CHIEF COMPLAINT: Necrotizing cellulitis to left lower extremity

PRESENT ILLNESS: 52 y/o male with DM, ESRD on PD, left tib/fib fx [**2185-5-12**] s/p
ORIF of fibula with external fixator to tibia, removed 14 days
later. Noted to have nonunion of tibia s/p tibial ORIF
complicated by wound infection requiring multiple depbridments
and VAC dressing.  Cultures at that time grew VRE, VSE,
acinetobacter, and anaerobes. He was treated with Zyvox,ciprox 5
weeks starting [**10-6**].
.
He was admitted to St. [**Hospital **] Hospital [**2186-1-30**] with complants of
increasing swellling and erythema in left leg. Patient was using
partial boot(posterior splint) and it "digged" into lateral
aspect of distal leg. Patient was placed on Daptomycin, Zosyn,
and Flagyl per Dr. [**Last Name (STitle) 25979**] of ID base on the cellullitis, bullous
leshions , erythema "discoloration and malodor" of left leg.
Left leg was debrided by orthopedic service during that
admission. PD was iniated [**2186-2-1**] to help reduce the edema.
Patient was transfered for second opinion re need for left leg
amputation.

MEDICAL HISTORY: Type I diabetes diagnosed about 25 years ago c/b nephropathy
with proteinuria
s/p 4 hip replacements
HTN
hypothyroidism
multiple R foot debridements and metatarsal head resections
LLE fracture [**5-6**]-with hardware placement and then revision due
to nonunion, course complicated by wound infection requiring
long course of IV antibiotics

MEDICATION ON ADMISSION: asa 81mg
amitryptyline 10mg,
Detemir 26 unis [**Hospital1 **]
novolog ss
fludrocortisone 0.1mg [**Hospital1 **]
sodium bicarb a650mg qid
diltizem 240mg
lasix 160mg daily-held @ outside hospital
epo 10K q wed, sat
lopressor 25mg [**Hospital1 **]
synthroid50mcg
ca acetate 667 mgm tab-4 tid
vit B-C-folate tid
vitamin D 50K monthly
flagyl 500 tid
daptomycin
zosyn 2.25GM tid

ALLERGIES: Clindamycin

PHYSICAL EXAM: Vital signs: 97.9-70-20 B/P 132/43 O2 sat 95% room air
Gen: AAOx3, NAD
HEENT: no carotid bruits
Heart: RRR, nl. S1 S2
Lungs: clear to auscultation
ABD: bengin, pd cath in place
EXT: bilateral lower extremity edema to hips. left leg wound
superficial without skin. significant portion of pretibial area
to proximal dorsum of foot and lateral leg. no odor, no
purulence
Pulses: Right: fem/[**Doctor Last Name **]/dp/pt 2+/2+/tri/tri; Left: 2+/1+/-/-
Neuro: nonfocal

FAMILY HISTORY: Mother w/ h/o DM2, died at 73 y/o from CHF. Father w/ h/o DM1,
died at 58 from CHF.

SOCIAL HISTORY: Lives with wife in [**Name (NI) 3844**], married 25 yrs. Former smoker,
quit 20 years ago. Occasional alcohol, no IVDU, herbal
supplements.
Infection and inflammatory reaction due to other internal orthopedic device, implant, and graft,End stage renal disease,Cellulitis and abscess of leg, except foot,Gangrene,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Nonunion of fracture,Other ascites,Acidosis,Ulcer of calf,Unspecified acquired hypothyroidism,Kidney dialysis as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Anemia in chronic kidney disease,Peritoneal adhesions (postoperative) (postinfection),Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Streptococcus infection in conditions classified elsewhere and of unspecified site, other streptococcus,Constipation, unspecified,Urinary obstruction, unspecified,Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled
React-oth int ortho dev,End stage renal disease,Cellulitis of leg,Gangrene,Hyp kid NOS w cr kid V,Nonunion of fracture,Ascites NEC,Acidosis,Ulcer of calf,Hypothyroidism NOS,Abn react-renal dialysis,Anemia in chr kidney dis,Peritoneal adhesions,Abn react-artif implant,Other streptococcus,Constipation NOS,Urinary obstruction NOS,DMI wo cmp nt st uncntrl
Admission Date:  [**2186-2-1**]              Discharge Date:   [**2186-2-21**]

Date of Birth:  [**2133-4-12**]             Sex:   M

Service: SURGERY

Allergies:
Clindamycin

Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Necrotizing cellulitis to left lower extremity

Major Surgical or Invasive Procedure:
Left below-the-knee amputation [**2186-2-6**]
Diagnostic laparascopy with PD catheter repositioning [**2186-2-8**]
Right femoral vein/artery temporary HD catheter placement
[**2186-2-8**]
Placement of right subclavian tunneled line HD catheter [**2186-2-17**]


History of Present Illness:
52 y/o male with DM, ESRD on PD, left tib/fib fx [**2185-5-12**] s/p
ORIF of fibula with external fixator to tibia, removed 14 days
later. Noted to have nonunion of tibia s/p tibial ORIF
complicated by wound infection requiring multiple depbridments
and VAC dressing.  Cultures at that time grew VRE, VSE,
acinetobacter, and anaerobes. He was treated with Zyvox,ciprox 5
weeks starting [**10-6**].
.
He was admitted to St. [**Hospital **] Hospital [**2186-1-30**] with complants of
increasing swellling and erythema in left leg. Patient was using
partial boot(posterior splint) and it "digged" into lateral
aspect of distal leg. Patient was placed on Daptomycin, Zosyn,
and Flagyl per Dr. [**Last Name (STitle) 25979**] of ID base on the cellullitis, bullous
leshions , erythema "discoloration and malodor" of left leg.
Left leg was debrided by orthopedic service during that
admission. PD was iniated [**2186-2-1**] to help reduce the edema.
Patient was transfered for second opinion re need for left leg
amputation.

Past Medical History:
Type I diabetes diagnosed about 25 years ago c/b nephropathy
with proteinuria
s/p 4 hip replacements
HTN
hypothyroidism
multiple R foot debridements and metatarsal head resections
LLE fracture [**5-6**]-with hardware placement and then revision due
to nonunion, course complicated by wound infection requiring
long course of IV antibiotics


Social History:
Lives with wife in [**Name (NI) 3844**], married 25 yrs. Former smoker,
quit 20 years ago. Occasional alcohol, no IVDU, herbal
supplements.


Family History:
Mother w/ h/o DM2, died at 73 y/o from CHF. Father w/ h/o DM1,
died at 58 from CHF.

Physical Exam:
Vital signs: 97.9-70-20 B/P 132/43 O2 sat 95% room air
Gen: AAOx3, NAD
HEENT: no carotid bruits
Heart: RRR, nl. S1 S2
Lungs: clear to auscultation
ABD: bengin, pd cath in place
EXT: bilateral lower extremity edema to hips. left leg wound
superficial without skin. significant portion of pretibial area
to proximal dorsum of foot and lateral leg. no odor, no
purulence
Pulses: Right: fem/[**Doctor Last Name **]/dp/pt 2+/2+/tri/tri; Left: 2+/1+/-/-
Neuro: nonfocal


Pertinent Results:
[**2186-2-1**] 10:12PM   WBC-12.1*# RBC-3.15* HGB-6.8* HCT-25.2*
MCV-80* MCH-21.5* MCHC-26.9* RDW-16.5*
[**2186-2-1**] 10:12PM   PLT COUNT-427
[**2186-2-1**] 10:12PM   PT-16.1* PTT-32.9 INR(PT)-1.4*
[**2186-2-1**] 10:12PM   GLUCOSE-147* UREA N-92* CREAT-14.4*#
SODIUM-138 POTASSIUM-4.0 CHLORIDE-109* TOTAL CO2-12* ANION
GAP-21*
[**2186-2-1**] 10:12PM   CALCIUM-7.6* PHOSPHATE-7.2* MAGNESIUM-1.7

Brief Hospital Course:
[**2186-2-2**] Admitted. wound c/s obtained.GRAM STAIN-FINAL; WOUND
CULTURE-FINAL {STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA,
ENTEROBACTER CLOACAE}; ANAEROBIC CULTURE-FINAL. Dapto and zosyn
continued after discussion with on call ID fellow.
Nephrology consulted for PD managment.
[**2186-2-3**] ID consulted. [**Last Name (un) **] consulted for DM managment.
Metabolic acidosis started on NaHCO3.
[**2186-2-6**] left BKA extubated and transcfered to PACU
stable.continuing elevation in WBC. esr 76, crp 96 cpk,alt,ast
normal alp phos 230. diffculty with pd secondary to fibrin IR
services required to help clear cahteter.
[**2186-2-7**] POD #1 renagel started.consider HD cath placement and
start HD if continue to have inadequated PD exchanges.Continued
to be followed by ID and [**Last Name (un) **] services.Blood c/s obtianed
secondary to continuing leukocytosis.Transplant service
consulted for dialysis acess.
[**2186-2-8**] POD#2 Lap-scope with repositioning of PD catheter. IR
rt. femoral temporary HD catheter placement. PT working with
patient.Hypotension with iniation of PD.reintubated and CVVH
started.cxr CHFsecondary to volume overload.Requiring IV insulin
gtt. vasopressor support.Meropenium started, dapto continued.
cipro and flagyl continued.
[**2186-2-9**] POD# [**1-28**] wean vasopressor support Exttubated..flagyl,
cipro d/c'd. attempted PD-failed, continued with CVVH.bactrium
added to cover stentotrophomonas.
[**2186-2-10**] POD# [**3-1**] extubated.followed by PT. PD restarted.
[**2186-2-11**] POD# [**4-1**] transfered to VICU
[**2186-2-12**] POD# [**5-3**] Insulin pump restarted, continue [**Last Name (un) 2830**] x 7 more
days. Continue bactrium x [**9-12**] more days. ID signs off
[**2186-2-13**] POD# [**6-3**] HD secondary poor return from PD cath.
traansfused for Hct. 23.6. PICC line d/c'd secondary to
accidental displacement of catheter.
[**2186-2-14**] POD# [**7-5**] PD restarted.
[**2186-2-15**] POD# [**8-6**] PD working intermittently.
[**2186-2-17**] POD# [**9-6**] Tunneled Right subclavian HD catheter placed,
patient begins HD with 2.3 kg taken off.  Tolerating HD well.
[**2186-2-18**] POD# [**10-8**] Repeated HD, patient tolerated well.  Wound
site with no progression of maceration.  Patient continues to
work with PT/OT.
[**2186-2-20**] Patient discharged to rehab in stable condition,
afebrile, vitals WNL, tolerating a regular diet, with good pain
control with PO medication.  Pt should continue Bactrim PO QD
indefinitely to follow-up.

Medications on Admission:
asa 81mg
amitryptyline 10mg,
Detemir 26 unis [**Hospital1 **]
novolog ss
fludrocortisone 0.1mg [**Hospital1 **]
sodium bicarb a650mg qid
diltizem 240mg
lasix 160mg daily-held @ outside hospital
epo 10K q wed, sat
lopressor 25mg [**Hospital1 **]
synthroid50mcg
ca acetate 667 mgm tab-4 tid
vit B-C-folate tid
vitamin D 50K monthly
flagyl 500 tid
daptomycin
zosyn 2.25GM tid


Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
8. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QID (4 times a
day) as needed for nausea.
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
10. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q48H
(every 48 hours) for 3 doses.
11. Epoetin Alfa 10,000 unit/mL Solution Sig: Ten (10) K
Injection MWF (MO,WE,FR).
12. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).

15. Heparin (Porcine) 1,000 unit/mL Solution Sig: 1000 (1000)
units Injection PRN (as needed) as needed for for PD fluid.
16. Insulin Regular Human 100 unit/mL Solution Sig: as directed
Injection once a day: insulin pump.
17. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
18. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
20. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).


Discharge Disposition:
Extended Care

Facility:
[**First Name8 (NamePattern2) **] [**Hospital **] Rehab

Discharge Diagnosis:
1. Left leg necrotizing cellulitis
2. Insulin dependent diabetes mellitus
3. End-stage renal disease new to PD [**2186-1-31**]
4. History of hypothyroidism
5. History of hip trauma in childhood s/p 4 hip replacements,
s/p multiple foot surgeries and bone rxns
6. s/p PD catheter insetion [**2186-1-12**]
7. s/p tunneled HD catheter placement on [**2186-2-17**]
8. s/p Right 1st ray amp of 1st met head with excision of ulcer
[**2185-6-8**],s/p Right foot debridment of plantar wound and [**Doctor First Name **]
[**2185-2-24**], s/p Right toe amps 5th, Right ist met head and toe
debridment, Left 5th toe amp
9. PD catheter malfunction-corrected
10. Postopersative CHF secondary to volume overload
11. Postoperative blood loss anemia-transfused
12. Postoperative hypotension requiring vassoopressor support
and reintubation-treated


Discharge Condition:
Stable, to rehab


Discharge Instructions:
Report to the ER for temperature greater than 101 F,
fever/chills, persistent nausea and/or vomiting, increasing
abdominal pain, spreading redness or soreness to your amputation
site, or foul smelling drainage from amputation site with
obvious signs of infection.
.
No stump shrinkers. Skin clips remain in place unitl seen by Dr.
[**Last Name (STitle) 1391**] in followup. Knee immoblizer while in bed
.
Take your medications exactly as prescribed.
.
Continue your dressing changes twice daily.
.

Followup Instructions:
3-4 weeks. Dr. [**Last Name (STitle) 1391**], call for an appointment [**Telephone/Fax (1) 1393**]





Name:  [**Known lastname **],[**Known firstname **] B.                    Unit No:   [**Numeric Identifier 4463**]

Admission Date:  [**2186-2-1**]              Discharge Date:   [**2186-2-21**]

Date of Birth:  [**2133-4-12**]             Sex:   M

Service: SURGERY

Allergies:
Clindamycin

Attending:[**First Name3 (LF) 231**]
Addendum:
[**2186-2-20**]: Patient with positive previous L IJ CVL line culture
with > 20 colonies [**Female First Name (un) 1441**] albicans. Infectious disease was
consulted and recommended 14 days PO Fluconazole 400mg QD, and
will continue to follow cultures following dispostion. Patient
has been afebrile with decreasing WBC (currently 11.5k).

Chief Complaint:
LLE Necrosis

Major Surgical or Invasive Procedure:
Left below-the-knee amputation [**2186-2-6**]
Diagnostic laparascopy with PD catheter repositioning [**2186-2-8**]
Right femoral vein/artery temporary HD catheter placement
[**2186-2-8**]
Placement of right subclavian tunneled line HD catheter [**2186-2-17**]


History of Present Illness:
As described in primary discharge summary from [**2186-2-20**].

Past Medical History:
As described in primary discharge summary from [**2186-2-20**].

Social History:
As described in primary discharge summary from [**2186-2-20**].

Family History:
As described in primary discharge summary from [**2186-2-20**].

Physical Exam:
As described in primary discharge summary from [**2186-2-20**].

Pertinent Results:
As described in primary discharge summary from [**2186-2-20**].

Brief Hospital Course:
As described in primary discharge summary from [**2186-2-20**].

Medications on Admission:
As described in primary discharge summary from [**2186-2-20**].

Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
8. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QID (4 times a
day) as needed for nausea.
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
10. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q48H
(every 48 hours) for 3 doses.
11. Epoetin Alfa 10,000 unit/mL Solution Sig: Ten (10) K
Injection MWF (MO,WE,FR).
12. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).

15. Heparin (Porcine) 1,000 unit/mL Solution Sig: 1000 (1000)
units Injection PRN (as needed) as needed for for PD fluid.
16. Insulin Regular Human 100 unit/mL Solution Sig: as directed
Injection once a day: insulin pump.
17. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
18. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
20. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
21. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO once a day
for 14 days.
Disp:*28 Tablet(s)* Refills:*0*


Discharge Disposition:
Extended Care

Facility:
[**First Name8 (NamePattern2) **] [**Doctor Last Name **]

Discharge Diagnosis:
1. Left leg necrotizing cellulitis
2. Insulin dependent diabetes mellitus
3. End-stage renal disease new to PD [**2186-1-31**]
4. History of hypothyroidism
5. History of hip trauma in childhood s/p 4 hip replacements,
s/p multiple foot surgeries and bone rxns
6. s/p PD catheter insetion [**2186-1-12**]
7. s/p tunneled HD catheter placement on [**2186-2-17**]
8. s/p Right 1st ray amp of 1st met head with excision of ulcer
[**2185-6-8**],s/p Right foot debridment of plantar wound and [**Doctor First Name **]
[**2185-2-24**], s/p Right toe amps 5th, Right ist met head and toe
debridment, Left 5th toe amp
9. PD catheter malfunction-corrected
10. Postopersative CHF secondary to volume overload
11. Postoperative blood loss anemia-transfused
12. Postoperative hypotension requiring vassoopressor support
and reintubation-treated


Discharge Condition:
Stable, to rehab


Discharge Instructions:
Report to the ER for temperature greater than 101 F,
fever/chills, persistent nausea and/or vomiting, increasing
abdominal pain, spreading redness or soreness to your amputation
site, or foul smelling drainage from amputation site with
obvious signs of infection.
.
Take your medications exactly as prescribed.
.
Continue your dressing changes twice daily.
.
Continue with your hemodialysis MWF as necessary.
.

Followup Instructions:
3-4 weeks. Dr. [**Last Name (STitle) **], call for an appointment [**Telephone/Fax (1) 236**]
.
Take your Fluconazole 400mg PO QD for 14 days following your
discharge.
.
You will need to follow up with the Transplant Surgery service
for removal of your peritoneal dialysis catheter.  This can be
done at your convenience.  Please call ([**Telephone/Fax (1) 4464**] to
schedule an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].


                             [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**]

Completed by:[**2186-2-21**]
{'Infection and inflammatory reaction due to other internal orthopedic device, implant, and graft,End stage renal disease,Cellulitis and abscess of leg, except foot,Gangrene,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Nonunion of fracture,Other ascites,Acidosis,Ulcer of calf,Unspecified acquired hypothyroidism,Kidney dialysis as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Anemia in chronic kidney disease,Peritoneal adhesions (postoperative) (postinfection),Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Streptococcus infection in conditions classified elsewhere and of unspecified site, other streptococcus,Constipation, unspecified,Urinary obstruction, unspecified,Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled'}


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: Necrotizing cellulitis to left lower extremity

PRESENT ILLNESS: 52 y/o male with DM, ESRD on PD, left tib/fib fx [**2185-5-12**] s/p
ORIF of fibula with external fixator to tibia, removed 14 days
later. Noted to have nonunion of tibia s/p tibial ORIF
complicated by wound infection requiring multiple depbridments
and VAC dressing.  Cultures at that time grew VRE, VSE,
acinetobacter, and anaerobes. He was treated with Zyvox,ciprox 5
weeks starting [**10-6**].
.
He was admitted to St. [**Hospital **] Hospital [**2186-1-30**] with complants of
increasing swellling and erythema in left leg. Patient was using
partial boot(posterior splint) and it "digged" into lateral
aspect of distal leg. Patient was placed on Daptomycin, Zosyn,
and Flagyl per Dr. [**Last Name (STitle) 25979**] of ID base on the cellullitis, bullous
leshions , erythema "discoloration and malodor" of left leg.
Left leg was debrided by orthopedic service during that
admission. PD was iniated [**2186-2-1**] to help reduce the edema.
Patient was transfered for second opinion re need for left leg
amputation.

MEDICAL HISTORY: Type I diabetes diagnosed about 25 years ago c/b nephropathy
with proteinuria
s/p 4 hip replacements
HTN
hypothyroidism
multiple R foot debridements and metatarsal head resections
LLE fracture [**5-6**]-with hardware placement and then revision due
to nonunion, course complicated by wound infection requiring
long course of IV antibiotics

MEDICATION ON ADMISSION: asa 81mg
amitryptyline 10mg,
Detemir 26 unis [**Hospital1 **]
novolog ss
fludrocortisone 0.1mg [**Hospital1 **]
sodium bicarb a650mg qid
diltizem 240mg
lasix 160mg daily-held @ outside hospital
epo 10K q wed, sat
lopressor 25mg [**Hospital1 **]
synthroid50mcg
ca acetate 667 mgm tab-4 tid
vit B-C-folate tid
vitamin D 50K monthly
flagyl 500 tid
daptomycin
zosyn 2.25GM tid

ALLERGIES: Clindamycin

PHYSICAL EXAM: Vital signs: 97.9-70-20 B/P 132/43 O2 sat 95% room air
Gen: AAOx3, NAD
HEENT: no carotid bruits
Heart: RRR, nl. S1 S2
Lungs: clear to auscultation
ABD: bengin, pd cath in place
EXT: bilateral lower extremity edema to hips. left leg wound
superficial without skin. significant portion of pretibial area
to proximal dorsum of foot and lateral leg. no odor, no
purulence
Pulses: Right: fem/[**Doctor Last Name **]/dp/pt 2+/2+/tri/tri; Left: 2+/1+/-/-
Neuro: nonfocal

FAMILY HISTORY: Mother w/ h/o DM2, died at 73 y/o from CHF. Father w/ h/o DM1,
died at 58 from CHF.

SOCIAL HISTORY: Lives with wife in [**Name (NI) 3844**], married 25 yrs. Former smoker,
quit 20 years ago. Occasional alcohol, no IVDU, herbal
supplements. 

### Response:
{'Infection and inflammatory reaction due to other internal orthopedic device, implant, and graft,End stage renal disease,Cellulitis and abscess of leg, except foot,Gangrene,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Nonunion of fracture,Other ascites,Acidosis,Ulcer of calf,Unspecified acquired hypothyroidism,Kidney dialysis as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Anemia in chronic kidney disease,Peritoneal adhesions (postoperative) (postinfection),Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Streptococcus infection in conditions classified elsewhere and of unspecified site, other streptococcus,Constipation, unspecified,Urinary obstruction, unspecified,Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled'}
