CHIEF COMPLAINT: Knee pain

PRESENT ILLNESS: This is a 65 year-old Male with a PMH significant for
insulin-dependent diabetes mellitus (complicated by peripheral
neuropathy and chronic diabetic nephropathy), coronary artery
disease, chronic diastolic dysfunction, chronic obstructive
pulmonary disease, prior colonic adenocarcinoma, hypertension,
hyperlipidemia, peripheral vascular disease, glaucoma and
degenerative arthritis who was admitted following a total left
knee replacement on [**2164-6-18**] at [**Hospital3 **] complicated by
acute exacerbation of his COPD requiring intubation, acute on
chronic diastolic dysfunction. He initially presented to [**Hospital1 18**]
on [**2164-7-17**] with evidence of wound infection from the operative
site, who is now s/p I&D and left knee liner exchange ([**2164-7-18**])
who has evidence of active infection with wound cultures
speciating coagulase positive Staphylococcus aureus (on
Vancomycin IV originally, now Nafcilin). Infectious Disease has
been consulted. Given his multiple comorbidities and his recent
hospitalization and post-operative course complicated by COPD
and acute diastolic failure exacerbation and active infectious
issues, requesting transfer to medical service.

MEDICAL HISTORY: PAST MEDICAL & SURGICAL HISTORY:
1. Insulin-dependent diabetes mellitus (last HbA1c 7.0% without
retinopathy; some evidence of peripheral neuropathy and chronic
diabetic nephropathy)
2. Coronary artery disease
3. Chronic diastolic dysfunction (had negative persantine-MIBI
study prior to knee replacement)
4. Chronic obstructive pulmonary disease
5. Obstructive sleep apnea (on CPAP, but rarely utilizes this)
6. Colonic adenocarcinoma (s/p exploratory laparotomy, subtotal
colectomy, cystectomy and ileal sigmoid anastomosis, [**2161-10-29**]
complicated by CVA/stroke without residual deficits)
7. Peripheral neuropathy (decreased sensation in the bilateral
lower extremities)
8. Hypertension
9. Hyperlipidemia
10. Glaucoma
11. Degenerative arthritis
12. Benign prostatic hypertrophy
13. Gout
14. Peripheral vascular disease (s/p left-to-right SFA
angioplasty; amputation of the right 5th digit - [**7-/2152**])
15. Unspecified psychiatric diagnosis
16. s/p left total knee replacement ([**2164-6-18**])
17. s/p right inguinal hernia repair
18. s/p appendectomy

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Theophylline SR 200 mg PO BID
2. Metoprolol Tartrate 50 mg PO BID
3. Amlodipine 10 mg PO DAILY
4. Vitamin D 1000 UNIT PO DAILY
5. Aspirin 81 mg PO DAILY
6. Simvastatin 20 mg PO DAILY
7. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES [**Hospital1 **]
8. Betaxolol Ophth Susp  0.25% 1 DROP RIGHT EYE DAILY
9. Acetaminophen 650 mg PO Q6H:PRN pain
10. PredniSONE 10 mg po daily Duration: 3 Days
11. PredniSONE 5 mg po daily Duration: 5 Days Start: After 10 mg
tapered dose.
12. Acetaminophen w/Codeine 1 TAB PO Q4H:PRN pain
13. Tiotropium Bromide 1 CAP IH DAILY
14. Fluticasone-Salmeterol Diskus (250/50)  1 INH IH [**Hospital1 **]
15. Xopenex Neb *NF* 1.25 mg/0.5 mL Inhalation Q6
16. Allopurinol 300 mg PO DAILY
17. Pantoprazole 40 mg PO Q24H
18. Multivitamins 1 TAB PO DAILY
19. Ferrous Sulfate 325 mg PO DAILY

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Physical Exam:
VITALS: 99.4, 87, 133/59, 18, 97% on 2L
GENERAL: Appears in no acute distress. Alert and interactive.
Well nourished appearing.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist.
NECK: supple without lymphadenopathy. JVD 8-cm.
CVS: Regular rate and rhythm, without murmurs, rubs or gallops.
S1 and S2 normal.
RESP: Clear to auscultation bilaterally without adventitious
sounds. No wheezing, rhonchi or crackles. Stable inspiratory
effort.
ABD: obese, soft, non-tender, non-distended, with normoactive
bowel sounds. No palpable masses or peritoneal signs.
EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses.
Large bandage on L knee with drain producing sanguinous
material.
NEURO: CN II-XII intact throughout. Alert and oriented x 3. DTRs
2+ throughout, strength 5/5 bilaterally, sensation grossly
intact. Gait deferred.

FAMILY HISTORY: Denies significant family history of cardiovascular disease,
early MI, arrhythmia or sudden cardiac death. Denies family
history of malignancy.

SOCIAL HISTORY: Patient lives at home with wife. Denies tobacco use or alcohol
use; no recreational substance use. Patient is independent in
ADLs and ambulates unassisted.
Infection and inflammatory reaction due to internal joint prosthesis,Acute kidney failure with lesion of tubular necrosis,Acute respiratory failure following trauma and surgery,Pyogenic arthritis, lower leg,Chronic diastolic heart failure,Acute posthemorrhagic anemia,Knee joint replacement,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Accidents occurring in residential institution,Chronic airway obstruction, not elsewhere classified,Coronary atherosclerosis of native coronary artery,Obstructive sleep apnea (adult)(pediatric),Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Personal history of malignant neoplasm of large intestine,Unspecified glaucoma,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Long-term (current) use of insulin,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Encounter for change or removal of surgical wound dressing,Other alteration of consciousness,Pressure ulcer, buttock,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate)
React-inter joint prost,Ac kidny fail, tubr necr,Ac resp flr fol trma/srg,Pyogen arthritis-l/leg,Chr diastolic hrt fail,Ac posthemorrhag anemia,Joint replaced knee,Abn react-artif implant,Accid in resident instit,Chr airway obstruct NEC,Crnry athrscl natve vssl,Obstructive sleep apnea,Hx TIA/stroke w/o resid,Hx of colonic malignancy,Glaucoma NOS,DMII neuro nt st uncntrl,Neuropathy in diabetes,Long-term use of insulin,Mth sus Stph aur els/NOS,Attn rem surg dressing,Other alter consciousnes,Pressure ulcer, buttock,Hy kid NOS w cr kid I-IV,Chr kidney dis stage III
Admission Date:  [**2164-7-17**]              Discharge Date:   [**2164-8-13**]

Date of Birth:  [**2098-11-24**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Knee pain

Major Surgical or Invasive Procedure:
Washout and debridement left knee by Dr [**Last Name (STitle) **] [**2164-7-18**]


History of Present Illness:
This is a 65 year-old Male with a PMH significant for
insulin-dependent diabetes mellitus (complicated by peripheral
neuropathy and chronic diabetic nephropathy), coronary artery
disease, chronic diastolic dysfunction, chronic obstructive
pulmonary disease, prior colonic adenocarcinoma, hypertension,
hyperlipidemia, peripheral vascular disease, glaucoma and
degenerative arthritis who was admitted following a total left
knee replacement on [**2164-6-18**] at [**Hospital3 **] complicated by
acute exacerbation of his COPD requiring intubation, acute on
chronic diastolic dysfunction. He initially presented to [**Hospital1 18**]
on [**2164-7-17**] with evidence of wound infection from the operative
site, who is now s/p I&D and left knee liner exchange ([**2164-7-18**])
who has evidence of active infection with wound cultures
speciating coagulase positive Staphylococcus aureus (on
Vancomycin IV originally, now Nafcilin). Infectious Disease has
been consulted. Given his multiple comorbidities and his recent
hospitalization and post-operative course complicated by COPD
and acute diastolic failure exacerbation and active infectious
issues, requesting transfer to medical service.

Past Medical History:
PAST MEDICAL & SURGICAL HISTORY:
1. Insulin-dependent diabetes mellitus (last HbA1c 7.0% without
retinopathy; some evidence of peripheral neuropathy and chronic
diabetic nephropathy)
2. Coronary artery disease
3. Chronic diastolic dysfunction (had negative persantine-MIBI
study prior to knee replacement)
4. Chronic obstructive pulmonary disease
5. Obstructive sleep apnea (on CPAP, but rarely utilizes this)
6. Colonic adenocarcinoma (s/p exploratory laparotomy, subtotal
colectomy, cystectomy and ileal sigmoid anastomosis, [**2161-10-29**]
complicated by CVA/stroke without residual deficits)
7. Peripheral neuropathy (decreased sensation in the bilateral
lower extremities)
8. Hypertension
9. Hyperlipidemia
10. Glaucoma
11. Degenerative arthritis
12. Benign prostatic hypertrophy
13. Gout
14. Peripheral vascular disease (s/p left-to-right SFA
angioplasty; amputation of the right 5th digit - [**7-/2152**])
15. Unspecified psychiatric diagnosis
16. s/p left total knee replacement ([**2164-6-18**])
17. s/p right inguinal hernia repair
18. s/p appendectomy

Social History:
Patient lives at home with wife. Denies tobacco use or alcohol
use; no recreational substance use. Patient is independent in
ADLs and ambulates unassisted.

Family History:
Denies significant family history of cardiovascular disease,
early MI, arrhythmia or sudden cardiac death. Denies family
history of malignancy.

Physical Exam:
Admission Physical Exam:
VITALS: 99.4, 87, 133/59, 18, 97% on 2L
GENERAL: Appears in no acute distress. Alert and interactive.
Well nourished appearing.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist.
NECK: supple without lymphadenopathy. JVD 8-cm.
CVS: Regular rate and rhythm, without murmurs, rubs or gallops.
S1 and S2 normal.
RESP: Clear to auscultation bilaterally without adventitious
sounds. No wheezing, rhonchi or crackles. Stable inspiratory
effort.
ABD: obese, soft, non-tender, non-distended, with normoactive
bowel sounds. No palpable masses or peritoneal signs.
EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses.
Large bandage on L knee with drain producing sanguinous
material.
NEURO: CN II-XII intact throughout. Alert and oriented x 3. DTRs
2+ throughout, strength 5/5 bilaterally, sensation grossly
intact. Gait deferred.

Discharge Physical Exam:
VS 98.2/99.3; 140-170s/70s; 80; 18; 99RA
NECK: supple without lymphadenopathy. JVP not elevated
CVS: RRR, no MRG, S1 and S2 normal
RESP: CTAB. No wheezing, rhonchi or crackles. Stable inspiratory
effort
ABD: Obese, soft, non-tender, non-distended, with normoactive
bowel sounds. No palpable masses or peritoneal signs
EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses. L.
knee incision C/D/I, sutures in place, minimal serosanginous
drainage
Exam otherwise unchanged since admission

Pertinent Results:
ADMISSION LABS:
[**2164-7-18**] 06:53AM BLOOD WBC-14.1* RBC-3.43* Hgb-10.6* Hct-31.7*
MCV-92 MCH-30.8 MCHC-33.4 RDW-14.4 Plt Ct-237
[**2164-7-18**] 06:53AM BLOOD PT-12.0 PTT-26.2 INR(PT)-1.1
[**2164-7-18**] 06:53AM BLOOD Glucose-136* UreaN-36* Creat-1.7* Na-135
K-4.5 Cl-101 HCO3-28 AnGap-11
[**2164-7-20**] 07:06AM BLOOD ALT-66* AST-35 LD(LDH)-223 AlkPhos-100
TotBili-1.2
[**2164-7-18**] 06:53AM BLOOD Calcium-8.0* Phos-3.4 Mg-1.8
[**2164-7-20**] 07:06AM BLOOD CRP-188.0*

DISCHARGE LABS:
[**2164-7-24**] 06:47AM BLOOD WBC-10.5 RBC-3.25* Hgb-9.5* Hct-29.6*
MCV-91 MCH-29.1 MCHC-32.0 RDW-14.4 Plt Ct-307
[**2164-7-24**] 06:47AM BLOOD Glucose-149* UreaN-18 Creat-1.9* Na-137
K-3.9 Cl-101 HCO3-26 AnGap-14
[**2164-7-24**] 06:47AM BLOOD Calcium-8.3* Phos-3.3 Mg-1.5*

Relevant Micro:
[**2164-7-21**] 9:09 am STOOL     CONSISTENCY: NOT APPLICABLE
      Source: Stool.
                            **FINAL REPORT [**2164-7-22**]**
   C. difficile DNA amplification assay (Final [**2164-7-22**]):
      Negative for toxigenic C. difficile by the Illumigene DNA
      amplification assay.
           (Reference Range-Negative)

[**2164-7-18**] 4:45 pm SWAB     Site: KNEE      LEFT KNEE.
                            **FINAL REPORT [**2164-7-22**]**

   GRAM STAIN (Final [**2164-7-18**]):
      4+   (>10 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      2+   (1-5 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND CLUSTERS.

   WOUND CULTURE (Final [**2164-7-21**]):
      STAPH AUREUS COAG +.    SPARSE GROWTH.
         SENSITIVITIES PERFORMED ON CULTURE # 353-0389A [**2164-7-17**].

      ENTEROCOCCUS SP..    SPARSE GROWTH.
         SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 112049**]
([**2164-7-17**]).

   ANAEROBIC CULTURE (Final [**2164-7-22**]):    NO ANAEROBES ISOLATED

[**2164-7-18**] 4:45 pm TISSUE     Site: KNEE      LEFT KNEE.

                            **FINAL REPORT [**2164-7-22**]**

   GRAM STAIN (Final [**2164-7-18**]):
      3+  (5-10 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      1+    (<1 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND CLUSTERS.

   TISSUE (Final [**2164-7-21**]):
      STAPH AUREUS COAG +.    SPARSE GROWTH.
         SENSITIVITIES PERFORMED ON CULTURE # 353-0389A [**2164-7-17**].

      ENTEROCOCCUS SP..
         Isolated from broth media only, INDICATING VERY LOW
NUMBERS OF
         ORGANISMS.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ENTEROCOCCUS SP.
                             |
AMPICILLIN------------   <=2 S
PENICILLIN G----------     4 S
VANCOMYCIN------------     1 S

   ANAEROBIC CULTURE (Final [**2164-7-22**]):    NO ANAEROBES ISOLATED.


[**2164-7-18**] 4:52 pm TISSUE     Site: KNEE      LEFT KNEE SYNOVIUM.

                            **FINAL REPORT [**2164-7-22**]**

   GRAM STAIN (Final [**2164-7-18**]):
      3+  (5-10 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      1+    (<1 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND CLUSTERS.

   TISSUE (Final [**2164-7-21**]):
      STAPH AUREUS COAG +.    SPARSE GROWTH.
         SENSITIVITIES PERFORMED ON CULTURE # 353-0389A [**2164-7-17**].

      ENTEROCOCCUS SP..    RARE GROWTH.
         SENSITIVITIES PERFORMED ON CULTURE # 353-1229A [**2164-7-18**].


   ANAEROBIC CULTURE (Final [**2164-7-22**]):    NO ANAEROBES ISOLATED.


[**2164-7-17**] 5:41 pm JOINT FLUID      Source: KneeLeft.

                            **FINAL REPORT [**2164-7-20**]**

   GRAM STAIN (Final [**2164-7-17**]):
      4+   (>10 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      3+  (5-10 per 1000X FIELD):   GRAM POSITIVE COCCI SINGLY
AND IN
      PAIRS.
      Reported to and read back by [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 112050**].

   FLUID CULTURE (Final [**2164-7-20**]):
      STAPH AUREUS COAG +.    SPARSE GROWTH.
         Staphylococcus species may develop resistance during
prolonged
         therapy with quinolones.   Therefore, isolates that are
initially
         susceptible may become resistant within three to four
days after
         initiation of therapy.  Testing of repeat isolates may
be
         warranted.
         REPORTED RIFAMPIN SENSITIVITY PER DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 112051**]
[**2164-7-20**].

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------   0.5 S
OXACILLIN-------------   0.5 S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------   <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S

Relevant Radiology:

CXR [**2164-7-20**]:
IMPRESSION:  Right PICC line in position with the tip in the low
SVC,
otherwise unremarkable chest radiograph.

Brief Hospital Course:
Pt is 65 year old man with multiple comorbidities (Diabetes,
chronic obstructive pulmonary disease, congestive heart failure,
chronic kidney disease, and hypertension) presenting with
infection to L knee several weeks out from knee replacement
surgery.

Active Issues:

# Prosthetic joint infection: Patient underwent washout of the
post-operative Left knee on [**2164-7-18**] and was found to be infected
with MSSA and enterococcus.  He was initially treated with
vancomycin that was later switched to nafcillin when the
sensitivity was known.  However, when cultures came back
positive also with enterococcus, patient switched back on
Vancomycin, at 1250mg IV q24 on [**7-22**] based on CrCl.  Will need
his vanc trough checked prior to his dose on [**7-25**] PM, and adjust
accordingly, to target trough of 15-20.  Pain was successfully
controlled with PRN oxycodone.  Patient will follow up with
outpatient ID.  Will require weekly surveillance labs with CBC,
BMP, LFTs, and vanc trough to be faxed to [**Telephone/Fax (1) 1419**].

# Acute on chronic Kidney Injury:  The patient has chronic
kidney disease, baseline Cr. ~1.7.  His creatinine began to rise
on [**2164-7-20**], peaked at 2.4.  This was attributed to his
nafcillin.  He was changed to vancomycin and Cr. decreased to
1.9.

Chronic Issues:

# Diabetes:  The patient was maintained on 30 units glargine at
breakfast and 20 units at bedtime with sliding scale through the
day.  Please adjust accordingly at rehab.

# Chronic Obstructive Pulmonary Disease:  During his prior
hospitalization several weeks prior the patient required
intubation due to respiratory failure.  However, during this
stay there were no issues and he was maintained on his home
medications.

# Congestive Heart Failure:  There have been no major
complications and he was continued on his prior medications. No
evidence of clinical heart failure during this admission.
Consider starting ACE-i when Cr stable.

# Hypertension:  Blood pressure was controlled.  Uptitrated
metroprolol from 50BID to 75BID.  Consider starting ACE-i when
Cr. stable.

# Prior Stroke/TIA:  There were no residual deficits.  He was
continued on prior blood pressure medications and aspirin.

# Transitional issues:
- Follow up with Ortho, ID
- code status: full code
- medication changes: started vanc, uptitrated metoprolol

Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Theophylline SR 200 mg PO BID
2. Metoprolol Tartrate 50 mg PO BID
3. Amlodipine 10 mg PO DAILY
4. Vitamin D 1000 UNIT PO DAILY
5. Aspirin 81 mg PO DAILY
6. Simvastatin 20 mg PO DAILY
7. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES [**Hospital1 **]
8. Betaxolol Ophth Susp  0.25% 1 DROP RIGHT EYE DAILY
9. Acetaminophen 650 mg PO Q6H:PRN pain
10. PredniSONE 10 mg po daily Duration: 3 Days
11. PredniSONE 5 mg po daily Duration: 5 Days Start: After 10 mg
tapered dose.
12. Acetaminophen w/Codeine 1 TAB PO Q4H:PRN pain
13. Tiotropium Bromide 1 CAP IH DAILY
14. Fluticasone-Salmeterol Diskus (250/50)  1 INH IH [**Hospital1 **]
15. Xopenex Neb *NF* 1.25 mg/0.5 mL Inhalation Q6
16. Allopurinol 300 mg PO DAILY
17. Pantoprazole 40 mg PO Q24H
18. Multivitamins 1 TAB PO DAILY
19. Ferrous Sulfate 325 mg PO DAILY


Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Betaxolol Ophth Susp  0.25% 1 DROP RIGHT EYE DAILY
5. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES [**Hospital1 **]
6. Fluticasone-Salmeterol Diskus (250/50)  1 INH IH [**Hospital1 **]
7. Metoprolol Tartrate 75 mg PO BID
Hold for SBP < 110 or HR < 55
8. PredniSONE 5 mg PO DAILY Duration: 3 Days
last day [**7-26**]
9. Theophylline SR 200 mg PO BID
10. Simvastatin 20 mg PO DAILY
11. Tiotropium Bromide 1 CAP IH DAILY
12. Vitamin D 1000 UNIT PO DAILY
13. Xopenex Neb *NF* 1.25 mg/0.5 mL Inhalation Q6
14. Docusate Sodium 100 mg PO BID
15. Enoxaparin Sodium 30 mg SC Q12H
16. Glargine 30 Units Breakfast
Glargine 20 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
17. OxycoDONE (Immediate Release)  5-10 mg PO Q4H:PRN Pain
18. Senna 1 TAB PO BID
19. Vancomycin 1250 mg IV Q 24H
20. Allopurinol 150 mg PO DAILY
21. Multivitamins 1 TAB PO DAILY
22. Pantoprazole 40 mg PO Q24H
23. Ferrous Sulfate 325 mg PO DAILY


Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
Left knee infection
Chronic obstructive pulmonary disease exacerbation
Acute on chronic kidney injury
Congestive heart failure
Hypertension


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
Mr. [**Known lastname **],

You were admitted to the hospital for a infected hardware in
your left knee. Our orthopaedics team cleaned out the infection
in your knee and replaced the liner of your prosthesis. They
feel you should follow up with your primary orthopaedic doctor,
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3646**] at [**Hospital3 **] ([**Telephone/Fax (1) 103978**]), for ongoing
issues about your knee. The cultures of the infection in your
knee grew two different organisms, so we consulted our
infectious disease doctors who recommended a course of IV
antibiotics to help treat your infection. Because this infection
occured inside of a joint, a longer course of antibiotics is
required.

We made the following changes to your medications:
Started:
Vancomycin (antibiotic)

Increased metoprolol for blood pressure

Followup Instructions:
Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 112052**], MD
Specialty: Orthopedics
When: Tuesday [**2164-7-31**] at 10:15am
Location: COMMUNITY PHYSICIANS ASSOCIATES
Address: [**Street Address(2) 4472**], [**Apartment Address(1) 112053**], [**Hospital1 **],[**Numeric Identifier 4474**]
Phone: [**Telephone/Fax (1) 103978**]

Department: INFECTIOUS DISEASE
When: MONDAY [**2164-8-13**] at 11:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: INFECTIOUS DISEASE
When: FRIDAY [**2164-9-7**] at 9:30 AM
With: [**Name6 (MD) 27568**] [**Name8 (MD) 27569**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Name: [**Name6 (MD) **] [**Name8 (MD) **], MD
Specialty: Primary Care
Address: [**Street Address(2) 4472**], [**Apartment Address(1) 51742**], [**Hospital1 **],[**Numeric Identifier 9331**]
Phone: [**Telephone/Fax (1) 31188**]
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.






Name:  [**Known lastname **],[**Known firstname **]                   Unit No:   [**Numeric Identifier 18400**]

Admission Date:  [**2164-7-17**]              Discharge Date:   [**2164-8-13**]

Date of Birth:  [**2098-11-24**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 342**]
Addendum:
This is an addendum to the prior discharge summary dated [**7-25**]
for patient [**Known lastname **], [**Known firstname **].

The patient was being prepared for discharge on the afternoon of
[**7-24**] (HD #8), but after recommendation by orthopaedics, it was
decided to take the patient to the OR again the following day
(HD #9) for a repeat washout of his right knee. Purulence was
noted within the joint space, and this was sent for reculture,
which grew rare GPCs. He tolerated the procedure well although
developed worsening anemia over the next day (Hgb 7.0 Hct 21.9),
although he remained asymptomatic. Due to his history of CAD he
was transfused 2 units of pRBCs with response in his blood
counts (Hgb 8.5 Hct 26.1). On HD #10 the patient developed
worsening [**Last Name (un) **] with a creatinine of 2.6. He was given gentle IV
hydration, however, his creatinine remained elevated at 2.6.
Orthopaedics removed his drain given that its output had
significantly decreased. His dosing of vancomycin was decreased
to 1000mg IV q24hrs, as his trough on [**7-28**] showed a
supratherapeutic level due to his altering in kidney function.
The patient was taken back to the OR on [**8-4**] at which time, due
to continued infection of his prosthesis, he had complete
removal of the hardware in his left knee. Following that
procedure, the patient failed extubation, likely due to a COPD
flare, and developed hypoxemic respiratory failure requiring
re-intubation and a short stay in the MICU. He improved
progressively and was extubated on [**8-5**] and transfered to the
floor. Once on the floor, intraoperative specimens began to go
enterobacter, so cefepime was added to his vancomycin on the
recommendation of ID. He was taken back to the OR for another
washout on [**8-6**] which was tolerated well, with noted significant
improvement in the character of his wound. On [**8-9**] he was taken
a final time to the OR with a washout performed by orthopaedics,
and assistance from plastic surgery performing a left
gastrocnemius flap and split thickness skin graft for improved
coverage of his knee wound. He is to be non-weight bearing on
his left lower extremity and keep his knee in the immobilizer at
all times. He should keep his leg elevated when possible to
prevent vascular congestion of his flap. Per IDs recommendation
he will need a continued 6 week course of outpatient
antibiotics, consisting of vancomycin and ceftriaxone. He will
follow up with his primary orthopaedic surgeon at [**Hospital1 11622**], as well as with ID and plastics here. At the time of
discharge, his renal function had stabilized, and his creatinine
remained at 2.0.

At the time of discharge, he is afebrile, with stable vital
signs, and his post-op pain is well controlled on oral
medications. He will be discharge to LTAC with follow up
appointments with his PCP and his primary orthopaedic surgeon at
[**Hospital3 3287**].

Chief Complaint:
Knee Pain

Major Surgical or Invasive Procedure:
[**7-18**]: Washout and debridement left knee with revision 1
component.
[**7-25**]: Staged debridement irrigation via arthrotomy
[**8-4**]:  Resection arthroplasty of septic left TKR (all
components); insertion of tobra/vanco spacer; VACUUM drainage
Staged debridement and irrigation, exchange of
antibiotic spacer, placement of vacuum sponge.
[**8-7**]: 1. Arthrotomy and debridement left knee.
2. Removal and reinsertion of cement spacer.
3. Application of vacuum-assisted closure sponge left knee.


History of Present Illness:
This is a 65 year-old Male with a PMH significant for
insulin-dependent diabetes mellitus (complicated by peripheral
neuropathy and chronic diabetic nephropathy), coronary artery
disease, chronic diastolic dysfunction, chronic obstructive
pulmonary disease, prior colonic adenocarcinoma, hypertension,
hyperlipidemia, peripheral vascular disease, glaucoma and
degenerative arthritis who was admitted following a total left
knee replacement on [**2164-6-18**] at [**Hospital3 3287**] complicated by
acute exacerbation of his COPD requiring intubation, acute on
chronic diastolic dysfunction. He initially presented to [**Hospital1 8**]
on [**2164-7-17**] with evidence of wound infection from the operative
site, who is now s/p I&D and left knee liner exchange ([**2164-7-18**])
who has evidence of active infection with wound cultures
speciating coagulase positive Staphylococcus aureus (on
Vancomycin IV originally, now Nafcilin). Infectious Disease has
been consulted. Given his multiple comorbidities and his recent
hospitalization and post-operative course complicated by COPD
and acute diastolic failure exacerbation and active infectious
issues, requesting transfer to medical service.


Past Medical History:
PAST MEDICAL & SURGICAL HISTORY:
1. Insulin-dependent diabetes mellitus (last HbA1c 7.0% without
retinopathy; some evidence of peripheral neuropathy and chronic
diabetic nephropathy)
2. Coronary artery disease
3. Chronic diastolic dysfunction (had negative persantine-MIBI
study prior to knee replacement)
4. Chronic obstructive pulmonary disease
5. Obstructive sleep apnea (on CPAP, but rarely utilizes this)
6. Colonic adenocarcinoma (s/p exploratory laparotomy, subtotal
colectomy, cystectomy and ileal sigmoid anastomosis, [**2161-10-29**]
complicated by CVA/stroke without residual deficits)
7. Peripheral neuropathy (decreased sensation in the bilateral
lower extremities)
8. Hypertension
9. Hyperlipidemia
10. Glaucoma
11. Degenerative arthritis
12. Benign prostatic hypertrophy
13. Gout
14. Peripheral vascular disease (s/p left-to-right SFA
angioplasty; amputation of the right 5th digit - [**7-/2152**])
15. Unspecified psychiatric diagnosis
16. s/p left total knee replacement ([**2164-6-18**])
17. s/p right inguinal hernia repair
18. s/p appendectomy

Social History:
Patient lives at home with wife. Denies tobacco use or alcohol
use; no recreational substance use. Patient is independent in
ADLs and ambulates unassisted.


Family History:
Denies significant family history of cardiovascular disease,
early MI, arrhythmia or sudden cardiac death. Denies family
history of malignancy.

Physical Exam:
Admission Physical Exam:
VITALS: 99.4, 87, 133/59, 18, 97% on 2L
GENERAL: Appears in no acute distress. Alert and interactive.
Well nourished appearing.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist.
NECK: supple without lymphadenopathy. JVD 8-cm.
CVS: Regular rate and rhythm, without murmurs, rubs or gallops.
S1 and S2 normal.
RESP: Clear to auscultation bilaterally without adventitious
sounds. No wheezing, rhonchi or crackles. Stable inspiratory
effort.
ABD: obese, soft, non-tender, non-distended, with normoactive
bowel sounds. No palpable masses or peritoneal signs.
EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses.
Large bandage on L knee with drain producing sanguinous
material.
NEURO: CN II-XII intact throughout. Alert and oriented x 3. DTRs

2+ throughout, strength 5/5 bilaterally, sensation grossly
intact. Gait deferred.

Discharge Physical Exam:
VS 98.2/99.3; 140-170s/70s; 80; 18; 99RA
NECK: supple without lymphadenopathy. JVP not elevated
CVS: RRR, no MRG, S1 and S2 normal
RESP: CTAB. No wheezing, rhonchi or crackles. Stable inspiratory

effort
ABD: Obese, soft, non-tender, non-distended, with normoactive
bowel sounds. No palpable masses or peritoneal signs
EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses. L.
knee wrapped and in immobilizer, minimal serosanginous
drainage
Exam otherwise unchanged since admission


Pertinent Results:
[**2164-8-13**] 03:45AM BLOOD WBC-7.9 RBC-2.74* Hgb-8.1* Hct-25.6*
MCV-94 MCH-29.8 MCHC-31.8 RDW-15.6* Plt Ct-314
[**2164-8-12**] 05:54AM BLOOD WBC-7.6 RBC-2.69* Hgb-8.1* Hct-24.9*
MCV-93 MCH-30.1 MCHC-32.4 RDW-15.6* Plt Ct-283
[**2164-8-11**] 11:21PM BLOOD WBC-8.6 RBC-2.58* Hgb-8.0* Hct-23.9*
MCV-93 MCH-31.1 MCHC-33.5 RDW-15.5 Plt Ct-277
[**2164-8-13**] 03:45AM BLOOD Plt Ct-314
[**2164-8-9**] 12:50AM BLOOD PT-12.4 PTT-31.9 INR(PT)-1.1
[**2164-8-13**] 03:45AM BLOOD Glucose-155* UreaN-14 Creat-1.9* Na-134
K-4.0 Cl-105 HCO3-25 AnGap-8
[**2164-8-13**] 03:45AM BLOOD Calcium-7.9* Phos-2.6* Mg-1.6

Brief Hospital Course:
As above

Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Theophylline SR 200 mg PO BID
2. Metoprolol Tartrate 50 mg PO BID
3. Amlodipine 10 mg PO DAILY
4. Vitamin D 1000 UNIT PO DAILY
5. Aspirin 81 mg PO DAILY
6. Simvastatin 20 mg PO DAILY
7. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES [**Hospital1 **]
8. Betaxolol Ophth Susp  0.25% 1 DROP RIGHT EYE DAILY
9. Acetaminophen 650 mg PO Q6H:PRN pain
10. PredniSONE 10 mg po daily Duration: 3 Days
11. PredniSONE 5 mg po daily Duration: 5 Days Start: After 10 mg
tapered dose.
12. Acetaminophen w/Codeine 1 TAB PO Q4H:PRN pain
13. Tiotropium Bromide 1 CAP IH DAILY
14. Fluticasone-Salmeterol Diskus (250/50)  1 INH IH [**Hospital1 **]
15. Xopenex Neb *NF* 1.25 mg/0.5 mL Inhalation Q6
16. Allopurinol 300 mg PO DAILY
17. Pantoprazole 40 mg PO Q24H
18. Multivitamins 1 TAB PO DAILY
19. Ferrous Sulfate 325 mg PO DAILY


Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Betaxolol Ophth Susp  0.25% 1 DROP RIGHT EYE DAILY
5. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES [**Hospital1 **]
6. Fluticasone-Salmeterol Diskus (250/50)  1 INH IH [**Hospital1 **]
7. Theophylline SR 200 mg PO BID
8. Simvastatin 20 mg PO DAILY
9. Tiotropium Bromide 1 CAP IH DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Xopenex Neb *NF* 1.25 mg/0.5 mL Inhalation Q6
12. Docusate Sodium 100 mg PO BID
13. Glargine 30 Units Breakfast
Glargine 20 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
14. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tab by mouth once a day Disp
#*60 Tablet Refills:*2
15. Multivitamins 1 TAB PO DAILY
16. Pantoprazole 40 mg PO Q24H
17. Ferrous Sulfate 325 mg PO DAILY
18. Outpatient Lab Work
On OPAT regimen. Please check CBC, BMP, LFTs and vancomycine
trough to be faxed to [**Hospital1 8**] OPAT [**Telephone/Fax (1) 1021**]
ICD-9: 711.06 Pyogenic arthritis, lower leg

19. Allopurinol 150 mg PO DAILY
20. Vancomycin 750 mg IV Q 24H
RX *vancomycin 750 mg 750mg daily Disp #*30 Vial Refills:*2
21. Sodium Chloride 0.9%  Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
RX *sodium chloride 0.9 % [Normal Saline Flush] 0.9 % Please use
as prescribed Daily Disp #*30 Syringe Refills:*2
22. OxycoDONE (Immediate Release)  10 mg PO Q3H:PRN Pain
23. Miconazole Powder 2% 1 Appl TP [**Hospital1 **]
To affected region
24. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
25. Metoprolol Tartrate 75 mg PO BID
Hold for SBP < 110 or HR < 55
26. Heparin 5000 UNIT SC TID
27. CeftriaXONE 1 gm IV Q24H


Discharge Disposition:
Extended Care

Facility:
Radius Specialty [**First Name9 (NamePattern2) 18401**] [**Hospital1 3983**]

Discharge Diagnosis:
Left knee infection
Chronic obstructive pulmonary disease exacerbation
Acute on chronic kidney injury
Congestive heart failure
Hypertension


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
Mr. [**Known lastname **],

You were admitted to the hospital for a infected hardware in
your left knee. Our orthopaedics team cleaned out the infection
in your knee and replaced the liner of your prosthesis. They
feel you should follow up with your primary orthopaedic doctor,
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Hospital3 3287**] ([**Telephone/Fax (1) 18402**]), for ongoing
issues about your knee. The cultures of the infection in your
knee grew two different organisms, so we consulted our
infectious disease doctors who recommended a course of IV
antibiotics to help treat your infection. Because this infection
occured inside of a joint, a longer course of antibiotics is
required. You went multiple times to the operating room to
wash-out your knee of any remaining infection, and your hardware
was removed. Most recently you had a portion of tissue grafted
to your knee to provide for better coverage of your wound, along
with skin graft. Your kidney function worsened while you were in
the hospital but it appears to have normalized. This should be
followed up with your primary care physician.

We made the following changes to your medications:
Started:
Vancomycin (antibiotic)
Ceftriaxone (antibiotic)

Increased metoprolol for blood pressure

Followup Instructions:
Department: PLASTIC SURGERY
When: WEDNESDAY [**2164-8-22**] at 3:15 PM
With: [**Known firstname **] [**Last Name (NamePattern4) 462**], MD [**Telephone/Fax (1) 18403**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) 3895**]) [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: COMMUNITY PHYSICIANS ASSOCIATES
Address: [**Street Address(2) 18404**], [**Apartment Address(1) 18405**], [**Hospital1 **],[**Numeric Identifier 18406**]
Phone: [**Telephone/Fax (1) 18402**]
Appointment: Thursday [**2164-8-23**] 1:15pm

Department: INFECTIOUS DISEASE
When: FRIDAY [**2164-9-7**] at 9:30 AM
With: [**Name6 (MD) 18407**] [**Name8 (MD) 18408**], MD [**Telephone/Fax (1) 496**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) 3895**]) [**Hospital 12881**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Name: NABI,[**Name8 (MD) 18362**] MD
Address: [**Street Address(2) 18404**], [**Apartment Address(1) 18409**], [**Hospital1 **],[**Numeric Identifier 18406**]
Phone: [**Telephone/Fax (1) 18363**]
**Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.


Department: PLASTIC SURGERY
When: WEDNESDAY [**2164-8-15**] at 3:15 PM
With: [**Known firstname **] [**Last Name (NamePattern4) 462**], MD [**Telephone/Fax (1) 18403**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) 3895**]) [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: INFECTIOUS DISEASE
When: FRIDAY [**2164-9-7**] at 9:30 AM
With: [**Name6 (MD) 18407**] [**Name8 (MD) 18408**], MD [**Telephone/Fax (1) 496**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) 3895**]) [**Hospital 12881**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 347**] MD [**MD Number(1) 348**]

Completed by:[**2164-8-13**]
{'Infection and inflammatory reaction due to internal joint prosthesis,Acute kidney failure with lesion of tubular necrosis,Acute respiratory failure following trauma and surgery,Pyogenic arthritis, lower leg,Chronic diastolic heart failure,Acute posthemorrhagic anemia,Knee joint replacement,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Accidents occurring in residential institution,Chronic airway obstruction, not elsewhere classified,Coronary atherosclerosis of native coronary artery,Obstructive sleep apnea (adult)(pediatric),Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Personal history of malignant neoplasm of large intestine,Unspecified glaucoma,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Long-term (current) use of insulin,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Encounter for change or removal of surgical wound dressing,Other alteration of consciousness,Pressure ulcer, buttock,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate)'}


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: Knee pain

PRESENT ILLNESS: This is a 65 year-old Male with a PMH significant for
insulin-dependent diabetes mellitus (complicated by peripheral
neuropathy and chronic diabetic nephropathy), coronary artery
disease, chronic diastolic dysfunction, chronic obstructive
pulmonary disease, prior colonic adenocarcinoma, hypertension,
hyperlipidemia, peripheral vascular disease, glaucoma and
degenerative arthritis who was admitted following a total left
knee replacement on [**2164-6-18**] at [**Hospital3 **] complicated by
acute exacerbation of his COPD requiring intubation, acute on
chronic diastolic dysfunction. He initially presented to [**Hospital1 18**]
on [**2164-7-17**] with evidence of wound infection from the operative
site, who is now s/p I&D and left knee liner exchange ([**2164-7-18**])
who has evidence of active infection with wound cultures
speciating coagulase positive Staphylococcus aureus (on
Vancomycin IV originally, now Nafcilin). Infectious Disease has
been consulted. Given his multiple comorbidities and his recent
hospitalization and post-operative course complicated by COPD
and acute diastolic failure exacerbation and active infectious
issues, requesting transfer to medical service.

MEDICAL HISTORY: PAST MEDICAL & SURGICAL HISTORY:
1. Insulin-dependent diabetes mellitus (last HbA1c 7.0% without
retinopathy; some evidence of peripheral neuropathy and chronic
diabetic nephropathy)
2. Coronary artery disease
3. Chronic diastolic dysfunction (had negative persantine-MIBI
study prior to knee replacement)
4. Chronic obstructive pulmonary disease
5. Obstructive sleep apnea (on CPAP, but rarely utilizes this)
6. Colonic adenocarcinoma (s/p exploratory laparotomy, subtotal
colectomy, cystectomy and ileal sigmoid anastomosis, [**2161-10-29**]
complicated by CVA/stroke without residual deficits)
7. Peripheral neuropathy (decreased sensation in the bilateral
lower extremities)
8. Hypertension
9. Hyperlipidemia
10. Glaucoma
11. Degenerative arthritis
12. Benign prostatic hypertrophy
13. Gout
14. Peripheral vascular disease (s/p left-to-right SFA
angioplasty; amputation of the right 5th digit - [**7-/2152**])
15. Unspecified psychiatric diagnosis
16. s/p left total knee replacement ([**2164-6-18**])
17. s/p right inguinal hernia repair
18. s/p appendectomy

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Theophylline SR 200 mg PO BID
2. Metoprolol Tartrate 50 mg PO BID
3. Amlodipine 10 mg PO DAILY
4. Vitamin D 1000 UNIT PO DAILY
5. Aspirin 81 mg PO DAILY
6. Simvastatin 20 mg PO DAILY
7. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES [**Hospital1 **]
8. Betaxolol Ophth Susp  0.25% 1 DROP RIGHT EYE DAILY
9. Acetaminophen 650 mg PO Q6H:PRN pain
10. PredniSONE 10 mg po daily Duration: 3 Days
11. PredniSONE 5 mg po daily Duration: 5 Days Start: After 10 mg
tapered dose.
12. Acetaminophen w/Codeine 1 TAB PO Q4H:PRN pain
13. Tiotropium Bromide 1 CAP IH DAILY
14. Fluticasone-Salmeterol Diskus (250/50)  1 INH IH [**Hospital1 **]
15. Xopenex Neb *NF* 1.25 mg/0.5 mL Inhalation Q6
16. Allopurinol 300 mg PO DAILY
17. Pantoprazole 40 mg PO Q24H
18. Multivitamins 1 TAB PO DAILY
19. Ferrous Sulfate 325 mg PO DAILY

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Physical Exam:
VITALS: 99.4, 87, 133/59, 18, 97% on 2L
GENERAL: Appears in no acute distress. Alert and interactive.
Well nourished appearing.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist.
NECK: supple without lymphadenopathy. JVD 8-cm.
CVS: Regular rate and rhythm, without murmurs, rubs or gallops.
S1 and S2 normal.
RESP: Clear to auscultation bilaterally without adventitious
sounds. No wheezing, rhonchi or crackles. Stable inspiratory
effort.
ABD: obese, soft, non-tender, non-distended, with normoactive
bowel sounds. No palpable masses or peritoneal signs.
EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses.
Large bandage on L knee with drain producing sanguinous
material.
NEURO: CN II-XII intact throughout. Alert and oriented x 3. DTRs
2+ throughout, strength 5/5 bilaterally, sensation grossly
intact. Gait deferred.

FAMILY HISTORY: Denies significant family history of cardiovascular disease,
early MI, arrhythmia or sudden cardiac death. Denies family
history of malignancy.

SOCIAL HISTORY: Patient lives at home with wife. Denies tobacco use or alcohol
use; no recreational substance use. Patient is independent in
ADLs and ambulates unassisted. 

### Response:
{'Infection and inflammatory reaction due to internal joint prosthesis,Acute kidney failure with lesion of tubular necrosis,Acute respiratory failure following trauma and surgery,Pyogenic arthritis, lower leg,Chronic diastolic heart failure,Acute posthemorrhagic anemia,Knee joint replacement,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Accidents occurring in residential institution,Chronic airway obstruction, not elsewhere classified,Coronary atherosclerosis of native coronary artery,Obstructive sleep apnea (adult)(pediatric),Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Personal history of malignant neoplasm of large intestine,Unspecified glaucoma,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Long-term (current) use of insulin,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Encounter for change or removal of surgical wound dressing,Other alteration of consciousness,Pressure ulcer, buttock,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate)'}
