMH: DM, COPD, HTN, Hyperlipidemia
PSH: Right knee surgery

MEDICATION ON ADMISSION: Lovastatin 20', Lisinopril 20', Metoprolol 25'', ISDN 30',
Albuterol, Ipatropium, Combivent, Glyburide 5AM, 2.5HS,
Omeprazole 40', Advair 250/50'', [**Doctor First Name **] 60'', Ibuprofen 800'',
Nicotine Patch

ALLERGIES: Penicillins

PHYSICAL EXAM: On admission:

FAMILY HISTORY: NC

SOCIAL HISTORY: Tobacco: 1ppd
EtOH/drugs: negative
Unspecified septicemia,Necrotizing fasciitis,Septic shock,Acute kidney failure, unspecified,Other pulmonary embolism and infarction,Cellulitis and abscess of leg, except foot,Acidosis,Severe sepsis,Morbid obesity,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Chronic airway obstruction, not elsewhere classified,Unspecified essential hypertension,Other and unspecified hyperlipidemia
Septicemia NOS,Necrotizing fasciitis,Septic shock,Acute kidney failure NOS,Pulm embol/infarct NEC,Cellulitis of leg,Acidosis,Severe sepsis,Morbid obesity,DMII wo cmp nt st uncntr,Chr airway obstruct NEC,Hypertension NOS,Hyperlipidemia NEC/NOS
Admission Date:  [**2139-11-18**]              Discharge Date:   [**2139-12-15**]

Date of Birth:  [**2077-8-1**]             Sex:   M

Service: SURGERY

Allergies:
Penicillins

Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
Nectrotizing Fascitis of the LLE and groin.


Major Surgical or Invasive Procedure:
Operative debridement of Necrotizing fascitis on [**11-18**].
Second operative debridemnet of necrotizing fascitiis [**11-18**].
Bedside debridement of Leg wound.
Picc line placment.


History of Present Illness:
62M transfered from outside hospital with nectrotizing
fascitis. Patient was seen at OSH two days ago with "boil" on
left leg and was discharged home (unknown whether he was treated
with Abx). Patient reports the erythema has spread over last two
days and has become painful. Patient presented to OSH ED today
secondary to shortness of breath and dysnea. Upon arrival to OSH
patient was found to be hypotensive and a soft tissue skin
infection was apparent on the left leg. Patient was given Zosyn
and Clindamycin, started on Levophed and transferred to [**Hospital1 18**].


Past Medical History:
PMH: DM, COPD, HTN, Hyperlipidemia
PSH: Right knee surgery


Social History:
Tobacco: 1ppd
EtOH/drugs: negative


Family History:
NC

Physical Exam:
On admission:

VS: T 98.0 P 107 BP 95/71 (on levophed) RR 20 O2 98% NC
PE:  Gen - alert and oriented
     CV - Tachycardic, no murmurs
     Pulm - clear to ascultation bilaterally
     Abd - S/NT/ND, no rebound/guarding
     GU - Diffuse erythema over scrotum and left inner thigh,
     with erythema extending below the knee. Skin necrosis
     found along left inner thigh with multiple skin blisters

Pertinent Results:
[**11-22**] CTA; Bibasilar effusions, no definite evidence for
pulmonary embolism.  Nasogastric tube terminating in the upper
stomach, with a sidehole noted at the gastroesophageal junction.

[**11-26**] Echo: Suboptimal image quality. Normal biventricular
cavity sizes with preserved global biventricular systolic
function. Left atrial enlargement. LVEF 55%.
[**12-7**] CTA:  Multifocal segmental and subsegmental pulmonary
emboli Improved bilateral small pleural effusions and bilateral
lower lobe atelectasis. Small bilateral pulmonary nodules. Left
thyroid nodule for which ultrasound is recommended if not
already
worked up elsewhere. Fatty liver.
[**12-8**] LE U/S: No deep venous thrombosis in the right lower
extremity. Limited evaluation of the left lower extremity due to
wound vac, no distal thrombus.



Brief Hospital Course:
[**11-18**] PT admitted to surgery for nectrotizing skin infection of
left leg and sepsis. PT went to OR for debridement. Broad
spectrum Abx ( meropenem, Vancomycin and Clindamycin, Flagyl)
and IVF resuscitation started.  Patient post op pt remained
intubated and was transferred to the ICU.  Taken back to the OR
for further debridment and [**Last Name (un) 7162**] kept intubated.  Infectious
disease was consulted.
[**11-19**]: Started vasopressin, placed SVO2 & Quinton cath, bolused
bicarb and maintained on bicarbonate gtt. Coagulase negative
Staph, Ecoli, Strep ciridans, and Corneybacterium diptheria were
cultured from the wound.
[**11-20**]: Renal consulted for Acute renal failure creatinine wtih
peak of 4.7. Hd ccathete placed. Pt was rehydrated with NS, All
meds were renally dosed.  Wound vac applied to wound.
[**11-21**]: Vancomycin q12, Meropenem q6, off vasopressin, HD cath
d/c'd.
[**11-22**]: Off levo, acute desat to 84-88%, hypotensive, resumed
levo gtt. CTA of the chest performed showed no no PE, moderate
b/l pleural effusions.
[**11-23**]: 1/2NS changed to LR, vac changed .
[**11-24**]: Trophic TF started, inc vanc to 1.25 q12 for trough 10.2.
 Wound care team consulted.
[**11-25**]: Advanced TF, PT given 25% albumin x 3, d/c clinda at the
reccommendation of ID.
[**11-26**]: D/c vanc, started dapto, Lasix gtt, [**Last Name (un) **] stim test neg.
Bedside debridment of necrotic tissue at edge of wound. Plastic
surgery consulted re possible flap coverage.  Still on pressors.

[**11-27**]: TSH 1.8, Lasix gtt on hold, switched to CPAP + PS
[**11-28**]: Restart Lasix gtt, weaned PS .  C difficile checked.
[**11-29**]: A fib with RVR.  PT given esmolol and converted
spontaneously, trop neg x 2.  Cardioloy consult.
[**11-30**]: Extubated, restarted home BB, TTE eprformend w/ LVEF>55%.
Per cardiology antiarrythmics held.  Pressors continued to wean.

[**12-1**]: Lasix gtt -> 20''', acetazolamide x2, restarted home
statin, glyburide, Haldol prn agitation, PICC placed by venous
access team.  PT consulted for therapy.
[**12-2**]: Lasix 20', d/c acetazolamide, restarted omeprazole
[**12-3**]: [**Hospital **] transferred to the floor.   Agitated o/n given
Haldol x 3 doses.
[**12-5**]: CXR perforemed.  Patient continued to be agitated.
[**12-6**] Psychiatry consult: Recs for infection workup and Serum tox
screen.  Replete thiamine, folate.
[**12-7**] Pt triggered on the floor for SaO2 <90%. PT transferred to
the ICU, intubated. CTA chest showed  B/l RUL and LUL
subsegmental PE.  Heparin GGT was started.  Plan to skin graft
with plastic surgery delayed by anticoagulation.
[**Date range (1) 25351**]: Heparin ggt, Intubated.
[**12-10**]: antibiotics d/c'd ; PT evaluation, lopressor frequency
increased TID, PO feeds started and tolerated well, arterial
line d/c. Vascular surgery cnsulted regarding IVC filter
(decided against placement).
[**12-11**]: Pt extubated.  Bridged to coumadin.  Transferred to the
floor.
[**Date range (1) 35672**]:  Pt advanced to regular diet.  Mental status
cleared.  Pt therapuetic on coumadin.  Heparin dc'd on the [**2142-12-13**]: Foley dc'd, Vac changed.  Rehab screening.
Pt discharged to rehab VSS, Afebrile, Pain well controlled with
Po pain medications, off antibiotics, with normal WBC count.
Plan to follow up with plastic surgery for skin grafting.


Medications on Admission:
Lovastatin 20', Lisinopril 20', Metoprolol 25'', ISDN 30',
Albuterol, Ipatropium, Combivent, Glyburide 5AM, 2.5HS,
Omeprazole 40', Advair 250/50'', [**Doctor First Name **] 60'', Ibuprofen 800'',
Nicotine Patch


Discharge Medications:
1. Glyburide 5 mg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)).
2. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*60 Tablet(s)* Refills:*0*
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
Disp:*60 Capsule(s)* Refills:*0*
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
7. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*0*
8. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
9. Sodium Chloride 0.9%  Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
10. Sodium Chloride 0.9%  Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
11. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q8H (every 8 hours) as needed for constipation.
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q4H (every 4 hours) as
needed.
15. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
17. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
18. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
19. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
20. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for itching.


Discharge Disposition:
Extended Care

Facility:
[**Hospital 5503**] Rehabilitation

Discharge Diagnosis:
Left thigh/groin necrotizing fascitis; sepsis, septic shock,
Acute renal failure, Pulmonary embolism.


Discharge Condition:
VSS, Wound vac in place.  Pain controlled on Po pain meds.
Tolerating a regular cardiac diet.


Discharge Instructions:
General:

* Please look at the wound  site every day for signs of
infection (increased redness, swelling, odor, yellow or bloody
discharge, fever).
-Note color, consistency, and amount of fluid in drain. Call
doctor if amount increases significantly or changes in
character.
-Maintain the site clean, dry, and intact.
-Avoid swimming, baths, hot tubs-do not submerge yourself in
water.
-Keep drain attached safely to body to prevent pulling

*Please call your doctor or return to the ER for any of the
following:
* Increased pain, and erythema of your leg wound.
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons.

* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or

back.

*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.

*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.


Followup Instructions:
1. Please Call to schedule follow up with Dr. [**First Name (STitle) 2819**] in 1 -2
weeks.([**Telephone/Fax (1) 6347**].
2. Please follow up with plastic surgery in 1 week [**Telephone/Fax (1) 4652**].
3. Please call your primary care to schedule follow up.



Completed by:[**2139-12-15**]
{'Unspecified septicemia,Necrotizing fasciitis,Septic shock,Acute kidney failure, unspecified,Other pulmonary embolism and infarction,Cellulitis and abscess of leg, except foot,Acidosis,Severe sepsis,Morbid obesity,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Chronic airway obstruction, not elsewhere classified,Unspecified essential hypertension,Other and unspecified hyperlipidemia'}


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: Nectrotizing Fascitis of the LLE and groin.

PRESENT ILLNESS: 62M transfered from outside hospital with nectrotizing
fascitis. Patient was seen at OSH two days ago with "boil" on
left leg and was discharged home (unknown whether he was treated
with Abx). Patient reports the erythema has spread over last two
days and has become painful. Patient presented to OSH ED today
secondary to shortness of breath and dysnea. Upon arrival to OSH
patient was found to be hypotensive and a soft tissue skin
infection was apparent on the left leg. Patient was given Zosyn
and Clindamycin, started on Levophed and transferred to [**Hospital1 18**].

MEDICAL HISTORY: PMH: DM, COPD, HTN, Hyperlipidemia
PSH: Right knee surgery

MEDICATION ON ADMISSION: Lovastatin 20', Lisinopril 20', Metoprolol 25'', ISDN 30',
Albuterol, Ipatropium, Combivent, Glyburide 5AM, 2.5HS,
Omeprazole 40', Advair 250/50'', [**Doctor First Name **] 60'', Ibuprofen 800'',
Nicotine Patch

ALLERGIES: Penicillins

PHYSICAL EXAM: On admission:

FAMILY HISTORY: NC

SOCIAL HISTORY: Tobacco: 1ppd
EtOH/drugs: negative 

### Response:
{'Unspecified septicemia,Necrotizing fasciitis,Septic shock,Acute kidney failure, unspecified,Other pulmonary embolism and infarction,Cellulitis and abscess of leg, except foot,Acidosis,Severe sepsis,Morbid obesity,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Chronic airway obstruction, not elsewhere classified,Unspecified essential hypertension,Other and unspecified hyperlipidemia'}
