CHIEF COMPLAINT: drainage at incision site and fever

PRESENT ILLNESS: The patient is a 57 yo female s/p left adrenalectomy and
splenectomy on [**2149-4-14**], d/c'd [**2149-4-28**], who returned to the [**Hospital1 18**]
ED on [**2149-4-30**] with fever and incision site discharge.

MEDICAL HISTORY: cushings syndrome, AVR [**2143**], pulmonary AVM repair [**2143**]

MEDICATION ON ADMISSION: Prednisone 10 daily
atenolol 50 daily
norvasc 10 daily
dyazide 37.5/25
lipitor 20
lasix 40 [**Hospital1 **]
coumadin 2 daily
foradil 12 [**Hospital1 **]
albuterol 2 puffs tid
singulari 10 daily
flagyl
abmanex 220 daily

ALLERGIES: Codeine / Talwin / Nafcillin

PHYSICAL EXAM: VS- Temp 102, HR 88, BP 122/60, RR 28, SO2 100 % on 12L FM
Gen- NAD, pleasant
Heart: RRR, loud SEM
Lungs: CTA b/l
Abd: soft, LLQ tenderness around incision site, + purulent
drainage
Neuro: AxOx3

FAMILY HISTORY: NC

SOCIAL HISTORY: NC
Other postoperative infection,Cardiac arrest,Acute kidney failure with lesion of tubular necrosis,Iron deficiency anemia secondary to blood loss (chronic),Congestive heart failure, unspecified,Urinary tract infection, site not specified,Methicillin susceptible pneumonia due to Staphylococcus aureus,Hyperosmolality and/or hypernatremia,Candidiasis of other urogenital sites,Unspecified septicemia,Severe sepsis,Septic shock,Acute gastritis, with hemorrhage,Heart valve replaced by other means,Hypercalcemia,Long-term (current) use of steroids,Other nonspecific abnormal serum enzyme levels,Delirium due to conditions classified elsewhere,Other specified disorders of pancreatic internal secretion,Adrenal cortical steroids causing adverse effects in therapeutic use
Other postop infection,Cardiac arrest,Ac kidny fail, tubr necr,Chr blood loss anemia,CHF NOS,Urin tract infection NOS,Meth sus pneum d/t Staph,Hyperosmolality,Candidias urogenital NEC,Septicemia NOS,Severe sepsis,Septic shock,Acute gastritis w hmrhg,Heart valve replac NEC,Hypercalcemia,Long-term use steroids,Abn serum enzy level NEC,Delirium d/t other cond,Pancreatic disorder NEC,Adv eff corticosteroids
Admission Date: [**2149-4-12**]        Discharge Date:

Date of Birth:  [**2092-3-16**]        Sex:  F

Service:  [**Last Name (un) **]


PREOPERATIVE DIAGNOSES:  Left adrenal tumor/[**Location (un) **] syndrome.

POSTOPERATIVE DIAGNOSES:  Left adrenal tumor/[**Location (un) **]
syndrome.

PROCEDURE:  Left adrenalectomy and splenectomy.

DISCHARGE CONDITION:  Good.

HOSPITAL COURSE:  Patient is a 57-year-old female with
[**Location (un) **] syndrome who was diagnose with a left adrenal tumor
noted to be a cortisol producing tumor. She also has a past
medical history significant for an aortic valve replacement
with a St. Jude valve as well as a pulmonary arteriovenous
malformation, which had recently been embolized in
preparation for surgery. She presented 2 days prior to
surgery in order to undergo heparinization for the aortic
valve while she was off Coumadin. She was taken to the
operating room on Monday [**4-14**] and underwent attempted
laparoscopic left adrenalectomy. The procedure needed to be
converted to open due to difficult in visualization. The
spleen was also removed at the time, because an injury to the
spleen was noted and the patient's need for anticoagulation
postop, it was felt that leaving an injured spleen in place
was not prudent. Postoperatively, the patient was placed on
high dosed steroid therapy. Her hospital course was
complicated by steroid psychosis, which was resolved once
steroid therapy was withdrawn. Low dose steroids were
replaced. Her pulmonary status also remained an issue for a 1
week postoperatively as the patient was CPAP dependent and
oxygen dependent at home. This required aggressive diuresis
and BiPAP therapy during the hospital. Due to the aggressive
diuresis, actually the patient did have an onset of acute
renal insufficiency. This was corrected with replacement of
IV fluid therapy. Regarding her anticoagulation, the patient
was begun on heparin drip and was noted to have some
bleeding, which was obvious from her drain left in place in
the surgical bed. The heparin drip was stopped and the
patient was just maintained on Coumadin therapy. Her INR
levels were rather variable ranging from 1.2 to 5.8.
Currently on discharge she is 1.8. Right now maintained on
half her Coumadin dose of 2 mg a day. Her respiratory status
has reverted back to normal. She is without CPAP during the
day and just uses CPAP at night. Her renal function is also
back to normal with a normal BUN and creatinine as were her
baseline. She did have some diarrhea in the hospital due to
the multiple antibiotics she had received. We had placed her
critically on Flagyl therapy. However, she does have 3 C diff
toxin A is negative and a toxin B culture is pending. This is
now postop day 14 and near her baseline status and will
likely be discharged home.

Neurologically the patient is completely at baseline. There
is no evidence of psychosis at this time.

Cardiovascularly she has remained stable. She is on all her
home medications for anti hypertension including atenolol and
amlodipine.

Pulmonary wise she has also reverted back to her baseline and
there is no evidence of a pneumonia. She is without CPAP
during the day and uses the CPAP at night. She has a marginal
pulmonary status in general but refuses adamantly to go to a
rehab location where more attention could be given to her
lungs.

GI, the patient is tolerating a cardiac regular diet.

GU, patient's renal function has resolved back to normal. She
is able to void without a Foley catheter.

Infectious disease, the patient is maintained on a 14 day
course of Flagyl. Her cultures have all been negative,
however, clinically it seemed that she may have had C
difficile, thus she will be sent home on 10 days of Flagyl
therapy.

Heme, patient's INR today is 1.8. She is maintained on half
her Coumadin dose of 2 mg and this dose should be titrated to
an INR of 2.0 to 2.5 for her aortic valve.

Endocrine, the patient's sugars have been well controlled
under 120. She has not required insulin for 2 days. Her
prednisone dose is currently 10 mg once a day given in the
morning.

FEN. The patient's electrolytes have been relatively normal.
She is not receiving any IV fluids.

This patient will be discharged home with home VNA services
and home PT services.  She refuses to go to a rehab location
despite our every attempt.



                        [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 23293**]

Dictated By:[**Last Name (NamePattern4) 61917**]
MEDQUIST36
D:  [**2149-4-28**] 09:11:35
T:  [**2149-4-28**] 09:33:22
Job#:  [**Job Number 61918**]


Admission Date:  [**2149-4-30**]              Discharge Date:   [**2149-7-17**]

Date of Birth:  [**2092-3-16**]             Sex:   F

Service: MEDICINE

Allergies:
Codeine / Talwin / Nafcillin

Attending:[**First Name3 (LF) 398**]
Chief Complaint:
drainage at incision site and fever

Major Surgical or Invasive Procedure:
EGD
s/p adrenalectomy and splenectomy


History of Present Illness:
The patient is a 57 yo female s/p left adrenalectomy and
splenectomy on [**2149-4-14**], d/c'd [**2149-4-28**], who returned to the [**Hospital1 18**]
ED on [**2149-4-30**] with fever and incision site discharge.

Past Medical History:
cushings syndrome, AVR [**2143**], pulmonary AVM repair [**2143**]

Social History:
NC

Family History:
NC

Physical Exam:
VS- Temp 102, HR 88, BP 122/60, RR 28, SO2 100 % on 12L FM
Gen- NAD, pleasant
Heart: RRR, loud SEM
Lungs: CTA b/l
Abd: soft, LLQ tenderness around incision site, + purulent
drainage
Neuro: AxOx3


Pertinent Results:
MICRO:
[**6-18**]: urine, stool, blood pending
[**6-14**]: stool negative
[**6-14**]: urine negative
[**6-13**]: CSF negative
[**6-9**]: BAL-acinetobacter, S only to gent and bactrim and GNR S to
bactrim
[**6-8**]-swab abd wound-enterocccus
[**6-8**]-urine yeast
[**6-6**]-urine yeast
[**6-6**]-BAL-1+ yeast, MSSA
[**6-6**] wound: no growth
[**6-5**] sputum: yeast, GNR
[**6-5**] UCx-neg
[**6-5**]-BCx pending
[**6-3**]-c.diff-neg
[**6-2**] VRE rectal swab: heavy growth.
[**6-2**] BAL: Staph aureus and GNR
[**6-1**] sputum: staph aureus and enterobacter, pan sensitive
[**6-1**]: blood cx NGTD, urine-neg
[**5-29**]-urine neg
[**5-22**] C Diff-neg
[**5-21**] blood:NGTD
[**5-21**] sputum:enterobacter, staph aureus
[**5-20**] blood:[**12-25**] bottle coag neg staph
[**5-20**] urine:Enterobacter
[**5-19**] urine: enterobacter
[**5-19**] blood:neg
[**5-15**] Wound Cx: [**Female First Name (un) **]
[**5-15**] C diff: Neg
[**5-14**] cdiff: Neg
[**5-13**] cath tip: Neg
[**5-12**] MRSA: Neg
.
<b> Studies: </b>
RADS:

[**6-20**]: CXR:
Dobbhoff catheter tip is not included on the radiograph. Stable
widening of the cardiac silhouette with left lower lobe
atelectasis and right mid and basilar consolidation.

[**6-19**]; CT Chest /Abdomen and pelvis: 1. Patchy ground-glass
opacity of the lungs may represent persistent volume overload
but is concerning for superimposed pneumonia.
2. Small bilateral pleural effusions with persistent collapse of
the left
lower lobe.
3. No change in a 2 cm soft tissue density adjacent to the
sternum, which is of uncertain etiology but may represent a
lymph node.
4. Stable inflammatory stranding in the splenectomy bed. No
fluid collection or abscess identified.

[**6-17**]; CXR: . Possible acute aortic dilatation or mediastinal
hematoma. Evaluation should begin with upright chest radiograph.

2. Improved severe pulmonary edema.
3. Worsening left upper lobe atelectasis. Unchanged left lower
lobe
atelectasis.

[**6-13**]: MR head w/Gd: 1. No abnormal enhancement, intraaxial
masses, or abnormal signal to suggest acute infarction.

2. Thin dural enhancement along the left parietal lobe that is
nonspecific in origin, but could reflect the sequelae of prior
trauma (resolved subdural hematoma) or prior lumbar puncture

[**6-12**]: Ct Abd/Pelv: No significant change in abdominal findings
compared to prior study. Slight improvement in ground glass
opacity consistent with improving edema. Interval increase in
size of bilateral pleural effusions, greater on the right side.

[**6-12**]: Ct head: Limited examination due to patient motion
artifact. No acute intracranial hemorrhage. Density seen in the
right sylvian fissure region may represent prior Pantopaque
administration or may be due to focal calcification in this
area.

[**6-8**]: US hepatic congestion and gallbladder edema without stones
or sludge, though to be due to right sided heart failure
[**6-6**] cxr-heterogenous diffuse appearance
[**6-5**] cxr: mod CM, bibasilar consolidation, atelectasis, worse
mod pulm edema.
[**6-4**] CXR: pulm edema RUL improved, dense consolidation LLL,
increased L pleural eff
[**6-1**] CXR: significantly worsened bilateral pulmonary edema
[**5-30**] CXR: consolidation and pleural effusions persist
[**5-26**] CXR: feeding tube below diaphragm.
[**5-24**] CXR: pulm edema and LLL consolidation unchanged.
[**5-21**] CXR: moderate fluid overload
[**5-16**] CT abd: Negative for collection;
[**5-14**] RUQ U/S: no biiliary pathology;
[**5-14**] KUB: dobhoff in antrum,
[**5-7**] CXR: patchy right opacity
[**5-4**] CT head: neg
[**5-4**] CT [**Last Name (un) 103**]: incr standing panc tail;
[**5-1**] CXR: unchanged patchy asymmetric B opacities, L basilar
opacity [**4-30**] CT abd: postop changes, bibasilar atelectasis,
small B pleural effusions
.
ECHO: [**6-5**]: EF 70%, symmetric LVH, increased left and right
filling pressures, dilated R ventricle.
.
ABX
[**Date range (1) 61919**] flagyl
[**Date range (1) 61920**] vanc
[**Date range (1) 61920**] zosyn
[**Date range (1) 30469**] fluconazole
[**Date range (1) **] ceftazidime
[**Date range (1) 3046**] vanco
[**Date range (1) 29219**] flagyl
[**Date range (1) 61921**] cefepime
[**2155-6-2**] vanc/cefepime
[**Date range (1) 61922**] flagyl
[**Date range (1) 61923**] Nafcillin
[**Date range (1) 61924**] levo
[**Date range (1) 25250**] ceftaz
[**Date range (1) 10233**] vancomycin
[**Date range (1) 61925**] cefepime
[**6-11**] bactrim


Brief Hospital Course:
The patient was admitted to [**Hospital1 18**] on [**2149-4-30**] with a post
operative fever and incision site drainage.  She was pan
cultured at that time and started on Zosyn and Flagyl
empirically.  A CXR at that time demonstrated patchy asymmetric
opacities bilaterally, concerning for pneumonia.  She refused a
CPAP mask but accepted 12L face mask oxygen.  She is home CPAP
dependent.  She was kept NPO.  Her coumadin was held in case she
needed an operation or drainage of an abscess.  She was started
on 10mg Prednisone, as she has known adrenal insufficiency.  She
tolerated her own CPAP machine overnight.  A CT scan with
contrast showed prominent inflammatory stranding in the left
upper quadrant and around the pancreatic tail, most likely
representing postoperative changes.  There was also a tiny
amount of fluid in the splenic fossa, but no drainable
collections were identified.  There was also bibasilar
atelectasis and small bilateral pleural effusions.  On HD 2 her
diet was advanced.  Zosyn was discontinued.  PT/OT saw her and
recommended rehab.  We treated her with aggressive pulmonary
toilet.  A CXR was unchanged.  Later that night the patient had
an acute event- Her HR was in the 40's with decreased oxygen
saturations and no palpable pulse.  Chest compressions were
begun and she was intubated emergently.  She was given
epinepherine X 1 and her HR improved to 100.  She was saturating
100%.  Her BP was 100/50.  A right IJ TLC was placed.  She was
transferred to the ICU.  She was sedated with propofol.  On HD
3, A chest X-ray demonstrated severe pulmonary edema.  Cardiac
enzymes were cycled and were not elevated.  An echocardiogram
showed an EF > 55%, moderate TR, and mild-moderate pulmonary
HTN.  She was kept NPO.  Her createnine bumped to 3.4, likely as
a result of contrast nephropathy.  She was started on Vancomycin
and Zosyn in addition to her Flagyl, as she was febrile to 102
and may have gone into septic shock.  Her TLC was changed to a
Swann Ganz catheter for better monitoring of her fluid status
given her new onset ARF and pulmonary edema.  On HD 4, she was
off of Levophed and she remained hemodynamically stable all day.
 Endocrinology saw the patient and started hydrocortisone at
100mg Q 8 hours for stress dose steroids.  The renal service saw
her and did not recommend dialysis at this time, but they did
recommend limiting her fluid intake.  She had only low grade
temperatures that day.  Her UOP was 91 for the day.  On HD 5,
her createnine was up to 4.0.  Her WBC was 18.  A CT of the head
was negative.  A repeat CT of the abdomen without contrast
showed increased inflammatory stranding and possibly a small
amount of fluid around the pancreatic tail, bilateral pulmonary
effusions (worsening on the right), but no extravasation of
prior contrast and no fluid collections around the surgical
incision.  Trophic tube feeds were started.  Her Swann Ganz
catheter [**Location (un) 1131**] were consistent witha septic picture (SVR 358,
CI 6.10).  She made 355 cc of urine and was afebrile.  ON HD 6,
her createnine was 4.0.  Her WBC was 15.8.  Her Hct was 23.7.
She was transfused 2 units of RBC for blood loss anemia.  Renal
saw her and determined that she was much improved with no need
for HD.  Endocrine put her on 37.5 mg hydrocortisone QID.  GI
saw her for hematemesisand performed a bedside EGD, which was
remarkable only for mild antral gastritis.  Her Protonix was
increased to 40mg [**Hospital1 **].  A heparin drip was started for aortic
valve prophylaxis (goal PTT 40-60).  She had a Tmax of 101.  Her
urine output was 1122 for the day.  On HD 7, her Swann was
changed to a TLC.  TPN was started since she was not tolerating
her tube feeds.  Her createnine was down to 2.1.  Her
hydrocortisone was tapered to 25 mg QID.  Her GI bleeding
resolved.  She made 520 cc of urine over the course of the day.
On HD 8, her createnine was down to 0.9.  Her WBC was 15 and her
Hct was 25.  Her ventillator was weaned to CPAP with PS.
Diuresis was begun with Lasix.  Fentanyl was changed to PO
Oxycodone and Lopressor was changed to PO as well. On POD 30,
the decision was made to continue abx until a 14 day course of
vanco/zosyn and 10 day course of flagyl was completed. The
patient was taken to the OR on POD 31 for an open trach and
placement of RSC 3xCVL by Thoracic team.  LFT's were tested and
WNL except for elevated Alk-phos.  Patient's foley was replaced
based on +UA from POD30, and presence of yeast.  On POD32 slow
vent weaning was attempted with probable vent rehab being
needed. Hydrocortisone was dropped to 25q8 and a RUQ US was done
to because of elevated AP levels, but did not show pathology.
Patient had tube feeds continued to goal as propofol was
gradually weaned with initiation of Haldol prn for agitation.
Attempts to diurese patient were started on POD33 with
initiation of prn Lasix with good response by patient.  Patient
had propofol weaned off by POD34 with increased haldol
requirements and occassional ativan for agitation.  Patient was
transfused for 1unit Prbc as Hct drifted to 20.8. WBC increased
to 29.2 for which CT scan of abdomen was repeated with no new
pathology/abscesses identified.  Patient had continued vent
weaning, agitation control, and TF's continued while sources of
infection were worked up.  Patient failed to tolerated vent
weaning and was placed on CPAP/PS with increased PEEP/PS levels
of 15/15 on POD39.  For continued fevers and discover of 3+GNR
in sputum and GNR in urine, ID was consulted with resultant
institution of ceftaz and flagyl for empiric C.Diff, and the
patients foley/CVL were exchanged.  Ceftaz was converted to
cefepime when urine cultures showed enterobacter resistance to
ceftaz.  Patient maintained this hospital course except for
initiation of free water by feeding tube for hypernatremia, and
continued Peep/Psupp wean.  patient developed tachypnea and
increased WOB overnight on [**5-31**] for which her Peep/Psupp was
increased and patient was given 1unit pRBC.  Patient improved
over the course of [**6-1**] until she had a temperature spike to
103.1 (the first following antibiotic course completion) and
sputum culture showing GPC pairs/clusters and GN diplocci.
Because of poor defervesence throughout [**6-1**] the patient was
empirically started on vanco/cefepime/flagyl.  Patient noted to
have a WBC of 24.3 on [**6-2**] and ID was reconsulted, who
recommended Flagyl and Nafcillin as cultures from sputum showed
MSSA.  Renal was also consulted for isolated BUN increase in
presence of stable Cr with recs c/w high protein TF
concentration and steroid use in patient.

#. Recurrent fevers: Patient had recurring fevers during her
hospitalization. Recent BAL from [**6-9**] showed no MSSA, but GNR
and acinetobacter sensitive to bactrim.   Repeat BAL from [**6-23**]
also showed bactrim-resistant acinetobacter, but no PMN's.
Vancpmycin course completed for 14 days for MSSA pneumonia.
Sputum cx showed Acinetobacter.  Pt completed 14 day course of
Bactrim. (D/Cd Cefepime when sensitivities returned).
Infectious disease was consulted and when sputum culture grew
aztreonam resistant acinetobacter, ID felt that it did not need
to be treated with gentamycin.  She completed a course of 7 days
of Vancomycin, Levofloxacin, fluconazole and flagyl and has been
off of these antibiotics several days prior to discharge from
the hospital.  She has been CDiff negative.  Repeat CT abdomen
[**6-12**] showed possible 2 cm organizing fluid collection which was
not felt to be an abscess. Another CT scan on [**6-19**] showed stable
inflammatory stranding of splenectomy bed, but no abscess.  IR
was contact[**Name (NI) **] and it was felt that this was not a drainable
fluid collection.  On [**6-21**], sent wound drainage from left chest
wall at JP drain site  for amylase, lipase to r/o pancreatitis
as cause of persistent wound. Wound drainage did have amylase
and lipase, however this was felt to be of unclear significance.
 The wound has since stopped draining.  Patient also has a soft
tissue mass near sternum (possible Lymph node) which has not
changed in size from 1 year prior and was not FDG avid at that
time.  Bronchoscopy was repeated on [**6-26**] and grew acinetobacter.
Per ID consult she repeated another course of will Flagyl, Levo
and Vanc for a total of 14 days, last day was [**7-12**].
Transesophageal Echocardiogram was performed on [**7-8**] and did not
show any valvular vegetations.  On [**7-14**] Tmax over previous 24
hours was 100.5F, on [**7-15**], Tmax was 99.8F and on [**7-16**], Tmax was
100/0F.  Her fever curve seems to be continually improving off
antibiotics.  The source of fevers continue to be unknown.
.
#. Delirium: Unclear etiology. Suspect steroid psychosis vs
steroid withdrawl psychosis vs icu psychosis vs non conculsive
seizure.  EEG done, no epileptiform activity. CT head showed no
acute pathology to account for mental status. MRI negative, LP
negative. 24 hour EEG negative. Mental status had improved, now
pt extremely tremulous and tachycardic (likely due to fever).
Appreciate neuro recs.
Gradually, klonopin, seroquel, olanzapine were discontinued.
She received ativan 1mg iv prn (and received 1-3 times/day
depending on her anxiety level.  Her mental status seems much
improved and she no longer seems delerious.
.
#. Respiratory Failure: Likely due to pneumonia, CHF, COPD.
Patient remained on CPAP + PS -> [**2149-6-21**]: Not able to reduce PEEP
from 8.  Pt tolerated decreased PS of [**7-29**], but was occasionlly
tachypneic and PS was increased.  Her vent was weaned and she
was receiving trach mask trials for a couple of hours a day to
strengthen her respiratory muscles as it was felt that her
difficulty with weaning from the vent was from deconditioning.
She was continued on combivent, fluticasone.  On [**7-11**] attempt
trach mask trial again, NIF 16, RSBI 60s.
.
#. Anemia: Acute drop in hct from 24 to 19 on [**6-8**]. Guaiac
positive brown stool and also with bloody respiratory secretions
and blood on BAL. Had antral gastritis earlier in course.  Now
resolved. Pt had hemoccult + vomiting on [**6-18**] and [**6-9**]. She has
been on anti-coagulation for her aortic valve replacement.  Her
Hematocrit has remained stable in the low 20's (mainly 22-24).
.
#. ARF: Secondary to AIN from Nafcillin. Prior to that had ATN
from contrast dye. Creatinine has improved, urine output has
been good and renal function appears back to baseline.
.
#. CV: Patient with no known CAD, at home was on atenolol,
norvasc and dyazide for BP. Weaned clonidine. She was restarted
on metoprolol 25mg [**Hospital1 **] -> titrated to 50mg [**Hospital1 **] on [**7-8**] and HR/BP
are tolerating this.
.
#. Adrenal insufficiency: s/p adrenalectomy with presumed
adrenal insufficiency due to suppression of other adrenal by a
cortisol secreting adenoma. Now should have adrenal
insufficiency regardless based on high doses of cortisol for 2
months. Began steroid wean with goal to reach physiologic doses
over a very long wean period. Per Endocrinology a cortisol stim
test would not be reliable at this point. Was on 25/10/10 of
hydrocortisone and changed to equal dose of prednisone 10 qday
as pt had at one point in [**Month (only) 547**] improved mental status on
prednisone and wished to determine if mental status would
improve. Has improved mental status since change with no
hemodynamic abn, only increased temp. Would favor continuing
prednisone and not switching to hydrocortisone. Appreciate
endocrinology recommendations.  PTH slightly low at 13, which is
likely in response to elevated calcium.  25-hydroxy Vitamin D
level was slightly low at 18 and Vitamin D [**1-15**] Dihydroxy was
pending at time of discharge.
.
#. Hypercalcemia: Consulted endocrine and rechecked PTH, sent
off 25-OH and 1,25-OH Vit D.  PTH was slightly low at 13, 25-OH
was slightly low at 18 and Vitamin D [**1-15**] OH was pending at time
of discharge.  Gave occasional doses of lasix 20 iv once with iv
fluids to reduce calcium levels.
.
#. Anticoagulation: For St. Jude's valve. Heparin drip was
transitioned to coumadin and her INR was supratherapeutic at
time of discharge.  Coumadin should be restarted when INR < 3.5.
.
#. Elevated Alkaline phosphatase with elevated GGT: trending
down. US [**6-8**] showed only liver hemangiomas which are not new.
[**Month (only) 116**] be due to secretion from small bowel or pancreas. R UQ
remains unchanged.  Appreciate Hep recs, considered MRCP to
further evaluate liver lesions, and then possibly liver biopsy
depending on results of MRCP.  However, pt currently not able to
hold breath for MRCP (would require paralysis). Will hold off on
MRI for now.
.
#. PPX: PPI, IV heparin, pneumoboots.
.
#. FEN: tube feeds, repleted electrolytes prn.  Consulted
surgery for PEG, but holding until fevers resolve. Post pyloric
tube placed.
.
#. Access: L PICC placed [**2149-5-27**], removed [**2149-6-18**]. R double lumen
PICC placed [**2149-6-18**] by IR and no evidence of infection at this
site.
.
#. Code: Full
.
#. Dispo: To rehab.  On discharge to rehab, INR was
supratherapeutic at 4.2.  Coumadin needs to be restarted at
rehab when INR < 3.5 (goal 2.5-3.5 for AVR).
.
#. Comm: with daughter

Medications on Admission:
Prednisone 10 daily
atenolol 50 daily
norvasc 10 daily
dyazide 37.5/25
lipitor 20
lasix 40 [**Hospital1 **]
coumadin 2 daily
foradil 12 [**Hospital1 **]
albuterol 2 puffs tid
singulari 10 daily
flagyl
abmanex 220 daily

Discharge Medications:
1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical  QID
(4 times a day) as needed.
2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
3. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation Q4H (every 4 hours) as needed.
4. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q4H (every 4 hours).
5. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl
Topical  PRN (as needed).
6. Lidocaine HCl 5 % Ointment Sig: One (1) Appl Topical  PRN (as
needed).
7. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
8. Acetaminophen 160 mg/5 mL Solution Sig: [**12-23**]  PO Q4-6H (every
4 to 6 hours) as needed.
9. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1)  PO BID (2
times a day).
10. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
13. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN.  Inspect site every shift.
14. Sodium Chloride 0.9%  Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
15. Pantoprazole 40 mg IV Q24H
16. Morphine Sulfate 1-2 mg IV Q4H:PRN
17. Lorazepam 1 mg IV BID:PRN
18. Dolasetron Mesylate 12.5 mg IV Q8H:PRN
coumadin currently on hold for supratherapeutic INR, should be
restarted when INR < 3.5


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 700**] - [**Location (un) 701**]

Discharge Diagnosis:
Post operative wound infection, cardiopulmonary arrest, blood
loss anemia, gastritis, acute renal failure, adrenal
insufficency


Discharge Condition:
stable


Discharge Instructions:
Please call or come to the ED with fevers > 101,
redness/warmth/drainage/tenderness around your incisions,
nausea, vomiting, abdominal pain, shortenss of breath, chest
pain, or any other unusual and worrisome event.  Please continue
with your CPAPO every night.  You may shower and resume regular
diet.
.
You should have you blood checked and coumadin should be
restarted when INR < 3.5 for goal 2.5-3.5.

Followup Instructions:
Please follow-up with your primary care physician upon discharge
from Rehab.
You should have bloodwork checked every other day until INR <
3.5 when coumadin should be restarted (consider 1-2mg coumadin
po qhs).  INR on day of discharge was 4.2.
{'Other postoperative infection,Cardiac arrest,Acute kidney failure with lesion of tubular necrosis,Iron deficiency anemia secondary to blood loss (chronic),Congestive heart failure, unspecified,Urinary tract infection, site not specified,Methicillin susceptible pneumonia due to Staphylococcus aureus,Hyperosmolality and/or hypernatremia,Candidiasis of other urogenital sites,Unspecified septicemia,Severe sepsis,Septic shock,Acute gastritis, with hemorrhage,Heart valve replaced by other means,Hypercalcemia,Long-term (current) use of steroids,Other nonspecific abnormal serum enzyme levels,Delirium due to conditions classified elsewhere,Other specified disorders of pancreatic internal secretion,Adrenal cortical steroids causing adverse effects in therapeutic use'}


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: drainage at incision site and fever

PRESENT ILLNESS: The patient is a 57 yo female s/p left adrenalectomy and
splenectomy on [**2149-4-14**], d/c'd [**2149-4-28**], who returned to the [**Hospital1 18**]
ED on [**2149-4-30**] with fever and incision site discharge.

MEDICAL HISTORY: cushings syndrome, AVR [**2143**], pulmonary AVM repair [**2143**]

MEDICATION ON ADMISSION: Prednisone 10 daily
atenolol 50 daily
norvasc 10 daily
dyazide 37.5/25
lipitor 20
lasix 40 [**Hospital1 **]
coumadin 2 daily
foradil 12 [**Hospital1 **]
albuterol 2 puffs tid
singulari 10 daily
flagyl
abmanex 220 daily

ALLERGIES: Codeine / Talwin / Nafcillin

PHYSICAL EXAM: VS- Temp 102, HR 88, BP 122/60, RR 28, SO2 100 % on 12L FM
Gen- NAD, pleasant
Heart: RRR, loud SEM
Lungs: CTA b/l
Abd: soft, LLQ tenderness around incision site, + purulent
drainage
Neuro: AxOx3

FAMILY HISTORY: NC

SOCIAL HISTORY: NC 

### Response:
{'Other postoperative infection,Cardiac arrest,Acute kidney failure with lesion of tubular necrosis,Iron deficiency anemia secondary to blood loss (chronic),Congestive heart failure, unspecified,Urinary tract infection, site not specified,Methicillin susceptible pneumonia due to Staphylococcus aureus,Hyperosmolality and/or hypernatremia,Candidiasis of other urogenital sites,Unspecified septicemia,Severe sepsis,Septic shock,Acute gastritis, with hemorrhage,Heart valve replaced by other means,Hypercalcemia,Long-term (current) use of steroids,Other nonspecific abnormal serum enzyme levels,Delirium due to conditions classified elsewhere,Other specified disorders of pancreatic internal secretion,Adrenal cortical steroids causing adverse effects in therapeutic use'}
