CHIEF COMPLAINT: Purulent drainage from previous surgical site

PRESENT ILLNESS: This is a 47 year old man with metastatic Renal Cell Carcinoma
status post T9-L2 fusion with Dr. [**Last Name (STitle) 548**] on [**2111-10-8**]. He
finished chemotherapy several weeks ago. He has not had
radiation since his surgery. He was doing well when he saw Dr.
[**Last Name (STitle) 548**] on [**2111-11-10**]. He reports that he developed more back pain
and lethargy during the past 2 weeks. He was at home and was in
bed most of the day. He can ambulate short distances
independently. On the day of admission, he developed new
purulent drainage from his thoracic wound. He denied lower
extremity pain, paresthesias or numbness. He had no
incontinence. He denied fever, chills, diaphoresis.

MEDICAL HISTORY: - Renal Cell Carcinoma (please see below)
- h/o RLE DVT [**8-/2107**]
- Colonic perforation
- Hyponatremia
- Anemia
- Cervical surgery with rod-placement due to C2 met
-[**2110-11-14**] Right colectomy, Segment VI partial liver resection,
resection of retroperitoneal tumor mass; ileal transverse
colostomy anastomosis (side to side). - T9-L2 posterior fusion
with T11 vertebrectomy

MEDICATION ON ADMISSION: -fentanyl 400 mcg/hour Patch 72 hr
-hydromorphone 2 mg Tablet  [**12-6**] Tablet(s) by mouth as needed,
for
breakthrough pain
-lorazepam 1 mg Tablet 1 Tablet(s) by mouth every eight (8)
hours
as needed for anxiety
-methadone 5 mg Tablet 0.5 (One half) Tablet(s) by mouth twice a
day
-ondansetron HCl 8 mg Tablet 1 Tablet(s) by mouth every eight
(8)
hours as needed for nausea/vomiting
-prochlorperazine maleate 10 mg Tablet  1 Tablet(s) by mouth
every
six (6) hours as needed for nausea/vomiting
-Scopolamine patch

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: PHYSICAL EXAM:
O: T: 97.6 F  BP: 104/71 HR: 51 R 20 O2Sats 95 % RA
Gen: NAD at rest, cachectic
T/L spine wound: mild dehiscence, purulent drainage saturating
dressing. No active drainage. Erythema at wound and areas of
tape.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Motor:Moves LE with good strength. Testing causes significant
back pain.
Sensation: Intact to light touch
Reflexes: Pa Ac
Right     1  0
Left      2  0
No clonus

FAMILY HISTORY: Mother died of a brain tumor. Father diagnosed with prostate
cancer in his 70s and is still living. He has 3 siblings and 2
children without medical concerns. Maternal aunt with lymphoma.
Father and sister have had h/o "blood clots."

SOCIAL HISTORY: Married and lives with wife.
Infection and inflammatory reaction due to other internal orthopedic device, implant, and graft,Intraspinal abscess,Fistula of intestine, excluding rectum and anus,Hyposmolality and/or hyponatremia,Secondary malignant neoplasm of brain and spinal cord,Secondary malignant neoplasm of lung,Body Mass Index less than 19, adult,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Anemia, unspecified,Other acute postoperative pain,Retention of urine, unspecified,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Personal history of malignant neoplasm of kidney,Arthrodesis status,Personal history of antineoplastic chemotherapy,Personal history of venous thrombosis and embolism,Acquired absence of intestine (large) (small),Colostomy status,Personal history of irradiation, presenting hazards to health
React-oth int ortho dev,Intraspinal abscess,Intestinal fistula,Hyposmolality,Sec mal neo brain/spine,Secondary malig neo lung,BMI less than 19,adult,Enterococcus group d,Anemia NOS,Acute postop pain NEC,Retention urine NOS,Abn react-artif implant,Hx of kidney malignancy,Arthrodesis status,Hx antineoplastic chemo,Hx-ven thrombosis/embols,Acquire absnce intestine,Colostomy status,Hx of irradiation
Admission Date:  [**2111-12-5**]              Discharge Date:   [**2111-12-12**]

Date of Birth:  [**2064-2-2**]             Sex:   M

Service: NEUROSURGERY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**Known firstname 2724**]
Chief Complaint:
Purulent drainage from previous surgical site

Major Surgical or Invasive Procedure:
T9-L2 incision and drainage of wound infection

History of Present Illness:
This is a 47 year old man with metastatic Renal Cell Carcinoma
status post T9-L2 fusion with Dr. [**Last Name (STitle) 548**] on [**2111-10-8**]. He
finished chemotherapy several weeks ago. He has not had
radiation since his surgery. He was doing well when he saw Dr.
[**Last Name (STitle) 548**] on [**2111-11-10**]. He reports that he developed more back pain
and lethargy during the past 2 weeks. He was at home and was in
bed most of the day. He can ambulate short distances
independently. On the day of admission, he developed new
purulent drainage from his thoracic wound. He denied lower
extremity pain, paresthesias or numbness. He had no
incontinence. He denied fever, chills, diaphoresis.

Past Medical History:
- Renal Cell Carcinoma (please see below)
- h/o RLE DVT [**8-/2107**]
- Colonic perforation
- Hyponatremia
- Anemia
- Cervical surgery with rod-placement due to C2 met
-[**2110-11-14**] Right colectomy, Segment VI partial liver resection,
resection of retroperitoneal tumor mass; ileal transverse
colostomy anastomosis (side to side). - T9-L2 posterior fusion
with T11 vertebrectomy


Social History:
Married and lives with wife.


Family History:
Mother died of a brain tumor. Father diagnosed with prostate
cancer in his 70s and is still living. He has 3 siblings and 2
children without medical concerns. Maternal aunt with lymphoma.
Father and sister have had h/o "blood clots."

Physical Exam:
PHYSICAL EXAM:
O: T: 97.6 F  BP: 104/71 HR: 51 R 20 O2Sats 95 % RA
Gen: NAD at rest, cachectic
T/L spine wound: mild dehiscence, purulent drainage saturating
dressing. No active drainage. Erythema at wound and areas of
tape.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Motor:Moves LE with good strength. Testing causes significant
back pain.
Sensation: Intact to light touch
Reflexes: Pa Ac
Right     1  0
Left      2  0
No clonus

Upon discharge;
cachetic, awake and alert, full motors, draining thoracic wound
with JP and pouch


Pertinent Results:
[**2111-12-4**] 11:45PM   PLT COUNT-523*
[**2111-12-4**] 11:45PM   NEUTS-89.4* LYMPHS-5.7* MONOS-3.5 EOS-0.7
BASOS-0.8
[**2111-12-4**] 11:45PM   WBC-10.8 RBC-4.06* HGB-11.2* HCT-33.8* MCV-83
MCH-27.6 MCHC-33.1 RDW-14.3
[**2111-12-4**] 11:45PM   CRP-291.3*
[**2111-12-4**] 11:45PM   GLUCOSE-150* UREA N-19 CREAT-0.9 SODIUM-129*
POTASSIUM-4.8 CHLORIDE-89* TOTAL CO2-28 ANION GAP-17
[**2111-12-5**] 04:15AM   PT-15.0* PTT-25.4 INR(PT)-1.3*

CT Thoracic spine [**2111-12-4**]

1. S/P T9-L2 posterior spinal fusion. R paraspinal fluid
collections with rim enhancement and increasing amount of air
within , concerning for paraspinal abscess. Two components of
the collection- the collection apposed to the spine and the
thecal sac measures approx 5.9 x 2.5 x 3.5 cm , extends from
T11-T12 level. The second collection more lateral in the
paraspinal soft tissues measures 8.0 x 5.2 x 1.7 cm. There is
enhancement of the thecal sac.No definite cord compression is
seen, but this study is limited given the streak artifacts.
2. Significant distention of the gall bladder, correlate
clinically for signs of acute cholecystitis.

3. Known metastatic disease

CT Torso [**2111-12-6**]

1. Expected postoperative changes at the lower thoracic spine as
described
above, with a small amount of residual post-surgical gas and
fluid.
2. No findings to suggest abdominal or pelvic abscess.
3. Stable appearance of known pulmonary metastatic disease.

Abdominal CT with contrast [**2111-12-9**]
1. Appearances are consistent with an enterocutaneous fistula
passing from
the right upper quadrant via the surgical drain tract to the
skin at the level of the surgical incision. The precise site of
communication cannot be identified; however, the mid jejunal
loops are considered the most likely given the proximity to the
extraluminal contrast. Air and oral contrast seen in close
relationship to the thecal sac at T12.
2. Enhancement of the paraspinal muscles suggestive of
inflammation, no
collection seen.
3. Multiple stable pulmonary metastases.
4. Duodenal diverticulum.


Brief Hospital Course:
Pt was admitted to the neurosurgery service and was kept NPO
after midnight in preparation of wound washout the following
morning. On laboratory studies his serum sodium was found to be
129 and he was started on NaCl tabs and his sodium levels were
checked daily. The ID team was consulted for appropriate
antibiotic regimen and he was initially started on vancomycin 1g
IV q12 with plan to add more broad spectrum coverage after
cultures were obtained from the OR.

On [**12-5**], he underwent incision and drainage of his infected
surgical wound with placement of a drain and tolerated this
procedure very well with no complications. Post-operatively he
was seen and he had no change in his previous physical exam.
Ciprofloxacin, flagyl and cefepime were added per ID
recommendations. The patient serum sodium was 129.  This was
reevaluated on [**12-6**] and was 134 without treatment. Wound and
blood cultures were sent.

On [**12-6**], the patient's exam was unchanged. He was experiencing
pain at his surgical site a level of 5 on a [**12-14**] pain scale.
His pain medications were reviewed and the patient was not
maximizing the currently ordered doses of pain medication.This
was discussed with the patient and nursing. Physical therapy and
occupational therapy consults were ordered.  The patient was
unable to get out of bed due to his discomfort.  A picc line was
placed for long term antibiotic therapy.  A CT of the lumbar
spine was ordered to evaluate the post operative surgical site.
This was stable with only minimal residual fluid collection at
surgical site. Per infectious disease recommendations
antibiotics were optimized for coverage.

1/3-4 The patient was seen by physical therapy and was able to
get OOB and ambulate. The JP drain remained in place due to high
output and he was continued on his antibiotic regimen per the ID
team. On [**12-8**] the cefepime was discontinued per the ID team. His
vanco trough on the evening of [**12-8**] was 21.7 and his a.m dose on
[**12-9**] was held. His pain was better controlled with PO dilaudid
every three hours and he required less IV pain medication for
breakthrough.

His wound continued to drain copious amounts of fluid, he was
maintained on IV antibiotics with ID consultation as cultures
grew enterococcus.  He underwent CT of abdomen which showed and
enteric fistula.  He was seen in consultation by Dr [**Last Name (STitle) **] who
had cared for the patient for fistula 3 years ago.
He had been scheduled to return to OR for thoracic washout [**12-10**]
but in light of fistula this was cancelled as would not provide
any relief to drainage of wound.  Mr [**Known lastname 73648**] case was
discussed at length with Neurosurgery, General Surgery,
Oncology, Infectious Disease, Palliative Care and the patient
and his wife.  Surgery would be extensive and high risk with
likely more risk than benefit.  The lower end of the incision
was opened and he was fit with colostomy drainage system.  Care
was arranged for transfer of patient to home with palliative
care bridging to hospice. He will maintain on antibiotics and
pain medication and will take PO only for comfort.

Medications on Admission:
-fentanyl 400 mcg/hour Patch 72 hr
-hydromorphone 2 mg Tablet  [**12-6**] Tablet(s) by mouth as needed,
for
breakthrough pain
-lorazepam 1 mg Tablet 1 Tablet(s) by mouth every eight (8)
hours
as needed for anxiety
-methadone 5 mg Tablet 0.5 (One half) Tablet(s) by mouth twice a
day
-ondansetron HCl 8 mg Tablet 1 Tablet(s) by mouth every eight
(8)
hours as needed for nausea/vomiting
-prochlorperazine maleate 10 mg Tablet  1 Tablet(s) by mouth
every
six (6) hours as needed for nausea/vomiting
-Scopolamine patch


Discharge Medications:
1. vancomycin in D5W 1 gram/200 mL Piggyback Sig: 1000 (1000) mg
Intravenous Q 12H (Every 12 Hours).
Disp:*[**Numeric Identifier **] mg* Refills:*2*
2. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/temp/HA.
3. methadone 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).

4. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
5. fentanyl 100 mcg/hr Patch 72 hr Sig: Four (4) Patch 72 hr
Transdermal Q72H (every 72 hours).
6. scopolamine base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours) as needed for nausea.
7. ceftriaxone 2 gram Recon Soln Sig: Two (2) gm Intravenous
Q24H (every 24 hours).
Disp:*60 gm* Refills:*2*
8. hydromorphone 2 mg Tablet Sig: 8-10 Tablets PO q3h as needed
for pain.
Disp:*180 Tablet(s)* Refills:*0*
9. hydromorphone 1 mg/mL Liquid Sig: 8-12 mg 10 mg/ml PO q3h as
needed for pain: Hydromorphone concentrated liquid 10mg/ml.
Disp:*250 ml* Refills:*0*
10. fluconazole in NaCl (iso-osm) 400 mg/200 mL Piggyback Sig:
Four Hundred (400) mg Intravenous Q24H (every 24 hours).
Disp:*[**Numeric Identifier 890**] mg* Refills:*2*
11. diazepam 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for spasm.
Disp:*40 Tablet(s)* Refills:*0*
12. Drainage Bag
Please dispense [**Location (un) **] [**Numeric Identifier 63605**] High Output drainage pouch.
110mm (4 [**12-7**] inch)


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 6138**] Home Care Services

Discharge Diagnosis:
metastatic Renal cell carcinoma
T9-L2 surgical wound infection
enteric fistula
hyponatremia
urinary retention
anemia of chronic disease


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.as tolerated for pain management


Discharge Instructions:
Take your pain medication as instructed

Followup Instructions:
Follow up with Dr [**Last Name (STitle) 43131**] for medication refills as needed.
Follow up with Dr [**Last Name (STitle) 548**] as needed.



Completed by:[**2111-12-12**]
{'Infection and inflammatory reaction due to other internal orthopedic device, implant, and graft,Intraspinal abscess,Fistula of intestine, excluding rectum and anus,Hyposmolality and/or hyponatremia,Secondary malignant neoplasm of brain and spinal cord,Secondary malignant neoplasm of lung,Body Mass Index less than 19, adult,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Anemia, unspecified,Other acute postoperative pain,Retention of urine, unspecified,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Personal history of malignant neoplasm of kidney,Arthrodesis status,Personal history of antineoplastic chemotherapy,Personal history of venous thrombosis and embolism,Acquired absence of intestine (large) (small),Colostomy status,Personal history of irradiation, presenting hazards to health'}


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: Purulent drainage from previous surgical site

PRESENT ILLNESS: This is a 47 year old man with metastatic Renal Cell Carcinoma
status post T9-L2 fusion with Dr. [**Last Name (STitle) 548**] on [**2111-10-8**]. He
finished chemotherapy several weeks ago. He has not had
radiation since his surgery. He was doing well when he saw Dr.
[**Last Name (STitle) 548**] on [**2111-11-10**]. He reports that he developed more back pain
and lethargy during the past 2 weeks. He was at home and was in
bed most of the day. He can ambulate short distances
independently. On the day of admission, he developed new
purulent drainage from his thoracic wound. He denied lower
extremity pain, paresthesias or numbness. He had no
incontinence. He denied fever, chills, diaphoresis.

MEDICAL HISTORY: - Renal Cell Carcinoma (please see below)
- h/o RLE DVT [**8-/2107**]
- Colonic perforation
- Hyponatremia
- Anemia
- Cervical surgery with rod-placement due to C2 met
-[**2110-11-14**] Right colectomy, Segment VI partial liver resection,
resection of retroperitoneal tumor mass; ileal transverse
colostomy anastomosis (side to side). - T9-L2 posterior fusion
with T11 vertebrectomy

MEDICATION ON ADMISSION: -fentanyl 400 mcg/hour Patch 72 hr
-hydromorphone 2 mg Tablet  [**12-6**] Tablet(s) by mouth as needed,
for
breakthrough pain
-lorazepam 1 mg Tablet 1 Tablet(s) by mouth every eight (8)
hours
as needed for anxiety
-methadone 5 mg Tablet 0.5 (One half) Tablet(s) by mouth twice a
day
-ondansetron HCl 8 mg Tablet 1 Tablet(s) by mouth every eight
(8)
hours as needed for nausea/vomiting
-prochlorperazine maleate 10 mg Tablet  1 Tablet(s) by mouth
every
six (6) hours as needed for nausea/vomiting
-Scopolamine patch

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: PHYSICAL EXAM:
O: T: 97.6 F  BP: 104/71 HR: 51 R 20 O2Sats 95 % RA
Gen: NAD at rest, cachectic
T/L spine wound: mild dehiscence, purulent drainage saturating
dressing. No active drainage. Erythema at wound and areas of
tape.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Motor:Moves LE with good strength. Testing causes significant
back pain.
Sensation: Intact to light touch
Reflexes: Pa Ac
Right     1  0
Left      2  0
No clonus

FAMILY HISTORY: Mother died of a brain tumor. Father diagnosed with prostate
cancer in his 70s and is still living. He has 3 siblings and 2
children without medical concerns. Maternal aunt with lymphoma.
Father and sister have had h/o "blood clots."

SOCIAL HISTORY: Married and lives with wife. 

### Response:
{'Infection and inflammatory reaction due to other internal orthopedic device, implant, and graft,Intraspinal abscess,Fistula of intestine, excluding rectum and anus,Hyposmolality and/or hyponatremia,Secondary malignant neoplasm of brain and spinal cord,Secondary malignant neoplasm of lung,Body Mass Index less than 19, adult,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Anemia, unspecified,Other acute postoperative pain,Retention of urine, unspecified,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Personal history of malignant neoplasm of kidney,Arthrodesis status,Personal history of antineoplastic chemotherapy,Personal history of venous thrombosis and embolism,Acquired absence of intestine (large) (small),Colostomy status,Personal history of irradiation, presenting hazards to health'}
