CHIEF COMPLAINT: transfer from outside hospital for management of ventral
epidural and preverteral abscesses

PRESENT ILLNESS: 43 yo M w/ no known medical problems transferred from
[**Name (NI) **] w/ epidural abscess found on Cspine MRI that
was done for concern of neck pain. Also has abscesses in
surrounding muscles (longus coli).
.
The patient states that he had sudden onset of left neck and
shoulder pain that occured when he was at work. Was given
vicodin/flexeril/naproxen with little effect. Went back to
orthopedist today and sent to ED because looked diaphoretic. Had
MRI which showed "extensive prevertebral phlegmon extending down
towards the mediastinum with bilateral longus coli abscesses.
Ventral epidural abscess at C6/C7 to C7/T1 which is narrowinf
the spinal canal and flattening the ventral cord. No evidence of
spondylodiskitis." He was given Vanc and dilaudid. Also noted to
be jaundiced and reports darkened urine starting two days ago.
LFTs with evidence of cholestasis.
.
In the ED, initial vs were: 98.1 109 144/98 17 95%. Patient was
seen by the on-call neurosurgeon, who reviewed the images and
examined the patient. Her assessment was that as there are no
motor defecits or clinical or radiological evidence of cord
compression, intervention is not urgent. It would be a
complicated resection and often these can be treated
conservatively. She recommended ENT consult to see if it would
be possible to drain the abscess from the anterior approach and
ID consult. He was not given antibiotics.
.
On transfer, vitals were 99.5 110 159/70 98 RA.
.
On the floor, the patient complained of [**5-28**] pain in his back
and bilateral shoulders and was unable to find a comfortable
position. He confirmed the history given in the ED. He also
reports having right ear/neck pain several months ago and a
"swollen uvula." He completed a course of amoxacillin and the
symptoms went away bur then he thinks they may have come back
once again. He also went for a dental tooth cleaning two weeks
ago. Prior to this monday, he does not recall any fevers/chills,
sore throat, cough, or any other symptoms. Also denies abdominal
pain, n/v. Does not report any acholic stools. No BRBPR/CP/SOB.

MEDICAL HISTORY: migraines

MEDICATION ON ADMISSION: Naproxen
Flexeril

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Exam on admission
O: 100.6  128/84  124  18  97% RA
Gen: no acute distress, diaphoretic, voice sounds muffled
HEENT: NCAT, PERRL, mild scleral icterus, MMM, white mucous film
on tongue, no appreciable lymphadenopathy, tenderness to
palpation of b/l cevical neck, trapezius
CV: S1, S2, rapid rate, no murmurs appreciated
Pulm: CTAB, no wheezes or crackles
Abd: obese, +BS, non-tender to palpation, no rebound or
guarding, negative [**Doctor Last Name 515**] sign
Ext: warm, well-perfused, no c/c/e
Derm: erythematous warm macular areas over anterior shins
Neuro: CNs [**12-31**] intact, preserved neck strength, LUE is [**3-23**]
throughout except triceps [**2-21**], RUE [**3-23**], lower extremities [**3-23**],
2+ reflexes, preserved gross sensation, normal gait

FAMILY HISTORY: non-contributory
no history of hypercoaguable states, no hx of PE or DVT

SOCIAL HISTORY: lives with wife. works for [**Company 87387**]. works on planes, loads
baggage. no recent travel. no sick contacts. occasional [**Name2 (NI) 5127**],
not more than 2/week. used to drink more when young but only
socially. never told needed to cut down. no smoking. no drugs.
has had one on and off partner other than wife. she does not
know. they have been married 15 years. he is uncomfortable
telling me. the other partner has been intermittent for years.
Unspecified septicemia,Intraspinal abscess,Abscess of mediastinum,Unspecified osteomyelitis, other specified sites,Candidiasis of mouth,Other complications due to other vascular device, implant, and graft,Acute venous embolism and thrombosis of superficial veins of upper extremity,Sepsis,Other specified disorders of biliary tract,Other and unspecified disc disorder, cervical region,Other specified disorders of liver,Thrombocytopenia, unspecified,Iron deficiency anemia, unspecified,Other thalassemia,Dermatitis due to drugs and medicines taken internally,Cephalosporin group causing adverse effects in therapeutic use,Accidents occurring in residential institution,Dysphagia, unspecified,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure
Septicemia NOS,Intraspinal abscess,Abscess of mediastinum,Osteomyelit NOS-oth site,Thrush,Comp-oth vasc dev/graft,Ac embl suprfcl up ext,Sepsis,Dis of biliary tract NEC,Disc dis NEC/NOS-cerv,Liver disorders NEC,Thrombocytopenia NOS,Iron defic anemia NOS,Thalassemia NEC,Drug dermatitis NOS,Adv eff cephalosporin,Accid in resident instit,Dysphagia NOS,Abn react-procedure NEC
Admission Date:  [**2118-8-19**]              Discharge Date:   [**2118-9-14**]

Date of Birth:  [**2074-12-31**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
transfer from outside hospital for management of ventral
epidural and preverteral abscesses

Major Surgical or Invasive Procedure:
Evacuation of prevertebral, paratracheal and paraesophageal
abscess
Evacuation of epidural abscess
Removal of previous hardware for a anterior cervical diskectomy
and fusion C6-C7.
Full corpectomy C6, full corpectomy C7, with adjacent diskectomy
C5-C6 and C7-T1.
Hardware placement for stabilization


History of Present Illness:
43 yo M w/ no known medical problems transferred from
[**Name (NI) **] w/ epidural abscess found on Cspine MRI that
was done for concern of neck pain. Also has abscesses in
surrounding muscles (longus coli).
.
The patient states that he had sudden onset of left neck and
shoulder pain that occured when he was at work. Was given
vicodin/flexeril/naproxen with little effect. Went back to
orthopedist today and sent to ED because looked diaphoretic. Had
MRI which showed "extensive prevertebral phlegmon extending down
towards the mediastinum with bilateral longus coli abscesses.
Ventral epidural abscess at C6/C7 to C7/T1 which is narrowinf
the spinal canal and flattening the ventral cord. No evidence of
spondylodiskitis." He was given Vanc and dilaudid. Also noted to
be jaundiced and reports darkened urine starting two days ago.
LFTs with evidence of cholestasis.
.
In the ED, initial vs were: 98.1 109 144/98 17 95%. Patient was
seen by the on-call neurosurgeon, who reviewed the images and
examined the patient. Her assessment was that as there are no
motor defecits or clinical or radiological evidence of cord
compression, intervention is not urgent. It would be a
complicated resection and often these can be treated
conservatively. She recommended ENT consult to see if it would
be possible to drain the abscess from the anterior approach and
ID consult. He was not given antibiotics.
.
On transfer, vitals were 99.5 110 159/70 98 RA.
.
On the floor, the patient complained of [**5-28**] pain in his back
and bilateral shoulders and was unable to find a comfortable
position. He confirmed the history given in the ED. He also
reports having right ear/neck pain several months ago and a
"swollen uvula." He completed a course of amoxacillin and the
symptoms went away bur then he thinks they may have come back
once again. He also went for a dental tooth cleaning two weeks
ago. Prior to this monday, he does not recall any fevers/chills,
sore throat, cough, or any other symptoms. Also denies abdominal
pain, n/v. Does not report any acholic stools. No BRBPR/CP/SOB.

.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.


Past Medical History:
migraines

Social History:
lives with wife. works for [**Company 87387**]. works on planes, loads
baggage. no recent travel. no sick contacts. occasional [**Name2 (NI) 5127**],
not more than 2/week. used to drink more when young but only
socially. never told needed to cut down. no smoking. no drugs.
has had one on and off partner other than wife. she does not
know. they have been married 15 years. he is uncomfortable
telling me. the other partner has been intermittent for years.

Family History:
non-contributory
no history of hypercoaguable states, no hx of PE or DVT

Physical Exam:
Exam on admission
O: 100.6  128/84  124  18  97% RA
Gen: no acute distress, diaphoretic, voice sounds muffled
HEENT: NCAT, PERRL, mild scleral icterus, MMM, white mucous film
on tongue, no appreciable lymphadenopathy, tenderness to
palpation of b/l cevical neck, trapezius
CV: S1, S2, rapid rate, no murmurs appreciated
Pulm: CTAB, no wheezes or crackles
Abd: obese, +BS, non-tender to palpation, no rebound or
guarding, negative [**Doctor Last Name 515**] sign
Ext: warm, well-perfused, no c/c/e
Derm: erythematous warm macular areas over anterior shins
Neuro: CNs [**12-31**] intact, preserved neck strength, LUE is [**3-23**]
throughout except triceps [**2-21**], RUE [**3-23**], lower extremities [**3-23**],
2+ reflexes, preserved gross sensation, normal gait

Exam on discharge
98.8 122/84 98 18 99% RA
Gen: NAD, resting comfortably in chair
HEENT: NCAT, PERRLA, mmm, no oropharyngeal lesions, aspen collar
in place
CV: regular rhythm, nl s1s2, no m/r/g
Abd: soft, nt, nd, + bs, no hsm
ext: wwp, no c/c/e.  no upper extremity swelling or tenderness
to palpation
neuro: CN II-XII grossly intact, [**3-23**] strenght throughout, normal
gait

Pertinent Results:
Admission labs:
[**2118-8-19**] 08:15PM BLOOD WBC-11.2* RBC-6.26* Hgb-12.1* Hct-37.9*
MCV-61* MCH-19.4* MCHC-32.0 RDW-15.4 Plt Ct-116*
[**2118-8-19**] 08:15PM BLOOD Neuts-70 Bands-6* Lymphs-13* Monos-7
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-3*
[**2118-8-19**] 08:15PM BLOOD PT-13.8* PTT-28.1 INR(PT)-1.2*
[**2118-8-20**] 05:00PM BLOOD ESR-28*
[**2118-8-19**] 08:15PM BLOOD Glucose-116* UreaN-14 Creat-0.8 Na-137
K-3.7 Cl-102 HCO3-26 AnGap-13
[**2118-8-19**] 08:15PM BLOOD ALT-119* AST-75* AlkPhos-229*
TotBili-5.1* DirBili-4.0* IndBili-1.1
[**2118-8-19**] 08:15PM BLOOD Lipase-13
[**2118-8-20**] 06:09AM BLOOD Calcium-8.2* Phos-2.1* Mg-1.5*
[**2118-8-19**] 08:15PM BLOOD HBcAb-NEGATIVE HAV Ab-NEGATIVE
[**2118-8-21**] 02:03PM BLOOD Smooth-NEGATIVE ANCA-NEGATIVE B
[**2118-8-19**] 08:15PM BLOOD CRP-300.0*
[**2118-8-19**] 08:15PM BLOOD HCV Ab-NEGATIVE
[**2118-8-19**] 08:16PM BLOOD Lactate-1.2
Discharge labs:
[**2118-9-14**] 05:58AM BLOOD WBC-5.5 RBC-4.42* Hgb-8.9* Hct-28.4*
MCV-64* MCH-20.1* MCHC-31.2 RDW-18.7* Plt Ct-194
[**2118-9-14**] 11:38AM BLOOD PT-27.0* PTT-38.5* INR(PT)-2.6*
[**2118-9-14**] 05:58AM BLOOD Glucose-111* UreaN-14 Creat-1.0 Na-141
K-4.2 Cl-104 HCO3-27 AnGap-14
[**2118-9-2**] 06:19AM BLOOD ALT-39 AST-28 LD(LDH)-194 AlkPhos-169*
TotBili-1.1 DirBili-0.6* IndBili-0.5
[**2118-9-14**] 05:58AM BLOOD Calcium-9.9 Phos-3.7 Mg-2.0
.
Significant Micro:
[**2118-8-19**] Blood cx: STAPH AUREUS COAG +
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------     1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------     1 S
.
[**2118-8-22**] Tissue cx: STAPH AUREUS COAG +
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------   0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
.
Imaging:
[**2118-8-19**] RUQ U/S: Normal right upper quadrant ultrasound
.
[**2118-8-20**] CT Chest, Abd, Pelvis: 1. Prevertebral soft tissue
stranding along the anterior margin of the lower cervical/upper
thoracic spine vertebral bodies, with concern of small fluid
collection at the lower cervical spine in the soft tissue
anterior to the vertebral body. Similar findings compared to
recent MR from an outside hospital, concerning for extensive
prevertebral phlegmon extending towards the mediastinum. 2.
Multiple nonspecific ground-glass opacities in the lungs, and
dependent atelectasis, nonspecific finding. 3. No extra- or
intra-hepatic biliary duct dilatation. Normal gallbladder. 4.
Splenomegaly.
.
[**2118-8-21**] EKG: Sinus tachycardia. Tracing is normal, except for
rate. No previous tracing available for comparison
.
[**2118-8-21**] RLE U/S: No evidence of DVT in the right lower
extremity. Calf edema.
.
[**2118-8-23**] TTE: The left atrium is normal in size. The estimated
right atrial pressure is 0-5 mmHg. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. No masses or vegetations are seen on the aortic
valve, but cannot be fully excluded due to suboptimal image
quality. The mitral valve leaflets are mildly thickened. There
is no mitral valve prolapse. No masses or vegetations are seen
on the mitral valve, athough the anterior leaflet tip is
thickened, concern for vegetation. Moderate (2+) mitral
regurgitation is seen. There is borderline pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion. IMPRESSION: Suboptimal image quality.
Cannot adequately assess for endocarditis. Normal biventricular
systolic function. Moderate mitral regurgitation. Recommend TEE
if clinically indicated.
.
[**2118-8-24**] Video Oropharyngeal Swallow: Minimal aspiration on thin
barium which the patient was able to clear.
Esophogram: Very limited examination as described above. In the
visualized aspect of the cervical esophagus, there is no
evidence of perforation or leak. Marked prevertebral soft tissue
swelling as noted on prior studies.
.
[**2118-8-24**] CT Chest: 1. Small fluid attenuation collection in the
superior aspect of the left posterior mediastinum at the level
of T1-T2 now appears more organized. 2. Reduction in size of
retropharyngealparaspinal abscess with new screw fixation of C6
and C7, better evaultaed with MRI.
3. Multiple right upper lobe ground-glass opacities which have
increased in number and size and may represent multifocal
pneumonia but the possible presence of cavitation in the lower
lobes raises the possibility of septic emboli, and in light of
persistent leukocytosis warrants further evaluation with
echocardiography. 4. New bilateral small pleural effusions.
.
[**2118-8-30**] TTE: The left atrium is normal in size. No atrial
septal defect or patent foramen ovale is seen by 2D, color
Doppler or saline contrast with maneuvers. Left ventricular wall
thicknesses and cavity size are normal. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve appears structurally normal with trivial mitral
regurgitation. The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion. A catheter is
seen in the right atrium. No vegetation seen (cannot
definitively exclude). Compared with the prior study (images
reviewed) of [**2118-8-23**], a catheter is seen in the right atrium.
Findings are similar.
.
[**2118-8-30**] CXR: The left PIC line now advances to the SVC, clearly
visible to the mid portion, but probably extending to the
superior cavoatrial junction, although the tip is obscured. No
pneumothorax, pleural effusion, or mediastinal widening is
present. Lungs are clear and the heart is normal size. A house
officer on the patient's care team and I discussed the findings
and their clinical significance over the telephone at the time
of dictation.
.
[**2118-9-1**] MR C/T Spine: Post-surgical changes from level C5
through T1, with prevertebral soft tissue swelling along
cervical spine, and anterior dural enhancement from C5 through
T1 with no definite evidence of epidural abscess. Persistent
small fluid collections in the prevertebral muscles bilaterally,
however, decreased in size. Normal signal in the cord, with no
evidence of cord compression.
.
[**2118-9-2**] CT Chest: 1. Interval decrease in size of
mediastinal/left paraspinal collection, now measuring up to 15 x
10 mm, without a definite fluid component. No new abscess or
collection in the mediastinum. 2. Near complete resolution of
multifocal ground-glass opacities in the lungs, without evidence
of persistent or recurrent infection.
.
[**2118-9-2**] LUE U/S: Extensive thrombus about the PICC involving
the left basilic, axillary as well as the subclavian vein (deep
venous thrombosis). This was discussed with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 87388**] at
4:30 PM on [**2118-9-2**].
.
[**2118-9-5**] RUE U/S: 1. No evidence of deep vein thrombosis. 2.
Thrombus noted within the right cephalic vein. Findings were
paged to Dr. [**Last Name (STitle) **] at the time of the examination.




Brief Hospital Course:
43 year-old M with no significant PMHx who presented to an
outside hospital with posterior neck and shoulder pain, was
found to have prevertebral and ventral epidural abscesses of the
C-spine and transferred here for management
.
# Prevertebral/Epidural abscesses: The patient was found to have
ventral epidural, prevertebral, and bilateral longus coli
abscesses. Neurosurgery was consulted in the ED. At first, it
was believed that the patient could be treated medically with
antibiotics and supportive care. He was started on intravenous
broad-spectrum antibiotics that were narrowed once blood culture
data returned (see below re: bacteremia). ID was consulted for
management recommendations. ENT was consulted for possible
aspiration of the collection, but were unable to based on
location. However, after the patient began to spike fevers and
exhibit signs of sepsis, as well as left upper extremity
weakness on extension, he was taken to the OR by Neurosurgery
for evacuation of the abscesses. There he also had C6-C7
anterior cervical diskectomy and fusion with allograft placement
and plating. Post-operatively the patient was continued on
intravenous antibiotics and given aggressive fluid hydration. He
continued to spike fevers and remained tachycardic. Thoracic
Surgery was consulted out of concern for mediastinal
involvement. Additional imaging revealed continued/recurrent
spinal prevertebral and epidural abscesses. He underwent a
second surgical procedure by Neurosurgery in which he had
re-evacuation of the abscesses, removal of the prior hardware,
full corpectomy of C6/C7 with adjacent diskectomy C5-C6 and
C7-T1, microscopic evacuation of epidural abscess, and placement
of a Globus cage and anterior plating. The procedure went well
without complications and he recovered nicely. He remained
afebrile. Additional imaging revealed no evidence of cord
compression and decreased size of longus coli abscesses. He is
to remain in an Aspen collar at all hours of the day and will
follow up with Neurosurgery in 12 weeks for additional imaging.
.
# MSSA bacteremia: The Infectious Disease team was very active
in the management of our patient. His blood cultures from the
outside hospital and on presentation to our facility grew coag +
staph aureus, for which he was started on intravenous vancomycin
and nafcillin. The sensitivites returned as methicillin
sensitive. He underwent a number of antibiotic changes
throughout his hospital course, but importantly, nafcillin was
discontinued secondary to a drug rash. His surveillance cultures
all returned negative. He had two TTEs and one intra-operative
TEE to evaluate for vegetations, which were not seen. The
patient was continued on intravenous vancomycin, which he will
receive at home via PICC for at least 6 weeks from his last
surgical debridement. The absolute length of antibiotic course
is still to be determined based on his clinical picture and
likely re-imaging. He will follow up in the outpatient
Infectious Disease clinic.
.
# Left upper extremity deep venous thrombosis: The patient was
found to have swelling of his distal left upper extremity and
ultrasound revealed venous thromboses of the left basilic,
axillary, and subclavian vein. This was provoked by the PICC
placed in that extremity (which had to be repositioned three
times prior to IR placement). The PICC was removed and the
patient was started on a heparin gtt, without bolus, to treat
the DVT. He was then began on Coumadin, which he will continue
as an outpatient (goal INR [**12-22**]). His INR was theraputic for 24
hours prior to discontinuation of the heparin gtt and discharge
from the hospital.  His course of coumadin will be at least 3
months and he will follow up at the [**Hospital3 **] at
[**Company 191**].
.
# Transaminitis: The patient presented with elevated
transaminases, and elevated direct hyperbilirubinemia. This was
attributed to his septic picture, perhaps a response to stress
(possible underlying [**Doctor Last Name 9376**]). He never had abdominal pain or
became hypotensive. A RUQ ultrasound and CT of the abdomen did
not reveal any dilation of the intra/extra hepatic biliary
ducts, gallbladder pathology, or abscess collections. His
hepatitis and HIV serologies were negative. His enzymes trended
down to normal as his clinical picture improved.
.
# Microcytic Anemia: likely chronic, stable throughout the
admission. Very low MCV and Fe studies consistent with
thalassemia. Imaging studies also commented on appearance of
chronic anemia. Patient had no chest pain, palpitations, or
dyspnea.
.
# Dysphagia: The patient experienced dysphagia on presentation
and after his surgical procedures. This was likely secondary to
inflammation of the local soft tissues. He never experienced any
respiratory distress. Speech was consulted and the patient had a
video swallowing study, which showed laryngeal penetration of
thin and nectar thick liquids but no aspiration. Over his
hospital course his dysphagia improved and his diet was advanced
to regular solids.
.
# Voice Hoarseness: Following the second surgical procedure the
patient had evidence of voice hoarsenss, which slowly improved.
He will follow up with ENT a few weeks after discharge to
evaluate for vocal cord damage, should his symptoms not resolve.

.
# Social Work, Occupational Therapy, and Physical Therapy were
consulted during his hospital admission. He will be discharged
with home services for intravenous medication administration and
continued occupational therapy to regain strength and dexterity
of his upper extremities.
.
# Code Status: Full

Medications on Admission:
Naproxen
Flexeril

Discharge Medications:
1. Outpatient Physical Therapy
for upper extremity strengthening and function
2. vancomycin 500 mg Recon Soln Sig: 2.5 Recon Solns Intravenous
Q 12H (Every 12 Hours) for 1 months.
Disp:*180 Recon Soln(s)* Refills:*0*
3. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
4. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
5. warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO once a day:
7.5 mg daily.
Disp:*90 Tablet(s)* Refills:*0*
6. Outpatient Lab Work
electrolyte, CBC, ESR, CRP to be drawn weekly and fax to [**Telephone/Fax (1) 87389**] (Infectious disease RNs)
7. Outpatient Lab Work
INR check every Mon, Wed, Fri to determine your Coumadin dose.


Discharge Disposition:
Home With Service

Facility:
Critical Care Systems

Discharge Diagnosis:
Primary:
Methicillin-sensitive Staph Aureus Bacteremia
Epidural and prevertebral cervical abscesses status-post
surgical evacuation
Full corpectomy of C6/C7 and diskectomy of C5-C6, C7-T1 with
hardware placement for stabilization


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
Dear Mr. [**Known lastname 6062**],
.
You were recently transferred to [**Hospital1 1170**] for management of an abscess (collection of infection)
near your spine. You were also found to have bacteria in your
blood. We have treated you with intravenous antibiotics and you
improved. You will need to continue these antibiotics at least
until [**10-7**] and follow up with the Infectious Disease
specialists, who will decide whether to continue antibiotics
after that.
.
You also underwent two separate surgical procedures by
Neurosurgery to remove the infectious collections near your
spine. They also removed part of the bone surrounding your
spine, and placed hardware to stabilize the area. **It is
important that you wear the Aspen collar at all times until you
follow up with Dr. [**Last Name (STitle) **] and he tells you otherwise.**
.
During your hospitalization you were found to have a clot in the
veins of your left upper extremity where the catheter was
placed. You were placed on a blood thinner to help the clot
dissolve. We then started you on another blood thinner,
Coumadin, which you will continue to take for 3 month to treat
the blood clots. You will need to have frequent lab work to
monitor your INR to adjust your Coumadin dose as needed.
.
Please do not hesistate to call you primary care physician or
return to the Emergency Room should you develop fever, chills,
or loss of strength or sensation anywhere in your body. It is
important that you keep all of your follow up appointments.
.
The following changes were made to your home medications:
- Intravenous (IV) Vancomycin 1250 mg was STARTED, to be taken
every 8 hours (course length to be determined by the Infectious
Disease specialists)
- Coumadin was STARTED, to be taken every day for at least 3
months.
- Flexaril (cyclobenzaprine) was STARTED, to be taken as needed
for muscle pain
- Oxycodone was STARTED at 5-10 mg every 6 hours as needed for
pain
.
You are being discharged home with visiting occupational therapy
services to regain strength and dexterity of your upper
extremities.

Followup Instructions:
Please follow up with your new primary care physician as
scheduled below:

Department: [**Hospital3 249**]
When: WEDNESDAY [**2118-9-20**] at 3:45 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
.
You will need to call the neurosurgery office at [**Telephone/Fax (1) 1669**] to
make an apptointment with Dr. [**Last Name (STitle) **] in for 1-2 weeks for a
clinic appointment as well as a Cervical Spine CT, non-contrast.
.
Department: INFECTIOUS DISEASE
When: TUESDAY [**2118-9-20**] at 1:30 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage
.
Department: INFECTIOUS DISEASE
When: FRIDAY [**2118-9-30**] at 10:00 AM
With: [**Name6 (MD) 2323**] [**Name8 (MD) 2324**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage
.
Department: OTOLARYNGOLOGY (ENT)
When: TUESDAY [**2118-10-18**] at 1:45 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39**], M.D. [**Telephone/Fax (1) 41**]
Building: LM [**Hospital Unit Name **] [**Location (un) 895**]
Campus: WEST     Best Parking: [**Doctor First Name **]. GARAGE
.
Department: RADIOLOGY
When: TUESDAY [**2118-11-15**] at 1 PM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST     Best Parking: [**Street Address(1) 592**] Garage
.
Department: NEUROSURGERY
When: TUESDAY [**2118-11-15**] at 1:30 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 9151**], MD [**Telephone/Fax (1) 1669**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage



Completed by:[**2118-9-14**]
{'Unspecified septicemia,Intraspinal abscess,Abscess of mediastinum,Unspecified osteomyelitis, other specified sites,Candidiasis of mouth,Other complications due to other vascular device, implant, and graft,Acute venous embolism and thrombosis of superficial veins of upper extremity,Sepsis,Other specified disorders of biliary tract,Other and unspecified disc disorder, cervical region,Other specified disorders of liver,Thrombocytopenia, unspecified,Iron deficiency anemia, unspecified,Other thalassemia,Dermatitis due to drugs and medicines taken internally,Cephalosporin group causing adverse effects in therapeutic use,Accidents occurring in residential institution,Dysphagia, unspecified,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}


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: transfer from outside hospital for management of ventral
epidural and preverteral abscesses

PRESENT ILLNESS: 43 yo M w/ no known medical problems transferred from
[**Name (NI) **] w/ epidural abscess found on Cspine MRI that
was done for concern of neck pain. Also has abscesses in
surrounding muscles (longus coli).
.
The patient states that he had sudden onset of left neck and
shoulder pain that occured when he was at work. Was given
vicodin/flexeril/naproxen with little effect. Went back to
orthopedist today and sent to ED because looked diaphoretic. Had
MRI which showed "extensive prevertebral phlegmon extending down
towards the mediastinum with bilateral longus coli abscesses.
Ventral epidural abscess at C6/C7 to C7/T1 which is narrowinf
the spinal canal and flattening the ventral cord. No evidence of
spondylodiskitis." He was given Vanc and dilaudid. Also noted to
be jaundiced and reports darkened urine starting two days ago.
LFTs with evidence of cholestasis.
.
In the ED, initial vs were: 98.1 109 144/98 17 95%. Patient was
seen by the on-call neurosurgeon, who reviewed the images and
examined the patient. Her assessment was that as there are no
motor defecits or clinical or radiological evidence of cord
compression, intervention is not urgent. It would be a
complicated resection and often these can be treated
conservatively. She recommended ENT consult to see if it would
be possible to drain the abscess from the anterior approach and
ID consult. He was not given antibiotics.
.
On transfer, vitals were 99.5 110 159/70 98 RA.
.
On the floor, the patient complained of [**5-28**] pain in his back
and bilateral shoulders and was unable to find a comfortable
position. He confirmed the history given in the ED. He also
reports having right ear/neck pain several months ago and a
"swollen uvula." He completed a course of amoxacillin and the
symptoms went away bur then he thinks they may have come back
once again. He also went for a dental tooth cleaning two weeks
ago. Prior to this monday, he does not recall any fevers/chills,
sore throat, cough, or any other symptoms. Also denies abdominal
pain, n/v. Does not report any acholic stools. No BRBPR/CP/SOB.

MEDICAL HISTORY: migraines

MEDICATION ON ADMISSION: Naproxen
Flexeril

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Exam on admission
O: 100.6  128/84  124  18  97% RA
Gen: no acute distress, diaphoretic, voice sounds muffled
HEENT: NCAT, PERRL, mild scleral icterus, MMM, white mucous film
on tongue, no appreciable lymphadenopathy, tenderness to
palpation of b/l cevical neck, trapezius
CV: S1, S2, rapid rate, no murmurs appreciated
Pulm: CTAB, no wheezes or crackles
Abd: obese, +BS, non-tender to palpation, no rebound or
guarding, negative [**Doctor Last Name 515**] sign
Ext: warm, well-perfused, no c/c/e
Derm: erythematous warm macular areas over anterior shins
Neuro: CNs [**12-31**] intact, preserved neck strength, LUE is [**3-23**]
throughout except triceps [**2-21**], RUE [**3-23**], lower extremities [**3-23**],
2+ reflexes, preserved gross sensation, normal gait

FAMILY HISTORY: non-contributory
no history of hypercoaguable states, no hx of PE or DVT

SOCIAL HISTORY: lives with wife. works for [**Company 87387**]. works on planes, loads
baggage. no recent travel. no sick contacts. occasional [**Name2 (NI) 5127**],
not more than 2/week. used to drink more when young but only
socially. never told needed to cut down. no smoking. no drugs.
has had one on and off partner other than wife. she does not
know. they have been married 15 years. he is uncomfortable
telling me. the other partner has been intermittent for years. 

### Response:
{'Unspecified septicemia,Intraspinal abscess,Abscess of mediastinum,Unspecified osteomyelitis, other specified sites,Candidiasis of mouth,Other complications due to other vascular device, implant, and graft,Acute venous embolism and thrombosis of superficial veins of upper extremity,Sepsis,Other specified disorders of biliary tract,Other and unspecified disc disorder, cervical region,Other specified disorders of liver,Thrombocytopenia, unspecified,Iron deficiency anemia, unspecified,Other thalassemia,Dermatitis due to drugs and medicines taken internally,Cephalosporin group causing adverse effects in therapeutic use,Accidents occurring in residential institution,Dysphagia, unspecified,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}
