CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is a 60-year-old
gentleman transferred from [**Hospital 21145**] Hospital after developing
fever, drainage and erythema from his surgical incision in
his lumbar spine.

MEDICAL HISTORY: Deep venous thrombosis in [**2147-1-14**] on Coumadin.  Multiple myeloma diagnosed in [**2146-12-14**].

MEDICATION ON ADMISSION: 

ALLERGIES: NO KNOWN DRUG ALLERGIES.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Unspecified septicemia,Disruption of external operation (surgical) wound,Multiple myeloma, without mention of having achieved remission,Other nervous system complications,Staphylococcal meningitis,Cellulitis and abscess of trunk,Acute, but ill-defined, cerebrovascular disease
Septicemia NOS,Disrup-external op wound,Mult mye w/o achv rmson,Surg comp nerv systm NEC,Staphylococc meningitis,Cellulitis of trunk,Cva
Admission Date:  [**2147-8-26**]       Discharge Date:  [**2147-9-19**]

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

Service:

HISTORY OF PRESENT ILLNESS:  The patient is a 60-year-old
gentleman transferred from [**Hospital 21145**] Hospital after developing
fever, drainage and erythema from his surgical incision in
his lumbar spine.

The patient had undergone an L4-S1 laminectomy and left
epidural tumor removal on [**2147-7-17**].  Postprocedure
included epidural tear, spinal headache and fevers prior to
discharge.

He has a history of multiple myeloma and DVT.

His wife reported increased confusion over the last week with
drainage out of the wound yesterday.  The patient fell on the
day of admission and reported increasing back pain.  The
patient was noted to have fever and was sent to [**Hospital 21145**]
Hospital.

ALLERGIES:  NO KNOWN DRUG ALLERGIES.

PAST MEDICAL HISTORY:  Deep venous thrombosis in [**2147-1-14**] on Coumadin.  Multiple myeloma diagnosed in [**2146-12-14**].

PHYSICAL EXAMINATION:  Vital signs:  Temperature 101??????, heart
rate 69, blood pressure 106/49, respirations 22, oxygen
saturation 96%.  HEENT:  Pupils equal, round and reactive to
light.  Extraocular movements full.  General:  He was awake
but disoriented.  Neck:  Supple.  Lungs:  Clear.
Cardiovascular:  Irregular rate.  Tachycardiac to the
100-120s.  Back:  There was erythema along the incision.  He
had two small openings, approximately 2-3 cm, with no
fluctuants and no drainage currently reported.  Neurological:
He was awake but lethargic.  He was oriented to person and
place.  He was following commands.  Motor strength was 5 out
of 5 in the triceps, biceps bilaterally.  IPs were 4+, ATs,
EHLs were 5, gastrocs 4+ bilaterally.  Sensation was intact
to light touch.

LABORATORY DATA:  He had a negative head CT.  CT of the
lumbar spine showed no abscess.

HOSPITAL COURSE:  The patient was admitted to the Medical
Intensive Care Unit for sepsis and hypotension.  He was
placed on a Neo-Synephrine drip.  He was seen by Infectious
Disease who recommended starting Vancomycin and Ceftazidime
for antibiotic coverage.  He was also seen by the Cardiology
Service for episodes of bradycardia and sinus pauses, and it
was felt that the patient would eventually need a pacemaker
placement; however, due to infection, this would have to be
delayed until infection cleared.

He was also seen by the Plastic Surgery Service who
recommended a flap closure of his wound.  The patient's
lumbar swab showed moderate growth of gram-negative rods,
most likely enterococcus and heavy Staphylococcus aureus
growth.

On [**2147-9-4**], the patient was taken to the Operating
Room by Dr. [**First Name (STitle) **] of Plastic Surgery for a flap wound
closure of his lumbar incision.  There were no intraoperative
complications.  Postoperatively his vital signs were stable,
and he was afebrile.

His flap incision was well perfused and clean, dry, and
intact.  He did have a JP drain in place.  He did spike a
temperature to 101?????? on [**2147-9-4**].  This was
pan-cultured, and he was started on Ciprofloxacin for added
coverage.

Currently the patient is on Vancomycin 1 g IV q.12 hours for
a total of six weeks.  He should have weekly Vancomycin
levels and CBC with CHEM7 checked.

He should follow-up in the Infectious Disease Clinic on
[**10-6**] at 10 a.m. with Dr. [**Last Name (STitle) 19862**], [**Telephone/Fax (1) 457**].  He had a
PICC line placed postoperatively which showed good placement
after a chest x-ray confirmed placement.  His JP drain
continues to be in place draining anywhere from 5-30 cc a
shift.

He was seen by Physical Therapy and Occupational Therapy and
felt to require acute rehabilitation due to the fact that he
is going to need cardiac telemetry due to his sinus pauses.
EP fellow again evaluated the patient and felt that the
patient was safe to be transferred to rehabilitation with
telemetry and will follow-up postinfection treatment for
possible pacemaker placement.

DISCHARGE MEDICATIONS:  Fentanyl patch 50 mcg topically q.72
hours, Milk of Magnesia 30 cc p.o. q.6 hours p.r.n.,
Miconazole powder 2% one application t.i.d. p.r.n., Percocet
[**12-15**] tab p.o. q.4 hours p.r.n., Coumadin 5 mg p.o. q.d.,
Decadron 40 mg p.o. q.week on Thursdays, Naproxen 500 mg p.o.
q.8 hours p.r.n. pain, Heparin 5000 U subcue q.8 hours,
.................... 200 mg p.o. q.d., Vancomycin 1000 mg IV
q.12 hours, Nystatin oral suspension 5 cc p.o. q.i.d., Colace
100 mg p.o. b.i.d., .................. 40 mg p.o. q.24 hours,
Lorazepam 0.5 mg q.4-6 hours p.r.n., Neurontin 900 mg p.o.
t.i.d.

CONDITION ON DISCHARGE:  Stable.

FOLLOW-UP:  He will need to follow-up with Dr. [**Last Name (STitle) 1327**] in two
weeks and with the Infectious Disease Service on [**2147-10-6**].  In addition he will follow-up with the Plastic Surgery
Service to have the JP drain removed in two weeks




                            [**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D.  [**MD Number(1) 1341**]

Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36

D:  [**2147-9-19**]  11:25
T:  [**2147-9-19**]  11:23
JOB#:  [**Job Number 46400**]


Admission Date:  [**2147-8-26**]       Discharge Date:  [**2147-9-19**]

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

Service:

HISTORY OF PRESENT ILLNESS:  The patient is a 61-year-old
gentleman with a history of multiple myeloma diagnosed in
[**2136-12-14**] status post radiation and Decadron
.................. protocol status post epidural tumor
removal and L4-S1 laminectomy on [**2147-7-15**].

The patient had consistent and mental status changes with
fever and hypotension for one week prior to admission.  He
also had a [**12-15**] day history of purulent drainage from his
lumbar incision.

On the day of admission, he fell and had a temperature of
102?????? and was taken to Brochton Emergency Department where he
was transferred to [**Hospital6 256**] for
further management.

He was evaluated in the Emergency Room with a blood pressure
of 63/30.  He was started on Dopamine.  He had a run of
supraventricular tachycardia into the 180s and was started on
Neo-Synephrine.

He did break with carotid massage and was transferred to the
Intensive Care Unit for close management.

PAST MEDICAL HISTORY:  Deep venous thrombosis.  L4-5 fusion.
He has an ejection fraction of 50%.  History of C-diff.
L4-S1 laminectomy done in [**Month (only) 216**] for the epidural tumor.

PHYSICAL EXAMINATION:  Vital signs:  On admission pulse was
64, respirations 17, oxygen saturation 100% on 2 L.  General:
He was comfortable, arousable but somnolent.  Pupils equal,
round and reactive to light.  Neck:  Supple.  Lungs:  Clear
to auscultation.  Cardiovascular:  Irregular.  No murmurs,
rubs, or gallops.  Abdomen:  Soft, nontender, nondistended.
Positive bowel sounds.  Extremities:  Warm with no edema.
There were 2+ pulses.  Back:  His back incision was dehiscing
with serous drainage.  Chest x-ray showed no pneumothorax, no
infiltrate.  Head CT was negative for masses, bleeds or bone
destruction.  Lumbar CT showed no epidural abscess or
collection in the soft tissue.  On [**2147-8-27**], his
lumbar wound opened at the bedside for purulent drainage.
Neurological:  His motor strength on admission in the biceps
and triceps was 5 out of 5 bilaterally, IPs were 4+, ATs 5,
EHLs were 5, gastrocs 4+.  Sensation was intact to light
touch in the lower extremities.

LABORATORY DATA:  CT of the lumbar spine again showed no
abscess but some gas in the soft tissue.

He was evaluated by Infectious Disease Service who
recommended starting Vancomycin and Ceftazidime for IV
antibiotic coverage.

He was transferred to the floor on [**2147-8-28**], with
stable vital signs.  He continued to be monitored by the
Infectious Disease Service.  He was also evaluated by the
Plastic Surgery Service for possible flap closure of the
wound.

Wound culture came back positive for gram-negative rods,
enterococcus and Staphylococcus aureus.  Blood cultures, 1out
of 6, came back positive with gram-positive cocci in pairs
and clusters.

MRI of the lumbar spine showed large fluid collection
posterior to the L4-L5 laminectomy site consistent with
pseudomeningocele, and an abnormal single ..................
At the L4-L5 level which could be consistent with
osteomyelitis.

On [**2147-8-28**], the patient also had episodes of
severe bradycardia and sinus pauses.  Cardiology was
consulted, and the patient was felt to require a pacemaker,
but in light of infection, was unable to have that done
during this hospitalization.  The patient will therefore be
monitored on telemetry until infection is cleared when he can
then be worked up for possible pacemaker placement.




                            [**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D.  [**MD Number(1) 1341**]

Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36

D:  [**2147-9-19**]  10:55
T:  [**2147-9-19**]  10:56
JOB#:  [**Job Number 46399**]


Admission Date:  [**2120-2-12**]       Discharge Date:  [**2147-11-16**]

Date of Birth:                    Sex:  M

Service:

ADDENDUM:  This is an Addendum to the Discharge Summary
originally dictated on [**2147-9-19**].

The patient was discharged on [**2147-11-16**].  As of the
last dictation:

On [**2147-9-30**] the patient had right-sided weakness,
right facial droop, and a seizure and was transferred to the
Coronary Care Unit on pressors.  A magnetic resonance imaging
scan of the head showed a left parietal cerebrovascular
accident.  The patient remained in the Intensive Care Unit on
pressors for two to three days.  His blood pressure came up
to the 100 to 110 range after being down to the 80 range.  He
was started on valproic acid and Dilantin, and once
therapeutic was transferred back to the regular floor.

The patient was eventually transferred back to [**Hospital Ward Name 121**] Five
where he remained stable; although, he continued to have
leakage from his flap site.

He eventually was taken back to the operating room on
[**2147-10-24**] for the leakage of this wound.  He had an
omental flap harvest, and retroperitoneal tunnel, and wound
debridement, and new flap placement.  At that point, the
patient had a ventricular drain placed.  The patient was then
admitted to the Surgical Intensive Care Unit where he
remained for five days with a ventricular drain in place.
The ventricular drain was clamped and removed on [**2147-10-30**].  Also, while the patient was in the Intensive Care
Unit, he had developed an ileus and was seen by the
Gastroenterology Service with a nasogastric tube in place for
decompression.  He had positive flatus on the 13th.  His
abdomen was soft, protruding, and his incision was mildly
erythematous.  His diet was advanced to clears, and the ileus
resolved.

The patient was also followed by the Infectious Disease
Service and was on vancomycin and ciprofloxacin for
intravenous antibiotic coverage.

The patient continued to have episodes of tachy-brady but
continued to be asymptomatic.  It was determined that the
patient would most likely need a pacemaker at a later time
after the infection was cleared and the patient was off
intravenous antibiotics.

The patient was then transferred to the floor on [**2147-10-30**] where he remained stable.  He had an episode of atrial
tachycardia and atrial fibrillation on [**11-4**].  The
patient was transferred to the Cardiology floor and was
successfully cardioverted.  The patient currently remains in
sinus bradycardia in the 50s to 60s with some episodes of a
heart rate down into the 40s.  The electrophysiology
attending saw the patient and cleared the patient to be off
telemetry.  The patient was to follow up with her in one
month.  The patient's heart rate was stable for the last 48
hours off telemetry.  The patient's blood pressure runs in
the low 90s to 100s; which is his baseline.

The [**Location (un) 1661**]-[**Location (un) 1662**] drain was removed on [**2147-11-13**].  The
patient's incision was clean, dry, and intact.  The staples
to be removed per the Plastic Surgery Service in followup.

MEDICATIONS ON DISCHARGE:  (The patient's medications at the
time of discharge included)
 1.  Decadron 40 mg by mouth once per week (on Friday).
 2.  Hydromorphone 2 mg to 8 mg by mouth q.4-6h. as needed
(for pain).
 3.  Colace 100 mg by mouth twice per day.
 4.  Ciprofloxacin 500 mg by mouth q.12h.
 5.  Methadone 10 mg by mouth twice per day.
 6.  Fentanyl patch 75-mcg patch topically q.72h.
 7.  Dilantin 100 mg by mouth three times per day.
 8.  Vancomycin 1250 mg intravenously q.12h.
 9.  Divalproex sodium 750 mg by mouth twice per day.
10.  Lansoprazole 30 mg by mouth once per day.
11.  Thalidomide 200 mg by mouth once per day (the patient
takes this on vacations).
12.  Lovenox 60 mg subcutaneously q.12h.
13.  Gabapentin 900 mg by mouth three times per day.
14.  Tylenol 650 mg by mouth q.4h. as needed.

CONDITION AT DISCHARGE:  The patient's condition on discharge
was stable.

DISCHARGE INSTRUCTIONS/FOLLOWUP:
1.  The patient was instructed to follow up with Dr. [**First Name8 (NamePattern2) **]
[**Name (STitle) 1327**] in one month.
2.  The patient was instructed to follow up with Plastic
Surgery Service in two to three weeks.




                            [**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D.  [**MD Number(1) 1341**]

Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36

D:  [**2147-11-14**]  10:35
T:  [**2147-11-14**]  10:36
JOB#:  [**Job Number 46417**]


Name:  [**Known lastname 8512**], [**Known firstname **]                      Unit No:  [**Numeric Identifier 8513**]

Admission Date:  [**2147-8-26**]     Discharge Date:  [**2147-11-21**]

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

Service:

Patient's condition has remained neurologically stable.  His
incision to his flap is clean, dry, and intact without
staples or stitches, open to air.  Wound should be monitored
for signs and symptoms of infection, redness, and drainage.
He has been out of bed ambulating with Physical Therapy.  He
should continue that at rehab.  He will have a follow-up
appointment with Dr. [**Last Name (STitle) **] in [**2-14**] weeks, with Dr. [**First Name (STitle) 735**] in
[**2-14**] weeks, and Dr. [**Last Name (STitle) 998**] from Cardiology in one month.

CONDITION ON DISCHARGE:  His condition was stable at time of
discharge.



                          [**Name6 (MD) 863**] [**Last Name (NamePattern4) 864**], M.D.  [**MD Number(1) 865**]

Dictated By:[**Last Name (NamePattern1) 366**]

MEDQUIST36

D:  [**2147-11-21**]  11:34
T:  [**2147-11-21**]  11:33
JOB#:  [**Job Number 8514**]
{'Unspecified septicemia,Disruption of external operation (surgical) wound,Multiple myeloma, without mention of having achieved remission,Other nervous system complications,Staphylococcal meningitis,Cellulitis and abscess of trunk,Acute, but ill-defined, cerebrovascular disease'}


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: 

PRESENT ILLNESS: The patient is a 60-year-old
gentleman transferred from [**Hospital 21145**] Hospital after developing
fever, drainage and erythema from his surgical incision in
his lumbar spine.

MEDICAL HISTORY: Deep venous thrombosis in [**2147-1-14**] on Coumadin.  Multiple myeloma diagnosed in [**2146-12-14**].

MEDICATION ON ADMISSION: 

ALLERGIES: NO KNOWN DRUG ALLERGIES.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Unspecified septicemia,Disruption of external operation (surgical) wound,Multiple myeloma, without mention of having achieved remission,Other nervous system complications,Staphylococcal meningitis,Cellulitis and abscess of trunk,Acute, but ill-defined, cerebrovascular disease'}
