CHIEF COMPLAINT: Presents for elective surgical repair of a right flank hernia.

PRESENT ILLNESS: Mr. [**Known lastname 46422**] is a 63 year old male who presented to [**Hospital1 18**] on
[**10-13**] for elective surgical repair of a right flank hernia by
Dr. [**Last Name (STitle) **]. He has a past medical history significant for
multiple myeloma and is s/p a decompressive laminectomy
complicated by a wound infection and a radiated field requiring
an omental graft which went off the abdominal wall on the right
side. A CT scan  demonstrated a large hernia in the abdominal
wall on the lateral aspect, with a defect of 5cm.

MEDICAL HISTORY: Past Medical History:

MEDICATION ON ADMISSION: Oxycontin
Oxycodone
Lasix
Potassium
Glyburide
Amiodarone
Depakote
Advair
Neurontin
Protonix
Bactrim
Synthroid

ALLERGIES: Tape

PHYSICAL EXAM: 

FAMILY HISTORY: Mother-breast cancer
[**Name (NI) 46425**], died MI age 32
Twin brother with no medical problems
[**Name (NI) 8765**] CAD

SOCIAL HISTORY: The patient lives with his fiance in [**Hospital1 1474**].
He quit smoking 2 yrs ago, smoked 1.5 ppd x 30 yrs.
He currently drinks infrequently; he formerly drank 30
beers/weekend
He denies h/o IVDU.
Hernia of other specified sites without mention of obstruction or gangrene,Multiple myeloma, without mention of having achieved remission,Other nervous system complications,Atrial fibrillation,Acute respiratory failure,Septicemia due to escherichia coli [E. coli],Meningitis due to gram-negative bacteria, not elsewhere classified,Severe sepsis,Other postoperative infection,Cauda equina syndrome with neurogenic bladder,Chronic osteomyelitis, other specified sites,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Intervertebral disc disorder with myelopathy, lumbar region,Fitting and adjustment of cardiac pacemaker,Unspecified hereditary and idiopathic peripheral neuropathy,Long-term (current) use of anticoagulants,Personal history of venous thrombosis and embolism,Personal history of irradiation, presenting hazards to health,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Infection with microorganisms resistant to penicillins,Encephalopathy, unspecified
Hernia NEC,Mult mye w/o achv rmson,Surg comp nerv systm NEC,Atrial fibrillation,Acute respiratry failure,E coli septicemia,Mningts gram-neg bct NEC,Severe sepsis,Other postop infection,Neurogenic bladder,Chr osteomyelit NEC,DMII wo cmp nt st uncntr,Lumb disc dis w myelopat,Ftng cardiac pacemaker,Idio periph neurpthy NOS,Long-term use anticoagul,Hx-ven thrombosis/embols,Hx of irradiation,Mth sus Stph aur els/NOS,Inf mcrg rstn pncllins,Encephalopathy NOS
Admission Date:  [**2150-10-13**]              Discharge Date:   [**2150-11-10**]

Date of Birth:  [**2086-10-30**]             Sex:   M

Service: SURGERY

Allergies:
Tape

Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Presents for elective surgical repair of a right flank hernia.

Major Surgical or Invasive Procedure:
[**10-13**]  Right flank hernia repair with mesh
[**10-14**] L3 laminectomy with scar tissue excision

History of Present Illness:
Mr. [**Known lastname 46422**] is a 63 year old male who presented to [**Hospital1 18**] on
[**10-13**] for elective surgical repair of a right flank hernia by
Dr. [**Last Name (STitle) **]. He has a past medical history significant for
multiple myeloma and is s/p a decompressive laminectomy
complicated by a wound infection and a radiated field requiring
an omental graft which went off the abdominal wall on the right
side. A CT scan  demonstrated a large hernia in the abdominal
wall on the lateral aspect, with a defect of 5cm.

Past Medical History:
Past Medical History:

1. Multiple Myeloma: diagnosed [**1-/2147**]; has been on monthly
IVIG, thalidomide, on decadron in past.  Monthly IVIG
required for frequent chronic infections.
2.  Recurrent pna, including MRSA (most recenly [**2148-12-2**])
3.  Atrial Arrhythmias (afib/flutter/sinus brady, s/p pacemaker
placement
4. ?MI [**8-16**]; TTE [**3-17**]- EF=50%, 1+ MR, 1+ TR, trace AR
              P-MIBI [**9-16**]: EF=51%, nl perfusion
5. LE DVT, on chronic coumadin therapy
6. DM
7. ?CVA with right-sided paresis, slurred speech, ?seizure
activity

Past Surgical History:

L4-S1 laminectomy, c/b MRSA infection of incision site

Social History:
The patient lives with his fiance in [**Hospital1 1474**].
He quit smoking 2 yrs ago, smoked 1.5 ppd x 30 yrs.
He currently drinks infrequently; he formerly drank 30
beers/weekend
He denies h/o IVDU.


Family History:
Mother-breast cancer
[**Name (NI) 46425**], died MI age 32
Twin brother with no medical problems
[**Name (NI) 8765**] CAD

Pertinent Results:
Post-operative:

[**2150-10-13**] 09:55PM BLOOD WBC-14.9*# RBC-3.91* Hgb-12.3* Hct-37.4*
MCV-96 MCH-31.5 MCHC-32.9 RDW-15.8* Plt Ct-180
[**2150-10-13**] 09:55PM BLOOD Plt Ct-180
[**2150-10-13**] 09:55PM BLOOD Glucose-100 UreaN-7 Creat-0.8 Na-138
K-3.8 Cl-104 HCO3-26 AnGap-12
[**2150-10-13**] 09:55PM BLOOD CK(CPK)-69 AlkPhos-69
[**2150-10-21**] 05:18AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2150-10-13**] 09:55PM BLOOD Calcium-7.9* Phos-3.1 Mg-1.8
[**2150-10-13**] 10:55PM BLOOD Lactate-0.8
[**2150-10-14**] 08:02PM BLOOD freeCa-1.03*

Discharge:

[**2150-11-8**] 05:42AM BLOOD WBC-6.7 RBC-3.21* Hgb-9.8* Hct-29.7*
MCV-93 MCH-30.7 MCHC-33.1 RDW-16.7* Plt Ct-403
[**2150-11-10**] 05:07AM BLOOD PT-16.1* PTT-31.3 [**Month/Day/Year 263**](PT)-1.5*
[**2150-11-8**] 05:42AM BLOOD Glucose-90 UreaN-19 Creat-0.6 Na-139
K-4.0 Cl-108 HCO3-24 AnGap-11
[**2150-10-22**] 04:02AM BLOOD ALT-16 AST-15 AlkPhos-66 Amylase-44
TotBili-0.7
[**2150-11-8**] 05:42AM BLOOD Calcium-8.5 Phos-3.2 Mg-2.2
[**2150-11-6**] 04:39AM BLOOD Valproa-60
[**2150-11-2**] 06:03AM BLOOD Valproa-14*

[**2150-10-21**] 5:21 am BLOOD CULTURE

                            **FINAL REPORT [**2150-10-27**]**

   AEROBIC BOTTLE (Final [**2150-10-27**]):
      ESCHERICHIA COLI.    FINAL SENSITIVITIES.
         WORK-UP SENSITIVITY FOR BACTRIM PER DR. [**First Name (STitle) **],[**Doctor Last Name **]
PAGER (
         [**Numeric Identifier 21494**]).
         Trimethoprim/Sulfa sensitivity testing confirmed by
[**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].

ANAEROBIC BOTTLE (Final [**2150-10-23**]):
      REPORTED BY PHONE TO [**Doctor Last Name **],VALESCA- CC5B [**Numeric Identifier 24691**]- @ 1653 ON
[**2149-10-21**].
      ESCHERICHIA COLI.    SENSITIVITIES PERFORMED FROM AEROBIC
BOTTLE.
[**2150-10-21**] 3:00 pm CSF;SPINAL FLUID     Site: LUMBAR PUNCTURE
      TUBE 3.

   GRAM STAIN (Final [**2150-10-23**]):
      REPORTED BY PHONE TO VALESKA ARTIS @ 8PM ON [**2150-10-21**].
      4+   (>10 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      2+   (1-5 per 1000X FIELD):   GRAM NEGATIVE ROD(S).
      SMEAR REVIEWED; RESULTS CONFIRMED.

   FLUID CULTURE (Final [**2150-10-27**]):
      ESCHERICHIA COLI.    RARE GROWTH.
         Trimethoprim/Sulfa sensitivity testing available on
request.
         BACTRIM (=SEPTRA=SULFA X TRIMETH) Susceptibility
testing requested
         by DR. [**Last Name (STitle) **] ([**Numeric Identifier 21494**]) [**2150-10-25**].  SENSITIVE TO AMIKACIN <=
2MCG/ML.
         Trimethoprim/Sulfa sensitivity testing performed by
[**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ESCHERICHIA COLI
                             |

   VIRAL CULTURE (Preliminary):    No Virus isolated so far.

[**2150-10-22**] 1:40 pm SWAB      LUMBAR SPINE WOUND.

                            **FINAL REPORT [**2150-10-26**]**

   GRAM STAIN (Final [**2150-10-22**]):
      THIS IS A CORRECTED REPORT ([**2150-10-23**]).
      REPORTED BY PHONE TO DR [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 46426**] [**2150-10-23**] AT 4PM.
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      1+    (<1 per 1000X FIELD):   GRAM NEGATIVE ROD(S).
                                   .
      PREVIOUSLY REPORTED AS.
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      1+    (<1 per 1000X FIELD):   GRAM NEGATIVE ROD(S).
      1+    (<1 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND CLUSTERS
([**2150-10-22**]).

   WOUND CULTURE (Final [**2150-10-24**]):
      ESCHERICHIA COLI.    SPARSE GROWTH.
         IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 46427**]
         ([**2150-10-21**]).

   ANAEROBIC CULTURE (Final [**2150-10-26**]):    NO ANAEROBES ISOLATED.


[**2150-10-23**] 3:30 pm BLOOD CULTURE

                            **FINAL REPORT [**2150-10-29**]**

   AEROBIC BOTTLE (Final [**2150-10-29**]):    NO GROWTH.

   ANAEROBIC BOTTLE (Final [**2150-10-29**]):    NO GROWTH.

   ANAEROBIC BOTTLE (Final [**2150-10-30**]):
      REPORTED BY PHONE [**Male First Name (un) 46428**] AT 2100 ON [**10-26**]..
      STAPHYLOCOCCUS, COAGULASE NEGATIVE.    ISOLATED FROM ONE
SET ONLY.
         WORK-UP SENSITIVITY PER DR. [**First Name (STitle) **],[**Doctor Last Name **] PAGER
([**Numeric Identifier 21494**]) [**2150-10-28**].
         Oxacillin RESISTANT Staphylococci MUST be reported as
also
         RESISTANT to other penicillins, cephalosporins,
carbacephems,
         carbapenems, and beta-lactamase inhibitor combinations.

         Rifampin should not be used alone for therapy.
VANCOMYCIN------------   <=1 S

[**2150-10-26**] 10:39 am MRSA SCREEN     Site: RECTAL
      Source: Rectal swab.

                            **FINAL REPORT [**2150-10-28**]**

   MRSA SCREEN (Final [**2150-10-28**]):    No MRSA isolated.

[**2150-10-27**] 10:00 am CSF;SPINAL FLUID      TUBE 3.

   GRAM STAIN (Final [**2150-10-27**]):
      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
      NO MICROORGANISMS SEEN.

   FLUID CULTURE (Final [**2150-10-30**]):    NO GROWTH.

   VIRAL CULTURE (Preliminary):    No Virus isolated so far.

   ANAEROBIC BOTTLE (Final [**2150-11-4**]):    NO GROWTH.

[**2150-10-29**] 5:03 am STOOL     CONSISTENCY: SOFT      Source: Stool.


                            **FINAL REPORT [**2150-10-29**]**

   CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2150-10-29**]):
      FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
      Reference Range:  Negative.

[**2150-10-31**] 11:50 pm BLOOD CULTURE

                            **FINAL REPORT [**2150-11-7**]**

   AEROBIC BOTTLE (Final [**2150-11-7**]):    NO GROWTH.

   ANAEROBIC BOTTLE (Final [**2150-11-7**]):    NO GROWTH.

[**2150-11-1**] 1:24 am BLOOD CULTURE      LINE  R-CVL.

                            **FINAL REPORT [**2150-11-7**]**

   AEROBIC BOTTLE (Final [**2150-11-7**]):    NO GROWTH.

   ANAEROBIC BOTTLE (Final [**2150-11-7**]):    NO GROWTH.

[**2150-11-2**] 10:09 pm STOOL     CONSISTENCY: SOFT

                            **FINAL REPORT [**2150-11-3**]**

   CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2150-11-3**]):
      FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
      Reference Range:  Negative.

[**2150-11-10**] 8:24 am STOOL     CONSISTENCY: SOFT      Source: Stool.


                            **FINAL REPORT [**2150-11-10**]**

   CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2150-11-10**]):
      FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
      Reference Range:  Negative.
OPERATIVE REPORT
[**Last Name (LF) **],[**First Name3 (LF) **] F.
Signed Electronically by [**Last Name (LF) **],[**First Name3 (LF) **] on [**Doctor First Name **] [**2150-10-15**]
11:09 AM

Name:  [**Known lastname **], [**Known firstname **]             Unit No:  [**Numeric Identifier 46429**]

Service:                          Date:  [**2150-10-13**]

Date of Birth:  [**2086-10-30**]        Sex:  M

Surgeon:  [**First Name11 (Name Pattern1) 333**] [**Last Name (NamePattern4) 366**], MD 2205

PREOPERATIVE DIAGNOSIS:  Flank hernia.

POSTOPERATIVE DIAGNOSES:  Flank hernia.

PROCEDURE:  Repair of flank hernia with mesh and division of
omental graft.

ASSISTANT:  Dr. [**First Name (STitle) **]

ANESTHESIA:  General.

INDICATION:  This gentleman has had multiple operations for
problems of myeloma decline. Most recently, he had an omental
graft which was harvested from the intra-abdominal cavity,
brought out through a flank wound and into an open wound of
the back. This was several years ago and allowed this would
to heal. Unfortunately, he has developed a hernia in this
area. He presents now for repair. The hernia itself was large
and bothersome but, more importantly, it is very large and
contains a fair amount of small and large intestine, through
a relatively [**Name2 (NI) 15403**] defect.  This does place him at risk for
incarceration or strangulation.

PREPARATION:  In the operating room, the patient was given
general endotracheal anesthetic. Intravenous antibiotics were
given. Catheter was placed into the bladder. The patient was
placed in the left lateral decubitus position, prepared with
Betadine solution and draped in the usual fashion.

INCISION:  The incision was opened along the inferior aspect
of one of the V-Y advancement incisions and carried down to
the subcutaneous tissue.

FINDINGS:  There was quite a large hernia sac. The defect
itself was [**Name2 (NI) 15403**] in size. One portion of the defect was the
anterior superior iliac spine. The omental graft went through
this defect.

PROCEDURE IN DETAIL:  The sac was dissected away from the
surrounding tissue. We were then able to find the omental
graft and dissect the surrounding tissues away from the edge
of the fascial defect and bone defect. We took care to stay
in a relatively extraperitoneal plane here and there was
certainly adequate amount of coverage of the bowel and its
contents with peritoneum such that we could use normal graft
material. The omental graft was then divided and a section of
it was removed. We thought that this would be perfectly
reasonable as the defect could not be closed without removing
it without a high-risk of recurrence and also that the tissue
had already experienced inset for the past several years and
was vascularized with surrounding focal vasculature.
Therefore, the graft was divided with clamps and ties of 2-0
Vicryl. The defect was then measured and we placed a Marlex
patch as an underlay with a lot of underlay, measuring at
least 3 to 5 cm underneath the fascial edges. We began the
most anterior part and ran these around with running full-
thickness mattress sutures. The repair was done under some
tension in order to have the edges come together nicely
which, indeed, they did. The tension was not excessive and
came together very well. We then finished the closure by
placing 4 Mitek anchors into the bone. These were attached to
number one sutures which were then sutured to the vasculature
to close off that portion of the defect. The area was then
inspected for hemostasis which was quite adequate.

CLOSURE:  The sac tissue was closed over the top of this in
order to exclude it from the wound and also to decrease
seroma formation. This was done with running suture of #2-0
PDS. The subcutaneous tissue was closed with interrupted
sutures of 2-0 Vicryl. Dermal sutures of 3-0 Vicryl were then
placed and a running subcuticular suture of 4-0 Monocryl was
then placed to close the skin.  A dry sterile dressing was
then applied. The patient was then extubated and sent to the
recovery area in satisfactory condition, having tolerated the
procedure well.

DRAINS:  None.

COMPLICATIONS:  None.

ESTIMATED BLOOD LOSS:  Minimal.

[**First Name11 (Name Pattern1) 333**] [**Last Name (NamePattern4) 366**], [**MD Number(1) 367**]
 OPERATIVE REPORT

[**Last Name (LF) **],[**First Name3 (LF) **] J.
Signed Electronically by [**Last Name (LF) **],[**First Name3 (LF) **] J on MON [**2150-10-19**] 8:17
AM

Name:  [**Known lastname **], [**Known firstname **]             Unit No:  [**Numeric Identifier 46429**]

Service:  [**Last Name (un) **]                     Date:  [**2150-10-14**]

Date of Birth:  [**2086-10-30**]        Sex:  M

Surgeon:  [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 1352**] [**Numeric Identifier 46430**]

ASSISTANT:  [**First Name5 (NamePattern1) 4468**] [**Last Name (NamePattern1) 46431**]

PREOPERATIVE DIAGNOSIS:
1.  Cauda equina syndrome.
2.  Previous lumbar decompression.
3.  Diskitis.
4.  Vertebral osteomyelitis.
5.  Multiple myeloma involving the lumbar spine.
6.  History of a dural tear.
7.  History of a previous omental flap.

POSTOPERATIVE DIAGNOSIS:  Severe stenosis at lumbar spine at
L3-L4.

PROCEDURE:  Revision decompression of the lumbar spine from
L2-L3 to L5-S1.

INSTRUMENTATION:  None.

ANESTHESIA:  General endotracheal.

FLUIDS:  3300 cc.

ESTIMATED BLOOD LOSS:  450 cc.

URINE OUTPUT:  450 cc.

DRAINS:  Two medium Hemovac drains placed deep in the wound.

SPECIMENS:  Both bone and soft tissue were sent for both
pathology and microbiology.

FINDINGS:  Severe stenosis at L3-L4 as well as to some degree
at L4-L5. Significant dural scar tissue. Well vascularized
omental flap.

COMPLICATIONS:  None.

SPONGE COUNT:  Correct.

INDICATIONS:  This is a 63 year-old gentleman who [**Last Name (NamePattern1) 1834**]
elective procedure involving the repair of a flank hernia
from a previous omental flap to cover a lumbar wound. He has
a complicated history with underlying multiple myeloma of the
lumbar spine as well as previous lumbar decompression
complicated by diskitis and osteomyelitis as well as a dural
tear and revision surgery. Postoperatively from the hernia
repair he had progressive weakness of his right leg greater
than his left leg as well as loss of rectal tone. A CT
myelogram was performed as he could not have an MRI because
of a pacemaker. CT myelogram showed cutoff at the L3 level.
There was no reconstitution of the dye column below the L3
level.
Based on these findings as well as clinical findings he was
taken to the operating room that night 1 day following repair
of his hernia. Consents were signed by his health proxy, his
[**Name2 (NI) 18933**] secondary to the being intubated and sedated. Due to
the severity of the clinical findings as well as the CT
myelogram it was felt that this was adequate although not
optimal.

PROCEDURE:  Consent was obtained as above. The patient was
given 1 gram of Vancomycin, was brought back to the operative
theater and placed prone on the [**Location (un) 1661**] frame. All bony
prominences were carefully padded. His lumbar spine was
prepped and draped sterilely in the usual fashion. He had
significant scar tissue on his back from his previous omental
flap and resections. The previous incision was incised and
extended proximally slightly about 4 cm. This was taken down
to known tissue and what was thought to be the L2 spinous
process based on his CT scan. The paraspinal muscles were
dissected off the L2 spinous process. The omental flap was
incised and was found to be well perfused. The lamina of L2
as well as the L2-3 facet was identified. The partial L3
spinous process was then dissected and soft tissue was
stripped from that. The bony anatomy in either gutter was
identified down to what was thought to be L5. A lateral
radiograph confirmed the levels.  At that point
an L3 laminectomy was performed as well as L2-L3
decompression. The L3 pedicles were well visualized. The L2-
L3 foramen was felt and felt to be open. The bilateral L3
pedicles were directly visualized and the L3 exiting nerve
roots were visualized after freeing up the scar tissue. This
was continued distally. The L4 pedicles were visualized after
freeing up the scar tissue from the lateral gutters. The
dural sac was freely mobile below that. The L5 pedicles were
then visualized bilaterally. On the left side there appeared
to be no bone laterally that could be stripped of soft tissue
as was consistent with the CT scan. On the right side there
was bony tissue visualized and the L5 pedicle was visualized
at that point. The dural sac at that point was felt to be
freely mobile without significant
posterior compression. Significant ligamentum flavum and
hypertrophic ligamentum flavum had been removed at the L3-L4
level. The discs and ventral dural sack could be
examined at the L3-4 level to some degree. Below this
it was felt that the risks of a dural tear were too high versus
looking for a ventral lesion.  Hemostasis was maintained.
Copious
irrigation was
used. Two drains were placed. The deep tissue was closed with
interrupted #0 Vicryls. The subcutaneous with #2-0 Vicryls
and the skin with staples. Patient was placed supine and
taken to the Intensive Care Unit without complications.

 [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 1352**] 20-ACN

OPERATIVE REPORT

[**Last Name (LF) **],[**First Name3 (LF) **] J.
Signed Electronically by [**Last Name (LF) **],[**First Name3 (LF) **] J on TUE [**2150-10-27**] 8:52
AM

Name:  [**Known lastname **], [**Known firstname **]             Unit No:  [**Numeric Identifier 46429**]

Service:                          Date:  [**2150-10-22**]

Date of Birth:  [**2086-10-30**]        Sex:  M

Surgeon:  [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 1352**] [**Numeric Identifier 46430**]

ASSISTANT:  [**First Name8 (NamePattern2) 803**] [**Last Name (NamePattern1) **]

PREOPERATIVE DIAGNOSIS:
1.  Infected posterior lumbar wound with persistent dural
    leak.
2.  Multiple myeloma involving L5 and S1.
3.  Status post previous L2-L3 to  L5-S1 lumbar decompression
    and revision decompression.
4.  Status post wound dehiscence with omental flap,
    persistent dural leak and infection.
5.  Cauda equina.

POSTOPERATIVE DIAGNOSIS:
1.  Infected posterior lumbar wound with persistent dural
    leak.
2.  Multiple myeloma involving L5 and S1.
3.  Status post previous L2-L3, L5-S1 lumbar decompression
    and revision decompression.
4.  Status post wound dehiscence with omental flap,
    persistent dural leak and infection.
5.  Cauda equina.

PROCEDURE:
1.  Incision and debridement lumbar wound.
2.  Laminotomy, right side at L2.
3.  Dural repair.

INSTRUMENTATION:  None.

ANESTHESIA:  General endotracheal.

FLUIDS:  1500 cc.

ESTIMATED BLOOD LOSS:  250 cc.

URINE OUTPUT:  580 cc.

DRAINS:  Two medium Hemovacs placed deep.

SPECIMENS:
1.  Two specimens were sent to Microbiology.
2.  One specimen was sent to Pathology which was deep tissue.

FINDINGS:
1.  Large fluid collection just above the dura.
2.  A dural tear that was the size of approximately a 20
    gauge needle tip on the right side at the level of the
    inferior aspect of the L2 lamina as predicted on CT
    based on CT myelogram.

COMPLICATIONS:  None.

SPONGE COUNT:  Correct.

X-ray showing no retained hardware.

INDICATIONS:  This is a 63 year old gentleman who I
previously did a revision L2-L3 to L5-S1 decompression for
cauda equina.  He did quite well in the postoperative period.
He regained his quad strength on his right and left side,
although nothing distal to that.  He was even scheduled and
considered for rehabilitation placement.  However, he
developed mental status changes on postoperative day 6 and
was intubated for fevers.  He became septic.  Blood cultures
grew out gram-negative rods.  The a spiral chest CT was
negative.  Chest x-ray was negative.  UA was negative.  CT of
the head was also negative.  Meningitis was considered,
although I thought it was unlikely.  A lumbar puncture was
positive for significant number of white cells as well as
protein without glucose.  Gram-negative rods were also seen
in the lumbar puncture.  An aspiration of a fluid collection
on a new CT of his lumbar spine also showed gram-negative
rods.  Beta-2 transferrin levels were pending.  On review
with the radiologist, the previous CT monitoring done on
[**10-16**], there is a dural leak that was not previously
present.  At that time, there was no posterior fluid
collection.  Secondary to the fact that there was a fluid
collection in his lumbar spine as well as gram negative rods,
he was consented through his fiance for an I and D of his
lumbar spine and at this point also could address the
persistent dural leak.

PROCEDURE:  The patient was brought from the trauma intensive
care unit intubated to the OR.  He was placed on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1661**]
table, bony prominences carefully padded.  The staples were
removed.  His lumbar wound was prepped and draped sterilely
in the usual fashion.  The incision was opened.  All Vicryl
sutures were removed.  This was taken down through the dura.
The skin edges as well as the superficial and deep tissues
from the wounds were freshened using curet, Leksells, back to
bleeding tissue.  Hemostasis was then obtained.  The deep
bone in the bilateral gutters were cleaned of soft tissue and
previous Gelfoam.  Copious pulse lavage was used including 9
liters of fluid after tissue resection had taken place.

The dural leak was exactly where it was predicted by the
radiologist which was on the right side just at the inferior
surface of the L2 lamina.  There was a poke hole and no other
area of leakage was noted.  A laminotomy was taken at L2 to
fully expose the leakage.  Copious irrigation was used.  When
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] was placed on this hole, no other area of leakage
could be identified.  At that time,  Duragen was placed over
this hole and then Tisseel was used over the Duragen.  At
this point, the wound was closed with interrupted 0 Vicryls
after medium Hemovacs were placed deep to this.  2-0 Vicryls
were used in the subcutaneous tissue.  The scar was removed
and the skin was closed with horizontal mattress 2-0 nylons.
Cultures had been taken as well as a piece of tissue from the
deep layer to Pathology.  Xeroform was placed and a sterile
dressing was placed.  The patient was placed supine on a
regular bed and taken back to the trauma intensive care unit.
I talked specifically to the team.  He is to stay flat for at
least 3 days.  He is to undergo DVT prophylaxis primarily
with compression stockings.  While the drains are in place,
he is to continue on his antibiotics and maximize the
nutrition.

[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 1352**] 20-ACN

RADIOLOGY  Final Report

CT HEAD W/O CONTRAST  [**2150-11-2**] 7:13 AM

CT HEAD W/O CONTRAST

Reason: Please r/o acute bleed/infx.

[**Hospital 93**] MEDICAL CONDITION:
64 year old man with acute decrease in mental status.
REASON FOR THIS EXAMINATION:
Please r/o acute bleed/infx.
CONTRAINDICATIONS for IV CONTRAST: None.

INDICATION: History of E-coli bacteremia. Acute decrease in
mental status.

COMPARISON: CT head [**2150-10-25**].

TECHNIQUE: CT head without intravenous contrast.

FINDINGS: There is no evidence of hemorrhage, mass, infarct, or
shift of normally midline structures. The [**Doctor Last Name 352**]-white matter
differentiation is preserved. Again noted a tiny focus of low
density within the left parietal region adjacent to vertex,
likely represents an area of chronic ischemic change. The soft
tissues are stable in appearance, including a likely sebaceous
cyst within the superficial scalp soft tissues posteriorly.
Osseous structures are stable in appearance.

IMPRESSION: No evidence of hemorrhage, mass, or edema. Subtle
areas of infection/abscess would be better demonstrated by MRI.

 RADIOLOGY  Final Report

CAROTID SERIES COMPLETE  [**2150-11-4**] 9:25 AM

CAROTID SERIES COMPLETE

Reason: Evaluate carotid arteries, hx. afib & stroke in past,
now wi

[**Hospital 93**] MEDICAL CONDITION:
64 year old man with hx. afib, CAD, s/p right flank hernia
repair [**10-13**], L3 laminectomy with scar tissue excision [**10-14**],
+bacteremia and meningitis, now with mental status changes
REASON FOR THIS EXAMINATION:
Evaluate carotid arteries, hx. afib & stroke in past, now with
mental status changes
CAROTID STUDY

HISTORY: AFib coronary artery disease, prior stroke, mental
status changes.

FINDINGS: No appreciable plaque or wall thickening involving
either carotid system. The peak systolic velocities bilaterally
are normal as are the ICA to CCA ratios. There is also normal
antegrade flow involving both vertebral arteries.

IMPRESSION: Normal study.
RADIOLOGY   Preliminary Report

CHEST (PORTABLE AP)  [**2150-11-9**] 4:50 AM

CHEST (PORTABLE AP)

Reason: SOB c O2 sats 89%->92 Facemask.

[**Hospital 93**] MEDICAL CONDITION:
63 year old man c acute SOB.
REASON FOR THIS EXAMINATION:
SOB c O2 sats 89%->92 Facemask.
AP CHEST 5:25 A.M. [**11-9**]

HISTORY: Acute shortness of breath and hypoxia.

IMPRESSION: AP chest compared to [**11-6**] and 26:

The patient is not intubated. Lungs are fully expanded and
clear. There is no pleural abnormality. Cardiomediastinal and
hilar silhouettes are normal. Tip of the right PIC line projects
over the junction of the brachiocephalic veins. Transvenous
right atrial and right ventricular pacer leads are in standard
placements. No pneumothorax.





Brief Hospital Course:
Mr. [**Known lastname 46422**] [**Last Name (Titles) 1834**] a repair of a right flank incisional
hernia on [**10-13**] by Dr. [**Last Name (STitle) **] and Dr. [**First Name (STitle) **] of plastic
surgery with no intra-operative complications. Post-operatively
he developed right and left lower extremity weakness and
decreased sensation, right > left; decreased motor and sensory
apparent on exam. A neurology and spine consult was obtained and
a steroid bolus was administered along with a steroid drip. A CT
scan of his thoracic/lumbar/spine was obtained with
abnormalities found involving the L4-S1 levels which compared to
last CT of [**4-16**] findings of L4-L5 were significantly worse
correlating with his exam, an MR was recommended but deferred
secondary to patient's pacemaker. On HD 2 he had mild
improvement in his right lower extremity, a CT myelogram was
requested by the spine service to evaluate the area of maximal
compression in planning for surgical decompression based on the
CT findings. A nephrology consult was obtained for clearance of
CT myelogram secondary to his PMH of multiple myeloma, his
creatinine was normal at 0.7 and he had adequate urine output;
he was cleared to receive contrast and [**Date Range 1834**] a CT myelogram
on HD 2.

On HD 2 he was then taken back to the operating room and
[**Date Range 1834**] a revision decompression of the lumbar spin from L2-L3
to L5-S1 with the findings of severe stenosis at lumbar spine
L3-L4 by the spine service with no intra-operative
complications. Post-operatively he was transferred to the
surgical intensive care unit; he was intubated, sedated, with
intravenous hydration through a central venous catheter,
Dilaudid PCA, foley catheter, and surgical drain. The steroids
were discontinued as recommended by the spine service. He was
hemodynamically stable, afebrile, on Vancomycin for a total of 3
doses, and receiving insulin coverage by a sliding scale. On HD
3 his pacemaker magnet was removed and he was adequately paced.
On HD 3 he was extubated without difficulty and [**Date Range 1834**] a
repeat CT myelogram with findings of improvement of spinal canal
stenosis, with moderate degree stenosis remaining at L3/L4 level
secondary to herniated disc. The spinal service reviewed
myelogram with no further interventions recommended since there
was no critical stenosis remaining. On exam he had trace
movement of his right and left hips but no movement distally,
deep vein thrombosis treatment was initiated with subcutaneous
Heparin. Physical and occupational therapy were consulted at
this time. On HD 4 he was transferred to an in-patient nursing
unit, his diet was advanced, his pain was controlled on
intravenous Dilaudid and remained afebrile. On HD 6 he continued
to have improvement in his quadriceps muscles bilaterally with
minimal sensation of his lower extremities, from knee to toes.

On HD 9 he developed sepsis with tachycardia, hypotension,
febrile, hypoxia, and mental status changes. He was intubated,
broad spectrum antibiotics were initiated, he received fluid
resuscitation, cultures were sent, a lumbar puncture was
performed via fluoroscopy, and he was transferred to the
intensive care unit. Cultures from blood, wound, and
cerebrospinal fluid demonstrated E.Coli with sensitivity to
Ciprofloxacin and Ceftazidime, and persistent MRSA
osteomyelitis. He had leukocytosis with a white blood cell count
of 18k. On HD 10 he [**Date Range 1834**] a CT myelogram which demonstrated
a dural leak, he was taken back to the operating room with
findings of a infected dural leak, wound dehiscence with omental
flap, and cauda equina syndrome; he [**Date Range 1834**] a laminotomy
revision of L2, incision and drainage, and dural repair. An
infectious disease consult was placed with recommendations of
continuation of Vancomycin, Ciprofloxacin, and Ceftazidime.

On HD 12 he was successfully extubated, the Ciprofloxacin and
Vancomycin were discontinued after final sensitivities were
reported, he was awake with diminished mental status function.
He was hemodynamically stable with a hematocrit of 26, tube
feeds were initiated via a Dobbhoff tube, and he was receiving
subcutaneous Heparin and pneumoboots for DVT prophylaxis, he had
movement of his lower extremities at his thighs bilaterally;
bilateral lower extremity ultrasound was negative for
thrombosis. On HD 14 his white blood cell count had continued
elevation to 23k, his mental status was still without
improvement, he was afebrile, oxygenating well on nasal cannula;
a head, spine, and chest CT scans were done with nonfocal
abnormalities and stable findings, negative for pulmonary
embolus; stool cultures were negative for C. Diff although he
was placed on empiric Flagyl, a repeat lumbar puncture was
performed at the level of L2-L3 with no bacteria identified. On
HD 17 he had improvement in his mental status, his white blood
cell count had decreased to
13k, an [**Date Range 461**] demonstrated his ejection fraction to be
70%. On HD 18 anticoagulation therapy was resumed with Lovenox
secondary to his past medical history of deep vein thrombosis,
the Flagyl was discontinued.

On HD 19 he was transferred to an in-patient step down nursing
unit, he was afebrile, and his diet was slowly advanced along
with continuation of the tube feeds. On HD 20 he was found to be
unresponsive to command with stable vital signs and a white
blood cell count of 13k, a head CT scan was negative for acute
changes or bleeding, an EKG and cardiac enzymes were negative
for ischemia, an EEG showed mild encephalopathy without
epileptiform; his Valproic Acid level was found to be
sub-therapeutic, he was bolussed with adjustments made in his
daily dose and improvement was noted in his mental status. A
PICC line was placed for a total of 4 week course of
Ceftazidime, until [**11-18**], and Bactrim DS was re-initiated for
life long suppressive therapy for Enterobacter/MRSA. On HD 23 a
carotid ultrasound was performed which was negative for carotid
stenosis, Coumadin therapy was resumed.
On HD 26 calorie counts were initiated with oral intake
encouraged, tube feeds were stopped, he was evaluated by speech
and swallow therapy without evidence of aspiration or dysphagia;
he received his monthly dose of IVIG for his multiple myeloma
without adverse reactions.

On HD 28 he had an episode of supraventricular tachycardia which
resolved spontaneously with desaturation to 90% on room air,
EKG was without ischemia, chest x-ray was without changes or
pneumothorax, his oxygenation improved with nasal cannula, he
was afebrile without leukocytosis.

He was followed by physical therapy throughout his
hospitalization with recommendations of continued therapy to
increase his balance and transfer training, strength, and
functional mobility. His lower extremity strength was still
limited, with the right less than the left at the time of
discharge. His mental status had improved at time of discharge,
he was oriented x 3, able to verbally communicate along with
following commands. The tube feeds were discontinued and he was
tolerating a regular diet with Ensure supplemenentation, his
calorie counts were averaging 900 calories per day, he was
encouraged to increase his caloric and protein intake. He
continued to have loose bowel movements, C.Diff samples were
negative to date, he was started on Imodium which was to be
continued upon discharge to [**Location (un) 38**].

Upon discharge to [**Location (un) 38**] his pain was well controlled with
Oxycodone elixir, he was afebrile, and was to continue the
Ceftazidime until [**11-18**]. His Valproic Acid level stabilized at
30. He was continued on Lovenox and Coumadin with daily checks
of his coagulation, at the time of discharge his [**Month/Day (4) 263**] was 1.5, he
had been receiving Coumadin 4mg daily. His back staples were to
be removed on [**11-12**], he was discharged with the foley catheter
which will be necessary for up to 6 weeks secondary to the Cauda
Equina syndrome. He was discharged in stable condition to
[**Hospital 38**] rehabilitation facility on [**11-10**].

Medications on Admission:
Oxycontin
Oxycodone
Lasix
Potassium
Glyburide
Amiodarone
Depakote
Advair
Neurontin
Protonix
Bactrim
Synthroid

Discharge Medications:
1. Insulin sliding scale  Sig: Insulin Sliding Scale   every six
(6) hours: Fingerstick q6hInsulin SC Sliding Scale
  Q6H
Regular
Glucose/InsulinDose
0-60 mg/dL [**12-15**] amp D50
61-119 mg/dL  0 Units
120-139 mg/dL 2   Units
140-159 mg/dL 3   Units
160-179 mg/dL 4   Units
180-199 mg/dL 5   Units
200-219 mg/dL 6   Units
220-239 mg/dL 7   Units
240-259 mg/dL 8   Units
260-279 mg/dL 9   Units
280-299 mg/dL 10   Units
300-319 mg/dL 11   Units
320-339 mg/dL 12   Units
340-359 mg/dL 13   Units
> 360 mg/dL Notify M.D.

.
2. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Acetaminophen 160 mg/5 mL Solution Sig: Twenty (20) mL PO
Q4-6H (every 4 to 6 hours) as needed for fever or pain.
4. Ranitidine HCl 15 mg/mL Syrup Sig: Ten (10) mL PO BID (2
times a day).
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Enoxaparin 100 mg/mL Syringe Sig: 0.9 mL Subcutaneous Q12H
(every 12 hours).
7. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed for pain.
8. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Oxycodone 5 mg/5 mL Solution Sig: Ten (10) mL PO Q4-6H (every
4 to 6 hours) as needed for pain.
10. Divalproex 125 mg Capsule, Sprinkle Sig: One (1) Capsule,
Sprinkle PO TID (3 times a day).
11. Erythromycin 5 mg/g Ointment Sig: 0.5 ointment Ophthalmic
QID (4 times a day).
12. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day).
13. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO Q8H
(every 8 hours).
14. Zolpidem 5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
15. Loperamide 4 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarhea, maximum 16mg in 24 hours, hold for
constipation.
16. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): Hold for HR < 60
Hold for SBP < 95.
17. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours).
18. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
19. Ceftazidime-Dextrose (Iso-osm) 2 g/50 mL Piggyback Sig: Two
(2) gm Intravenous  Q8H (every 8 hours): Until [**11-18**], last dose
that evening of [**11-18**].
20. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous  DAILY (Daily) as needed: 10ml NS followed by
Heparin
For PICC line.
21. Hydralazine 20 mg/mL Solution Sig: One (1) mL Injection
Q4-6H (every 4 to 6 hours) as needed for For SBP > 160: For SBP
> 160.
22. Other  Sig: Coumadin Dosing   at bedtime: Coumadin dosing by
MD
[**First Name (Titles) 18303**] [**Last Name (Titles) 263**] b/w [**1-16**].
23. other  Sig: PT, PTT, [**Month/Day (3) 263**]   once a day: Daily PT, PTT, [**Month/Day (3) 263**]
for Coumadin dosing.
24. Valproic Acid Level  Sig: Valproic Acid Level   once a week:
Check Valproic Acid level once a week, adjust dose accordingly
.
25. Coumadin 4 mg Tablet Sig: One (1) Tablet PO once: Give pm
[**11-10**] for [**Month/Year (2) 263**] of 1.5
Will need daily dosing by MD.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]

Discharge Diagnosis:
Right flank hernia
Cauda equina syndrome
E. Coli bacteremia and meningitis
Dural leak
Multiple myeloma
MRSA
Atrial fibrilllation


Discharge Condition:
Stable


Discharge Instructions:
Notify MD/NP/PA/RN at rehabilitation facility or return to the
emergency department if you experience:

*Increased or persistent pain not relieved by pain medication
*Fever > 101.5 or chills
*Decreased sensation or strength in upper extremities
*Nausea, vomiting, diarrhea, or abdominal distention
*Inability to pass gas or stool
*If incision appears red or if there is drainage
*Any other symptoms concerning to you

Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in 2 weeks, call [**Telephone/Fax (1) 2981**] for
an appointment



Completed by:[**2150-11-10**]
{'Hernia of other specified sites without mention of obstruction or gangrene,Multiple myeloma, without mention of having achieved remission,Other nervous system complications,Atrial fibrillation,Acute respiratory failure,Septicemia due to escherichia coli [E. coli],Meningitis due to gram-negative bacteria, not elsewhere classified,Severe sepsis,Other postoperative infection,Cauda equina syndrome with neurogenic bladder,Chronic osteomyelitis, other specified sites,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Intervertebral disc disorder with myelopathy, lumbar region,Fitting and adjustment of cardiac pacemaker,Unspecified hereditary and idiopathic peripheral neuropathy,Long-term (current) use of anticoagulants,Personal history of venous thrombosis and embolism,Personal history of irradiation, presenting hazards to health,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Infection with microorganisms resistant to penicillins,Encephalopathy, unspecified'}


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: Presents for elective surgical repair of a right flank hernia.

PRESENT ILLNESS: Mr. [**Known lastname 46422**] is a 63 year old male who presented to [**Hospital1 18**] on
[**10-13**] for elective surgical repair of a right flank hernia by
Dr. [**Last Name (STitle) **]. He has a past medical history significant for
multiple myeloma and is s/p a decompressive laminectomy
complicated by a wound infection and a radiated field requiring
an omental graft which went off the abdominal wall on the right
side. A CT scan  demonstrated a large hernia in the abdominal
wall on the lateral aspect, with a defect of 5cm.

MEDICAL HISTORY: Past Medical History:

MEDICATION ON ADMISSION: Oxycontin
Oxycodone
Lasix
Potassium
Glyburide
Amiodarone
Depakote
Advair
Neurontin
Protonix
Bactrim
Synthroid

ALLERGIES: Tape

PHYSICAL EXAM: 

FAMILY HISTORY: Mother-breast cancer
[**Name (NI) 46425**], died MI age 32
Twin brother with no medical problems
[**Name (NI) 8765**] CAD

SOCIAL HISTORY: The patient lives with his fiance in [**Hospital1 1474**].
He quit smoking 2 yrs ago, smoked 1.5 ppd x 30 yrs.
He currently drinks infrequently; he formerly drank 30
beers/weekend
He denies h/o IVDU. 

### Response:
{'Hernia of other specified sites without mention of obstruction or gangrene,Multiple myeloma, without mention of having achieved remission,Other nervous system complications,Atrial fibrillation,Acute respiratory failure,Septicemia due to escherichia coli [E. coli],Meningitis due to gram-negative bacteria, not elsewhere classified,Severe sepsis,Other postoperative infection,Cauda equina syndrome with neurogenic bladder,Chronic osteomyelitis, other specified sites,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Intervertebral disc disorder with myelopathy, lumbar region,Fitting and adjustment of cardiac pacemaker,Unspecified hereditary and idiopathic peripheral neuropathy,Long-term (current) use of anticoagulants,Personal history of venous thrombosis and embolism,Personal history of irradiation, presenting hazards to health,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Infection with microorganisms resistant to penicillins,Encephalopathy, unspecified'}
