CHIEF COMPLAINT: 

PRESENT ILLNESS: This is a 43 year old woman with
end stage renal disease on hemodialysis with multiple
complications of renal failure, hypertension, status post
mitral valve replacement in [**2180-1-20**], and a history of
multiple line infections who was admitted for somnolence,
hypotension and hypothermia.  She had a recent admission from
[**8-15**], to [**9-18**] for calciphylaxis which was
complicated by necrosis of her toes and fingers.  She also
had a left fifth finger amputation for an abscess and
bacteroides fragilis osteomyelitis, discharged to [**Hospital6 **] on a six week course of Cipro and
Flagyl.  The morning of admission she was noted to be
somnolent and minimally responsive with a systolic blood
pressure in the 60s to 70s.  Her normal systolic blood
pressure is in the 80s to 90s.  Her temperature was 93?????? F at
that point.  She was given a dose of Vancomycin and
gentamicin at rehab and sent to [**Hospital6 2018**] Emergency Room.  In the Emergency Department her
systolic blood pressure was 78 and her heartrate was 68.  Her
temperature was 93.  She was given 1 liter of normal saline
and additional Vancomycin.  A bear hugger was placed over her
and she was started on a Neo drip.  She was at that point
admitted to the Medicine Intensive Care Unit.  Her systolic
blood pressure improved to 90 to 100 and her mentation
improved somewhat.  In the Medicine Intensive Care Unit she
was changed to Levophed drip.  She noted to chest pain,
abdominal pain, shortness of breath or other complaints.  She
was not oriented or able to remember any events leading up to
her admission.  Of note, her last dialysis prior to admission
was on [**2180-9-23**].  She is typically anuric at
baseline.

MEDICAL HISTORY: 1.  End stage renal disease secondary to percentive
glomerulonephritis which she was diagnosed with in [**2165**].  She
is anuric and on hemodialysis for the past five years.  She
has a left arm fistula.  She has a history of a right arm
fistula in the past.  Her complications of end stage renal
disease include secondary hyperparathyroidism, status post
parathyroidectomy, anemia currently on Epogen and
calciphylaxis with distal digital necrosis and status post a
fifth digit, left hand, amputation for abscess and
osteomyelitis, currently on six weeks of Cipro and Flagyl.
2.  Hypertension.
3.  History of rheumatic heart disease with mitral stenosis
status post mitral valve replacement.  She has no history of
coronary artery disease by catheterization in [**2178**].
4.  Presumed subacute bacterial endocarditis in [**2175**] with
positive vegetation but negative cultures.
5.  Anxiety and depression with suicidal ideation
6.  Migraines.
7.  Multiple episodes of line sepsis including Vancomycin
sensitive enterococcus in [**2179-1-20**].
8.  Bilateral ovarian cysts, status post cystectomy.
9.  Paroxysmal ectopic atrial tachycardia to 100s to 110s.
10. Back surgery.

MEDICATION ON ADMISSION: 

ALLERGIES: Penicillin causes anaphylaxis; Tylenol causes
rash; Zantac causes thrombocytopenia; Ultram.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: She lives with her daughters although she is
currently in rehabilitation.  She is widowed.  She has no
alcohol, tobacco or intravenous drug use.  Her oldest
daughter is her health care proxy.
Infection and inflammatory reaction due to other vascular device, implant, and graft,Other staphylococcal septicemia,Nephritis and nephropathy, not specified as acute or chronic, with unspecified pathological lesion in kidney,Ulcer of thigh,Anemia in chronic kidney disease,Gangrene,Heart valve replaced by other means,Unspecified acquired hypothyroidism
React-oth vasc dev/graft,Staphylcocc septicem NEC,Nephritis NOS,Ulcer of thigh,Anemia in chr kidney dis,Gangrene,Heart valve replac NEC,Hypothyroidism NOS
Admission Date:  [**2180-9-26**]       Discharge Date:  [**2180-10-5**]

Date of Birth:   [**2137-5-6**]       Sex:  F

Service:  [**Hospital1 139**]

HISTORY OF PRESENT ILLNESS:  This is a 43 year old woman with
end stage renal disease on hemodialysis with multiple
complications of renal failure, hypertension, status post
mitral valve replacement in [**2180-1-20**], and a history of
multiple line infections who was admitted for somnolence,
hypotension and hypothermia.  She had a recent admission from
[**8-15**], to [**9-18**] for calciphylaxis which was
complicated by necrosis of her toes and fingers.  She also
had a left fifth finger amputation for an abscess and
bacteroides fragilis osteomyelitis, discharged to [**Hospital6 **] on a six week course of Cipro and
Flagyl.  The morning of admission she was noted to be
somnolent and minimally responsive with a systolic blood
pressure in the 60s to 70s.  Her normal systolic blood
pressure is in the 80s to 90s.  Her temperature was 93?????? F at
that point.  She was given a dose of Vancomycin and
gentamicin at rehab and sent to [**Hospital6 2018**] Emergency Room.  In the Emergency Department her
systolic blood pressure was 78 and her heartrate was 68.  Her
temperature was 93.  She was given 1 liter of normal saline
and additional Vancomycin.  A bear hugger was placed over her
and she was started on a Neo drip.  She was at that point
admitted to the Medicine Intensive Care Unit.  Her systolic
blood pressure improved to 90 to 100 and her mentation
improved somewhat.  In the Medicine Intensive Care Unit she
was changed to Levophed drip.  She noted to chest pain,
abdominal pain, shortness of breath or other complaints.  She
was not oriented or able to remember any events leading up to
her admission.  Of note, her last dialysis prior to admission
was on [**2180-9-23**].  She is typically anuric at
baseline.

Of note at rehabilitation she had been started on Neurontin,
Vioxx, and Klonopin.  She has had a bad reaction from
benzodiazepine use in the past with decreased mental status.
Her Fentanyl patch was also increased from 75 mcg to 125 mcg
due to her pain from her calciphylaxis.

PAST MEDICAL HISTORY:
1.  End stage renal disease secondary to percentive
glomerulonephritis which she was diagnosed with in [**2165**].  She
is anuric and on hemodialysis for the past five years.  She
has a left arm fistula.  She has a history of a right arm
fistula in the past.  Her complications of end stage renal
disease include secondary hyperparathyroidism, status post
parathyroidectomy, anemia currently on Epogen and
calciphylaxis with distal digital necrosis and status post a
fifth digit, left hand, amputation for abscess and
osteomyelitis, currently on six weeks of Cipro and Flagyl.
2.  Hypertension.
3.  History of rheumatic heart disease with mitral stenosis
status post mitral valve replacement.  She has no history of
coronary artery disease by catheterization in [**2178**].
4.  Presumed subacute bacterial endocarditis in [**2175**] with
positive vegetation but negative cultures.
5.  Anxiety and depression with suicidal ideation
6.  Migraines.
7.  Multiple episodes of line sepsis including Vancomycin
sensitive enterococcus in [**2179-1-20**].
8.  Bilateral ovarian cysts, status post cystectomy.
9.  Paroxysmal ectopic atrial tachycardia to 100s to 110s.
10. Back surgery.

MEDICATIONS:
1.  RenaGel 300 mg t.i.d. with meals
2.  Nephrocaps one q. day
3.  Epogen [**Numeric Identifier 7206**] units subcutaneously q. Monday, Wednesday
and Friday given at dialysis
4.  Fentanyl 125 mcg transdermally q. 72 hours
5.  Colace 100 mg b.i.d.
6.  Prilosec
7.  Neurontin 300 mg b.i.d.
8.  Vioxx 25 mg q. day
9.  Cipro 200 mg intravenously q. 12 hours
10. Flagyl 500 mg intravenously q. 12 hours
11. Lovenox 30 mg subcutaneously b.i.d.

ALLERGIES:  Penicillin causes anaphylaxis; Tylenol causes
rash; Zantac causes thrombocytopenia; Ultram.

SOCIAL HISTORY:  She lives with her daughters although she is
currently in rehabilitation.  She is widowed.  She has no
alcohol, tobacco or intravenous drug use.  Her oldest
daughter is her health care proxy.

PHYSICAL EXAMINATION:  This is a somnolent but arousable
woman who appears older than her stated age and is quite
wasted and cachectic.  She is oriented to place and person.
She appears comfortable.  Vital signs:  She has a blood
pressure of 90/60 on Neo, heartrate of 80 and a temperature
of 96.  Her head, eyes, ears, nose and throat examination is
unremarkable except for dry mucous membranes.  Her lungs are
clear to auscultation bilaterally.  Her heart is slightly
tachycardiac with a regular rhythm.  She has a loud S1 and a
normal S2 with a physiologic split.  She has an S4 gallop.
She has a II/VI holosystolic murmur that is loudest at the
left upper sternal border.  Her abdomen is benign, soft,
nontender, nondistended and with good bowel sounds.  She has
known hepatosplenomegaly.  She has multiple abdominal scars.
Her extremities reveal distal necrosis with wrapped hands and
feet and no edema.  Her neurological examination reveals
intact cranial nerves, awake and oriented to place and person
and she is moving all of her extremities spontaneously.  On
skin examination she has extensive desquamation with necrotic
areas of both of her feet, especially over her heels.
Bilaterally her first and second toes have dry gangrene.  Her
right thigh has a 5 by 5 cm ulcerated lesion with a
superficial ulcer with a necrotic yellow base.  Her left
lateral thigh has a similar lesion.  Her right hand has
diffuse desquamation with dry gangrene of her fourth finger.
Her left hand has diffuse desquamation with a fifth digit
amputation.  She has exposed bone, tendon and subcutaneous
tissue.  The tendons of her third and fourth fingers are
partially necrotic.  The desquamation extends partially down
the medial aspect of her forearm about midway down her
forearm.  She has mild skin sloughing over her coccyx.

LABORATORY DATA:  Labs show a white count of 12.6 with 79%
neutrophils and 15% lymphocytes.  Her hematocrit is 32 which
is stable for her.  Her platelet count is 214.  Her chem-7 is
normal aside from a BUN of 33 and a creatinine of 5.3.  Her
INR is 2.4.  Calcium is 8.7, magnesium is 2.0, and phosphorus
is 3.4.  Her albumin is 1.4.  Her alkaline phosphatase is
111.  Her TSH is 8.2 and her free T4 is 0.9.  Her TSH is high
and increased from [**2180-6-21**] when it was 3.6.  Her free T4
is within normal limits on the low end of normal.

Chest x-ray reveals no acute cardiopulmonary pathology.
Electrocardiogram is normal sinus rhythm at 95 beats/minute,
no acute changes.

HOSPITAL COURSE:  Ms [**Known lastname 7568**] was admitted to the Medicine
Intensive Care Unit and maintained on a Levophed drip.  She
also received many intravenous fluid boluses with an
improvement in her blood pressure to the point where the
pressors could be stopped.  She was continued on Vancomycin
and Gentamicin.  Serial blood cultures were drawn over four
days which revealed no growth.  Her midline which was her
main access was removed and the tip grew out Coagulase
negative Staphylococcus.  The Plastic Surgery Service was
consulted to evaluate her wound to look for signs of active
infection.  A wound culture from her thigh wound grew skin
Flora.  The Plastic Service evaluated her and stated that she
had dry gangrene but no signs of super infection or signs
that would require need for surgery.  Her Klonopin, Neurontin
and Vioxx were initially held for fear that they may have
been contributing to her decrease in mental status.  He
Neurontin and Vioxx were shortly thereafter restarted.
During the workup for her hypotension, a Cortisol stim test
was done which showed that she was not adrenally
insufficient.  She did appear to be subclinically hypothyroid
as evidenced by her thyroid function test, and she was
started on a low dose of Synthroid.  She was maintained on a
heparin drip for her mitral valve replacement.  A pain
consult was obtained as she was in significant pain when her
wound dressings were changed.  She was fairly comfortable at
baseline when her dressings were not being changed.  Her pain
was regimen was tailored according to the recommendations of
the Pain Consult Service.  After her blood pressure had been
stable for about 24 hours off of pressors, she was
transferred to the floor for further care.  Her hypotension
and hypothermia were believed to be secondary to line sepsis
from her midline which was colonized with Coagulase negative
Staphylococcus.  The fluid boluses and initial pressors were
able to be stopped after she received adequate treatment with
Vancomycin and Gentamicin.  She completed a seven day course
of the antibiotics.  Her blood pressure initially was to low
to allow her to go to hemodialysis but she eventually was
able to tolerated hemodialysis with an acceptable blood
pressure.  Her systolic blood pressure is now in the 90s to
100s which is good for her.

She received a seven day course of Vancomycin and Gentamicin
which was renally dosed.  She was continued on her
Ciprofloxacin and her Flagyl for her left hand osteomyelitis.

Her altered mental status was believed to be multifactorial.
Mostly, we have come to believe that her infection and her
debilitated state lead to her somnolence at presentation.
Her somnolence was very slow to clear even after her blood
pressure and temperature had improved.  She also experienced
a bit of delirium with fluctuating mental status that has
mostly resolved at this point.  Aside from sepsis, her high
dose of opiates, and her uremia were likely contributing to
her altered mental status.  Although we wish to minimize the
daily medications we did not wish to have her in any pain and
so her narcotics were continued.  She is currently on a
regimen of Fentanyl, Vioxx, and Neurontin with Dilaudid for
breakthrough pain.  After surveillance blood cultures came
back negative a new PICC catheter was placed by
Interventional Radiology under fluoroscopy for access so that
she can complete her courses of Ciprofloxacin and Flagyl.
She was also followed by a wound care nurse throughout her
stay and her wounds were stable throughout her course.  Her
mental status improved to close to baseline by the time of
discharge.

CONDITION AT DISCHARGE:  Improved.

DISCHARGE STATUS:  To Rehabilitation to follow up with her
primary nephrologist, Dr. [**Last Name (STitle) 174**] as needed.

DISCHARGE DIAGNOSIS:
1.  Coagulase negative Staphylococcus line sepsis
2.  End stage renal disease complicated by calciphylaxis with
distal digital necrosis
3.  Anemia
4.  Osteomyelitis of her left fifth digit
5.  Hypertension
6.  Rheumatic heart disease status post mitral valve
replacement
7.  Anxiety
8.  Depression with suicidal ideation
9.  Paroxysmal ectopic atrial tachycardia

DISCHARGE MEDICATIONS:
1.  Ciprofloxacin 200 mg intravenously q. 12 hours until
[**2180-10-9**]
2.  Flagyl 500 mg intravenously q. 12 hours until [**2180-10-16**]
3.  Fentanyl 125 mcg transdermally q. 72 hours
4.  Dilaudid 2 to 4 mg intravenously/p.o. q. 2 hours prn
5.  Neurontin 300 mg p.o. b.i.d.
6.  Vioxx 25 mg p.o. q.d.
7.  Protonix 40 mg p.o. q.d.
8.  Colace 100 mg p.o. b.i.d.
9.  Epogen [**Numeric Identifier 7206**] units subcutaneously q. Monday, Wednesday
and Friday at hemodialysis
10. Nephrocaps 1 p.o. q.d.
11. RenaGel 300 p.o. t.i.d. with meals
12. Zoloft 50 mg p.o. q.d.
13. Lovenox 30 mg subcutaneously b.i.d.
14. Synthroid 25 mcg p.o. q.d.





                            [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern1) 97867**], M.D.  [**MD Number(1) 97868**]

Dictated By:[**Name8 (MD) 1552**]
MEDQUIST36

D:  [**2180-10-4**]  15:06
T:  [**2180-10-4**]  15:05
JOB#:  [**Job Number 18839**]
{'Infection and inflammatory reaction due to other vascular device, implant, and graft,Other staphylococcal septicemia,Nephritis and nephropathy, not specified as acute or chronic, with unspecified pathological lesion in kidney,Ulcer of thigh,Anemia in chronic kidney disease,Gangrene,Heart valve replaced by other means,Unspecified acquired hypothyroidism'}


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: 

PRESENT ILLNESS: This is a 43 year old woman with
end stage renal disease on hemodialysis with multiple
complications of renal failure, hypertension, status post
mitral valve replacement in [**2180-1-20**], and a history of
multiple line infections who was admitted for somnolence,
hypotension and hypothermia.  She had a recent admission from
[**8-15**], to [**9-18**] for calciphylaxis which was
complicated by necrosis of her toes and fingers.  She also
had a left fifth finger amputation for an abscess and
bacteroides fragilis osteomyelitis, discharged to [**Hospital6 **] on a six week course of Cipro and
Flagyl.  The morning of admission she was noted to be
somnolent and minimally responsive with a systolic blood
pressure in the 60s to 70s.  Her normal systolic blood
pressure is in the 80s to 90s.  Her temperature was 93?????? F at
that point.  She was given a dose of Vancomycin and
gentamicin at rehab and sent to [**Hospital6 2018**] Emergency Room.  In the Emergency Department her
systolic blood pressure was 78 and her heartrate was 68.  Her
temperature was 93.  She was given 1 liter of normal saline
and additional Vancomycin.  A bear hugger was placed over her
and she was started on a Neo drip.  She was at that point
admitted to the Medicine Intensive Care Unit.  Her systolic
blood pressure improved to 90 to 100 and her mentation
improved somewhat.  In the Medicine Intensive Care Unit she
was changed to Levophed drip.  She noted to chest pain,
abdominal pain, shortness of breath or other complaints.  She
was not oriented or able to remember any events leading up to
her admission.  Of note, her last dialysis prior to admission
was on [**2180-9-23**].  She is typically anuric at
baseline.

MEDICAL HISTORY: 1.  End stage renal disease secondary to percentive
glomerulonephritis which she was diagnosed with in [**2165**].  She
is anuric and on hemodialysis for the past five years.  She
has a left arm fistula.  She has a history of a right arm
fistula in the past.  Her complications of end stage renal
disease include secondary hyperparathyroidism, status post
parathyroidectomy, anemia currently on Epogen and
calciphylaxis with distal digital necrosis and status post a
fifth digit, left hand, amputation for abscess and
osteomyelitis, currently on six weeks of Cipro and Flagyl.
2.  Hypertension.
3.  History of rheumatic heart disease with mitral stenosis
status post mitral valve replacement.  She has no history of
coronary artery disease by catheterization in [**2178**].
4.  Presumed subacute bacterial endocarditis in [**2175**] with
positive vegetation but negative cultures.
5.  Anxiety and depression with suicidal ideation
6.  Migraines.
7.  Multiple episodes of line sepsis including Vancomycin
sensitive enterococcus in [**2179-1-20**].
8.  Bilateral ovarian cysts, status post cystectomy.
9.  Paroxysmal ectopic atrial tachycardia to 100s to 110s.
10. Back surgery.

MEDICATION ON ADMISSION: 

ALLERGIES: Penicillin causes anaphylaxis; Tylenol causes
rash; Zantac causes thrombocytopenia; Ultram.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: She lives with her daughters although she is
currently in rehabilitation.  She is widowed.  She has no
alcohol, tobacco or intravenous drug use.  Her oldest
daughter is her health care proxy. 

### Response:
{'Infection and inflammatory reaction due to other vascular device, implant, and graft,Other staphylococcal septicemia,Nephritis and nephropathy, not specified as acute or chronic, with unspecified pathological lesion in kidney,Ulcer of thigh,Anemia in chronic kidney disease,Gangrene,Heart valve replaced by other means,Unspecified acquired hypothyroidism'}
