CHIEF COMPLAINT: 

PRESENT ILLNESS: Miss [**Known lastname **] is a 48 year old woman
with a past medical history of hypothyroidism carrying the
diagnosis of systemic lupus erythematosus who presents from
[**Hospital3 35813**] Center in [**Doctor Last Name 792**]with Group A beta
hemolytic Strep sepsis, rash, anopsia, myalgia, arthralgia and
hypoxia, and respiratory failure requiring intubation.

MEDICAL HISTORY: 1.  Hypothyroidism.
2.  Systemic lupus erythematosus.
No coronary artery disease, diabetes mellitus, pulmonary or
renal disease.

MEDICATION ON ADMISSION: 

ALLERGIES: The patient denies any allergies, however, the
patient did have a rash to Dilaudid at the outside hospital.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Streptococcal septicemia,Other shock without mention of trauma,Infective myositis,Urinary tract infection, site not specified,Systemic lupus erythematosus,Other specified cardiac dysrhythmias
Streptococcal septicemia,Shock w/o trauma NEC,Infective myositis,Urin tract infection NOS,Syst lupus erythematosus,Cardiac dysrhythmias NEC
Admission Date:  [**2178-4-23**]       Discharge Date:  [**2178-5-10**]

Date of Birth:   [**2129-5-19**]       Sex:  F

Service:  Medicine

HISTORY OF PRESENT ILLNESS:  Miss [**Known lastname **] is a 48 year old woman
with a past medical history of hypothyroidism carrying the
diagnosis of systemic lupus erythematosus who presents from
[**Hospital3 35813**] Center in [**Doctor Last Name 792**]with Group A beta
hemolytic Strep sepsis, rash, anopsia, myalgia, arthralgia and
hypoxia, and respiratory failure requiring intubation.

She initially presented to [**Hospital3 35813**] Center on the evening
of [**4-19**], complaining of upper extremity pain and fever to 102.0
F.  The pain was most severe in her left axilla and shoulder.
Four weeks prior to admission, she began having upper extremity
swelling and stiffness particularly in her hands.  She was
prescribed Vioxx for her symptoms.

On the 1st, she was referred to a rheumatologist who prescribed
Prednisone 20 mg q. day and then she presented to the outside
hospital on the 4th complaining of fever, diarrhea, stiff joints
and puffiness in her hands.  She decided to go the Emergency
Department particularly because her left arm and shoulder had
increased in pain.

She had an outside hospital course notable for increased
erythematous rash on the left arm, neck, and chest, increased
white blood cell count to 22.0 with bandemia approximately 10 to
12%, positive blood cultures, four out of four bottles drawn
on the 4th for Group A beta hemolytic strep.  She initially was
started on Rocephin which was changed to penicillin and
clindamycin.

On [**5-22**], she developed wheezing, hypoxia and shortness of
breath.  She was transferred to the Medical Intensive Care Unit.
She was intubated on the 7th.  Chest x-rays showed evidence of
pulmonary edema but she had a normal transthoracic
echocardiogram, normal ejection fraction and no evidence of
vegetations at the outside hospital.  She had a chest CT scan
that showed significant lymphadenopathy in the mediastinum,
axillae, retroperitoneum and supraclavicular regions with some
question of mediastinal fluid.

The patient has a distant history of a malar rash especially
related to photosensitivity, sun exposure.  Her [**Doctor First Name **] was positive
1 to 320 at the outside rheumatologist's office on the first. The
CRP and ESR were also elevated, CRP to 144 and the ESR to 74.
There was some concern at the outside hospital, but at [**Hospital1 1444**] her platelets were normal.  Her
INR was normal.   Her fibrinogen was 653.  On the date of
transfer to [**Hospital1 69**], the patient was
given one dose of intravenous IG at 36 grams times one.  On
transfer she was hemodynamically stable without need for
pressors.

PAST MEDICAL HISTORY:
1.  Hypothyroidism.
2.  Systemic lupus erythematosus.
No coronary artery disease, diabetes mellitus, pulmonary or
renal disease.

MEDICATIONS ON TRANSFER:
1.  Synthroid 50 micrograms intravenous q. day.
2.  Zantac intravenously q. 12.
3.  Heparin subcutaneously.
4.  Clindamycin 900 mg intravenous q. eight.
5.  Intravenous IG 36 grams times one.
6.  Ativan 2 to 4 grams intravenously.
7.  Morphine sulfate 2 to 4 gram intravenous p.r.n.
8.  At home the patient was taking Vioxx and Synthroid 100
micrograms q. day.

ALLERGIES:   The patient denies any allergies, however, the
patient did have a rash to Dilaudid at the outside hospital.

LABORATORY:  Microbiological data drawn on the [**5-20**], the
patient had four out of four bottles of Group A beta hemolytic
strep at the outside hospital.

EKG sinus tachycardia, normal axis, normal intervals.  The
patient had ultrasound of the left upper extremity which revealed
no deep venous thrombosis; this was on the [**5-20**] at the
outside hospital.

The patient had a chest x-ray at the outside hospital on [**4-23**]
with parenchymal changes consistent with low grade edema,
vascular engorgement, congestive heart failure. The patient had a
CT scan of the chest as noted on the 5th, adenopathy in
mediastinum, retroperitoneal, axilla, supraclavicular regions
with small pericardial effusion.  Possible question of
mediastinal fluid/mediastinitis.

Pertinent laboratory data at transfer:  Lyme serology negative.
Hepatitis B, Hepatitis C negative.  Parvovirus B19 negative.
Antistreptolysin 46, P-ANCA negative. Rheumatoid factor 19.  [**Doctor First Name **]
positive 1:320, homogenous, anticentromere antibody negative. CRP
1 in 44; ESR 74; antismooth antibody negative.  Ferritin 759.

Hemoglobin 9.1, hematocrit 27.4, white count 14.6 with 7 bands,
82 PMNs, one meta.  INR 1.2, platelets 196.  Sodium 131,
potassium 4.3, chloride 99, bicarbonate 21, anion gap 11, BUN 26,
creatinine 1.0, glucose 96.  Albumin 2, total bilirubin 1.0, SGOT
62, down from 200; SGPT 40, down from 131.

CBC from the outside hospital on the 4th: her white blood
cell count was 22 with 11 bands.  This decreased to 15.6 on
the day prior to transfer to 14.6 on the day of transfer.

Platelets on presentation were 219 the day prior to transfer,
196 on the day of transfer.  TSH was 12.8, T4 was 6.6.
Ventilation settings at the time of transfer was AC-550 by
14, 50%, PEEP of 5 with an arterial blood gas of 7.33, 44,
151.  She was on 15 of Propofol for sedation.

PHYSICAL EXAMINATION:   Pulse 78; blood pressure 120/70; 97%
on the above stated ventilator settings.  Her intakes and
outputs were roughly on presentation the first 12 hours one
liter in and one liter out.  Temperature at presentation was
99.8 F.; temperature maximum of 100.4 F.; she was sedated and
intubated.  She had erythema in her right neck
supraclavicular region as well as her left breast and left
medial aspect of her arm.  There is petechiae in her right
ankle.  There was swelling and warmth in her shoulder,
deltoid and axilla region on the left hand side.  Upon
palpation of these areas the patient would grimace, bite down
the ETT tube and become hypertension and tachycardic implying
pain in the region.  HEENT:  Pupils equally round and
reactive to light and accommodation.  Neck with no jugular
venous distention.  No bruit.  Lungs were clear to
auscultation anteriorly however, there were scattered wheezes
bilaterally.  Regular rate and rhythm.  S1, S2.  There is a I
to II systolic ejection murmur at the apex to axilla.
Abdomen was soft, normoactive bowel sounds, no
hepatosplenomegaly.  Abdomen was mildly distended.  Plus two
upper extremity edema in hands as well as plus one in the
feet.  As stated earlier, the patient was sedated.

Ventilator settings at [**Hospital1 69**]
on presentation were AC40%, 550 by 16, volume approximately
8.8, PEEP of 8.

ASSESSMENT:  This is a 48 year old woman with Group alpha beta
hemolytic strep sepsis transferred from the outside hospital.
She was hemodynamically stable, not on pressors, with report of
toxic shock syndrome but with normal renal and end-organ function
with the exception of Pulmonary status at presentation, with left
arm axilla pain at presentation.

HOSPITAL COURSE:
1.  BETA HEMOLYTIC STREP SEPSIS:  Unclear at the entry for
the source of the Group A beta hemolytic strep.  The patient
denies symptoms of pharyngitis, however, there were reports later
on after discussion with the patient of excoriations and possibly
a dermatological portal of entry.

The infectious disease service was consulted, and the patient was
continued on penicillin and Clindamycin until the [**2178-5-3**], at which time penicillin was discontinued. The patient's
white count decreased to 6.4 on the 18th with no bands and 76
PMNs.

Given the patient's pain and significant adenopathy and CT scan
from the outside hospital, it was felt that the left shoulder was
indeed the portal source for the bacteremia. The patient had an
MRI on the [**4-25**] which showed edema and enhancement about
the left shoulder girdle, prominent tracking along the subclavian
and axillary vessels and in the subacromial and subdeltoid bursa,
fat and along the superficial surface of the deltoid and within
the anterior fibers of the deltoid.  These findings are
consistent with inflammation making this highly suspicious for
soft tissue infection including focal myositis of the deltoid.

Both the Surgical and Orthopedic Teams felt that given the
patient's improvement clinically in terms of a white count and
examination of the left shoulder, that there was no indication to
have a surgical intervention.  There was no focal collection of
fluid and although the patient seemed to have evidence of mild
myositis, there was no evidence of necrotizing fasciitis on
clinical examination.

The patient will require a total of three weeks of Clindamycin,
at which time the patient should get a repeat MRI to evaluate the
left shoulder, and then follow-up at Infectious Disease clinic
with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].

2.  FEVER:  The patient's fever curve generally improved.
Although her baseline temperature was low grade 99 to 100.0
F., she had spike to 102.0 F.  Multiple blood cultures were
drawn.  The patient has blood cultures from the 19th, two
sets; 15th two sets; 12th two sets; 11th one set; 10th two
sets; 9th two sets.  Only positive cultures were coagulase
negative Staphylococcus on the [**2178-4-30**].

The patient had had a PICC line on the [**2178-4-27**].
This PICC line was associated with hypotension and ventricular
tachycardia.  The PICC line was placed at the bedside.  The
patient had runs of ventricular tachycardia with blood pressure
into the 80s.  The patient was bolused intravenous fluids.  The
line was pulled back 8 cm with resolution of the abnormal heart
rhythm.  Further x-ray was done which showed the tip of the
catheter PICC line still in the right ventricle.  This was pulled
back an additional 4 cm.  Due to the prolonged exposure of the
PICC line to the environment, when patient spiked on the 15th,
the PICC line was promptly removed.  However, the patient
continued to have fevers even after this line was discontinued.

Despite a general improvement in her swelling of her left arm
and left soft tissues, continued maintenance of a white count in
the 6.0 range as well as good urine output and no focal symptoms,
one possibility was the Clostridium difficile infection, the
patient did not have diarrhea and had two negative cultures for
Clostridium difficile on the 12th.  However, given the treatment
with clindamycin, this placed the patient at a high risk for
Clostridium difficile and it is noted that the patient should be
monitored for Clostridium difficile infections.  If she has any
continued fevers, high white counts or diarrheal symptoms, that
Clostridium difficile toxin should be sent and empiric coverage
with Flagyl should be considered.  A possible source of
the patient's fever was a reaction to beta lactate antibiotics,
particular penicillin.  The patient had a maculopapular rash on
her left arm as well as on her flanks associated with fever
spikes in the context of taking penicillin with her clindamycin.

The patient had a urine culture on the [**4-24**] which showed
extended spectrum beta lactamase E. coli.  Unclear whether this
was a colonizer or a pathogen but the patient had a Foley
catheter in place.  The patient was treated with Ciprofloxacin
for five days and repeat urine cultures thereafter were negative.

3.  HYPOXEMIC RESPIRATORY FAILURE:  The patient was intubated
at the outside hospital.  Shortly after being transferred to [**Hospital1 1444**], she was switched from AC to
pressure support and did well.  The patient eventually did well
on the spontaneous breathing trial.  The cuff was taken down and
the patient did not have a cuff leak around the balloon,
suggesting airway edema.  The patient also had expiratory
wheezes.  Given the patient's chest x-ray it was hypothesized the
wheezes might be secondary to volume overload as the patient
did not have any asthma history or reactive airway history.
The patient was given empiric treatment with intravenous
Lasix, but this did not improve the cuff leak around the ET tube.
However, it should be noted that the patient's pulmonary
edema/infiltrates that were reported at the outside hospital
improved as her infection improved after treatment course
progressed, most likely suggesting some degree of capillary leak
at the outside hospital.

The patient was brought to the Operating Room for extubation.
She had no supplemental oxygen requirement after four additional
days.

4.  SYSTEMIC LUPUS ERYTHEMATOSUS:  The patient has a past
medical history consistent with possible systemic lupus
erythematosus.

Please see the next discharge summary for further details
regarding the patient's continued care.



                            [**Name6 (MD) **] [**Name8 (MD) **], M.D.  [**MD Number(1) 4446**]

Dictated By:[**Last Name (NamePattern1) 1659**]
MEDQUIST36

D:  [**2178-5-5**]  14:50
T:  [**2178-5-5**]  16:50
JOB#:  [**Job Number 48209**]


Admission Date:  [**2178-4-23**]       Discharge Date:  [**2178-5-6**]

Date of Birth:   [**2129-5-19**]       Sex:  F

Service:

ADDENDUM:  The previous dictation was cut off at hospital
course, point being systemic lupus erythematosus.

HOSPITAL COURSE BY ISSUE/SYSTEM (CONTINUED):

1.  SYSTEMIC LUPUS ERYTHEMATOSUS ISSUES:  The patient has
numerous parts of her medical history consistent with
systemic lupus erythematosus including joint pain,
photophobic rash, positive antinuclear antibody, pericardial
effusion on the outside hospital computerized axial
tomography, and proteinuria on her initial urinalysis.

However, further urinalysis showed only trace protein when
the patient was not afebrile.  The initial urinalysis showed
protein; however, the patient was febrile at that time.
Antinuclear antibody of 1:1280, being very suspicious for
connective tissue disease; although, this was in the context
of an acute infection.  The patient's streptolysin was very
elevated; consistent with a strep infection at the patient's
presentation.  BSI and anti-SNRP/anti-double stranded DNA
antibodies were negative.  However, the patient will require
further outpatient workup regarding systemic lupus
erythematosus.  The patient had seen a rheumatologist as an
outpatient prior to admission at the outside hospital, who
discussed with the patient the need for followup regarding
this matter when she leaves rehabilitation and is over her
acute infection so further laboratory work and examination
can be done.

2.  LYMPHADENOPATHY ISSUES:  The patient had a computerized
axial tomography on presentation with a very impressive
lymphadenopathy.  This needs to be re-evaluated as an
outpatient following the resolution of her acute infection.
The differential diagnosis included connective tissue disease
or malignancy; however, it was most likely secondary to an
acute infection the patient presented with as well as the
toxic shock-like syndrome that was prior to this infection.

3.  ANEMIA ISSUES:  The patient presented from an outside
hospital with a hematocrit of approximately 27.  Her ferritin
was markedly elevated; making iron studies in the acute
setting of an acute phase reactant less than useful on the
presentation to [**Hospital1 69**].

When she presented, there was some question of whether her
low blood count could be secondary to hemolysis secondary to
the toxic shock-like syndrome of her strep infection;
however, her total bilirubin was not elevated.  Her LDH was
within normal limits.  Her haptoglobin was also normal.   It
was possible that her anemia is possibly secondary to
systemic lupus erythematosus or possible hemolysis that
occurred prior to presentation to [**Hospital1 190**].  Her nadir was 23.6 in the Medical Intensive
Care Unit.  Her hematocrit was 26.8 on [**5-5**] without a
transfusion.

4.  ACCESS ISSUES:  The patient initially came with
peripheral intravenous lines and was noted to require
long-term intravenous antibiotics.  The peripherally inserted
central catheter mentioned earlier was placed at the bedside
and was removed.  Later a peripherally inserted central
catheter was placed under Interventional Radiology on [**5-5**]
without complications.  The tips from the peripherally
inserted central catheter line that was removed did not grow
out any organisms.

While intubated, the patient received tube feeds.  Status
post extubation, the patient was able to take normal oral
intake and did not have any problems swallowing pills, or
solids, or liquids and was leaving the hospital on a regular
oral intake diet.

5.  COMMUNICATION ISSUES:  The patient's primary care
physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 48210**] was called regarding her
presentation and course by the Medical Intensive Care Unit
intern.

Also, the patient's family was frequently informed about not
only her condition but plan, and general outlook, and
followup regarding the patient's care.

6.  PROPHYLAXIS ISSUES:  The patient was initially on
lansoprazole solution via orogastric tube.  This was changed
to famotidine 20 p.o. twice per day when she was taking oral
intake.  She was subcutaneous heparin three times per day and
then was getting physical therapy status post extubation.

The patient was transferred to the floor on [**2178-5-4**] with
a disposition to a [**Hospital 3058**] rehabilitation.

DISCHARGE DIAGNOSES:
1.  Group A beta-hemolytic strep sepsis.
2.  Soft tissue infection of the left shoulder.
3.  Possible systemic lupus erythematosus.
4.  Diffuse lymphadenopathy.
6.  Mediastinal retroperitoneum, subauricular region axilla.
7.  Fever likely secondary to a febrile reaction from
beta-lactam antibiotic; specifically penicillin.
8.  Hypoxic respiratory failure; status post intubation and
extubation.

MEDICATIONS ON DISCHARGE:
 1.  Clindamycin 900 mg intravenously q.8h. (to complete
three weeks of treatment).
 2.  Usaryn apply twice per day to affected area.
 3.  Ibuprofen 600 mg p.o. q.8h. as needed.
 4.  Levothyroxine sodium 100 mcg p.o. once per day.
 5.  Albuterol/ipratropium bromide nebulizer solution inhaled
q.6h. as needed.
 6.  Albuterol 1 to 2 puffs inhaled q.6h. as needed.
 7.  Combivent meter-dosed inhaler q.6h. as needed.
 8.  Atarax 25 mg p.o. q.4-6h. as needed (for itching).
 9.  Senna one tablet p.o. twice per day as needed.
10.  Tylenol 325 mg to 650 mg p.o. q.4-6h. as needed (for
fever).
11.  Heparin 5000 units subcutaneously q.8h. (for deep venous
thrombosis prophylaxis if the patient is not ambulating).

DISCHARGE INSTRUCTIONS/FOLLOWUP:
1.  The patient was instructed regarding the need for
intravenous antibiotics and then follow up with a magnetic
resonance imaging as an outpatient after she is finished with
her antibiotic course and then follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
at the Infectious Disease Clinic at [**Hospital1 190**] approximately one week after the magnetic
resonance imaging.
2.  The patient was also instructed to follow up with her
rheumatologist as an outpatient following her discharge from
[**Hospital 3058**] rehabilitation.
3.  The patient was also instructed to follow up with her
primary care physician to help coordinate her care regarding
these subspecialty matters.





                            [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3090**], M.D.
[**MD Number(1) 3091**]

Dictated By:[**Last Name (NamePattern1) 1659**]
MEDQUIST36

D:  [**2178-5-5**]  15:04
T:  [**2178-5-5**]  16:57
JOB#:  [**Job Number 48211**]


Name:  [**Known lastname **], [**Known firstname **] A                       Unit No:  [**Numeric Identifier 8902**]

Admission Date:  [**2178-4-23**]     Discharge Date:  [**2178-5-10**]

Date of Birth:   [**2129-5-19**]     Sex:  F

Service:

This addendum is to the original Intensive Care Unit dictation.
These are the events on the Medical floor.

When the patient got to the Medical floor, blood cultures were
obtained on [**2178-5-4**].  When these blood cultures were negative
for 24 hours, a PICC line was placed so that the patient could
get IV clindamycin.  The patient continued to have fevers of 101
and persistent left shoulder pain. Therefore, a MRI of the left
shoulder was reimaged showing interval decrease in extensive
edema and enhancement surrounding the left rotator cuff muscles
and left deltoid muscle.  There is a slight increase in the
enhancement of synovium in the joint capsule and plenty amount of
fluid in the joint has not increased in the interval since the
last MRI of the left shoulder.

Patient was sent down to Interventional Radiology for possible
tap of the left shoulder, but the tap was not successful.  The
Infectious Disease team was reconsulted, and they felt that the
patient could be switched over to po clindamycin for three weeks.
The patient's left shoulder then did improve after the imaging of
it.  However, her fevers persist.

A chest x-ray was obtained showing no evidence of pneumonia.
Urine culture was obtained which showed mixed bacterial flora.
Her fevers were felt secondary to possible lupus or a healing
myositis.  She is to have followup with Rheumatology on an
outpatient basis for her lupus and continue on her oral
clindamycin until she follows for her infectious disease doctor,
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3769**].  She is also to have a reimaging of her left
shoulder prior to seeing her infectious disease doctor.  She was
instructed to return if any further additional persistent fevers
or increasing pain in the left shoulder.

DISCHARGE DIAGNOSES:
1. Group A beta hemolytic Streptococcus bacteremia.
2. Hypoxic respiratory failure / adult respiratory distress
syndrome.
3. Lupus.
4. Anemia of chronic disease.
5. Hypothyroidism.

DISCHARGE MEDICATIONS:
1. Levothyroxine 100 mcg po q day.
2. Clindamycin 450 mg po qid through [**2178-5-25**].
3. Hydroxyzine 25 mg po q4-6h prn pruritus.

DISCHARGE CONDITION:  Stable.

DISCHARGE STATUS:  Home.

FOLLOWUP:
1. The patient is to followup with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in
Infectious Disease on [**2178-5-25**] at 1:30 pm on [**Hospital Ward Name 257**] 11th
floor, phone #[**Telephone/Fax (1) 496**].
2. The patient is to followup with Dr. [**Last Name (STitle) 8903**] in
Rheumatology on [**2178-7-9**] at 1 pm on the [**Hospital **] Medical
Building, Fourth Floor,  [**Hospital Unit Name 8904**], phone #[**Telephone/Fax (1) 8905**].
3. The patient is to schedule a followup MRI prior to seeing
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3769**].




                                   [**Name6 (MD) 1034**] [**Name8 (MD) 1035**], M.D.

Dictated By:[**Last Name (NamePattern1) 4387**]

MEDQUIST36

D:  [**2178-5-12**]  12:28
T:  [**2178-5-12**]  13:12
JOB#:  [**Job Number 8906**]
{'Streptococcal septicemia,Other shock without mention of trauma,Infective myositis,Urinary tract infection, site not specified,Systemic lupus erythematosus,Other specified cardiac dysrhythmias'}


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: Miss [**Known lastname **] is a 48 year old woman
with a past medical history of hypothyroidism carrying the
diagnosis of systemic lupus erythematosus who presents from
[**Hospital3 35813**] Center in [**Doctor Last Name 792**]with Group A beta
hemolytic Strep sepsis, rash, anopsia, myalgia, arthralgia and
hypoxia, and respiratory failure requiring intubation.

MEDICAL HISTORY: 1.  Hypothyroidism.
2.  Systemic lupus erythematosus.
No coronary artery disease, diabetes mellitus, pulmonary or
renal disease.

MEDICATION ON ADMISSION: 

ALLERGIES: The patient denies any allergies, however, the
patient did have a rash to Dilaudid at the outside hospital.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Streptococcal septicemia,Other shock without mention of trauma,Infective myositis,Urinary tract infection, site not specified,Systemic lupus erythematosus,Other specified cardiac dysrhythmias'}
