CHIEF COMPLAINT: hip pain

PRESENT ILLNESS: HPI: This is a 76 year-old Female with a PMH significant for
coronary artery disease (4-vessel CABG), critical aortic
stenosis with bovine AVR (s/p re-do sternotomy for wound
dehiscence with rib plating), s/p carcinoid tumor resection,
obstructive sleep apnea (on 2L NC at nighttime), history of deep
venous thrombses (IVC filter currently not on anticoagulation),
hypertension, hyperlipidemia, insulin-dependent diabetes
mellitus, chronic systolic heart failure (LVEF 40%) and anemia
of chronic disease who has a complicated surgical history after
a left subtrochanteric femur fracture repair in [**2197**] with
subsequent opeartive site infection, debridement and irrigation
of a left hip abscess with hardware removal and antibiotic
spacer placement ([**2205-7-30**]) followed by repeat washout and
antibiotic spacer exchange for on-going left septic hip joint
([**2205-8-15**]) now presenting from her rehab facility with persitent
hip pain, spacer dislocation and evidence of a larger open
wound.
.
Her infectious history begins when her left prosthetic joint
speciated S.lugdenesis in [**2-/2204**] requiring washout with a
retention strategy and 6-weeks of IV Vancomycin and Rifampin,
followed by 3-months of Rifampin and Doxycycline.
.
She was subsequently re-admitted on [**2205-7-29**] with on-going left
hip pain and underwent debridement and irrigation of a left hip
abscess, removal of arthroplasty hardware components, antibiotic
spacer placement, with VAC application for wound closure on
[**2205-7-30**]. Tissue cultures at that time again noted S.lugdenesis
and coagulase negative Staphylooccus. Her post-operative course
was complicate by delirium, hypotension and acute renal failure
and episodes of coffee-ground hematemesis without decreased
hematocrit (treated for H. pylori infection) and she was
discharged to rehab on IV Vancomycin for 6-weeks (on [**2205-8-9**]).
.
Her most recent admission to [**Hospital1 18**] was on [**2205-8-12**], at which time
she returned from rehab with a decrease in her hematocrit to 22%
and evidence of sanguinous drainage from her left hip. She was
reportedly hypotensive to the 80s in the ED, but responsive to
IV fluids and 2 units of packed red cells. She underwent an
uncomplicated incision and drainage and placement of
articulating antibiotic spacer on [**2205-8-15**]. Tissue cultures from
her prior debridement had speciated Staphylococcus lugdunensis
(similar to her prior hip infection) and her blood cultures from
[**2205-8-12**] speciated two species of Staphylococcus epidermidis.
Infectious disease was involved and recommended continuing the
extended course of Vancomycin IV. She was discharged to rehab on
[**2205-8-20**] to continue IV antibiotics.
.
She is now being directly admitted from clinic given on-going
hip pains and evidence of a larger open wound. She was
interviewed with her daughter presents. She has been doing
'okay' while at rehab. She has no fevers or chills, ocassional
sweats at nighttime. She is tolearting PO intake with nausea,
emesis or abdominal pain. She has no headaches or vision
changes. She denies chest pain or trouble breathing. No
numbness, paresthesias or new weakness in the lower extremities.
She denies changes in her bowel habits. Her left hip is painful
and has this pain has been escalating while at rehab; she gains
some relief from Oxycodone PO. She has been working with PT at
rehab, but has not ambulated since her first surgery in late
[**2205-6-28**].
.
ROS: Denies headaches or vision changes. No cough or upper
respiratory symptoms. Denies chest pain, dizziness or
lightheadedness; no palpitations. Denies shortness of breath or
exertional dyspnea. No nausea or vomiting; denies abdominal
pain. No dysuria or hematuria. Denies muscle weakness, myalgias
or neurologic complaints. No leg swelling. Denies rashes or
lesions.
.

MEDICAL HISTORY: 1. Coronary artery disease (4-vessel CABG, [**2190**] - LIMA-LAD,
RSVG-RI, OM and PLA of RCA)
2. Critical, symptomatic aortic stenosis with bovine AVR (re-do
sternotomy for wound dehiscence with rib plating, [**10/2203**])
3. Carcinoid tumor of the lung (right middle lobe, s/p
resection)
4. Obstructive sleep apnea (oxygen-dependent since lung
resection; utilizes 2L nasal cannula O2 only at nighttime; no
BiPAP)
5. History of chronic congestive heart failure
6. History of deep venous thrombosus (in [**2176**] twice, s/p IVC
filter placement; no chronic anticoagulation since [**2197**])
7. Hypertension
8. Hyperlipidemia
9. Insulin-dependent diabetes mellitus
10. Restrictive lung disease
11. Carpel tunnel syndrome (bilateral decompressions, [**2179**])
12. Chronic systolic heart failure (LVEF 40% in [**2205**])
13. Anemia of chronic disease (baseline HCT 26-31%)
.
PAST PERTINENT SURGICAL HISTORY:
1. s/p right middle lobe resection, VATS for carcinoid tumor
([**2195-3-20**])
2. s/p intramedullary rod fixation of left subtrochanteric femur
fracture ([**2197-6-3**])
3. s/p irrigation debridement left hip joint, arthrotomy,
exchange bipolar component left hip hemiarthroplasty ([**2204-3-14**])
4. s/p debridement and irrigation of hip abscess, removal of
arthroplasty hardware components, antibiotic spacer placement,
VAC application for wound closure ([**2205-7-30**])
5. s/p debridement irrigation hip hematoma, removal of
antibiotic spacer and placement of functional antibiotic spacer
and application of surface VAC sponge ([**2205-8-15**]) for left septic
hip joint

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from Family/Caregiver.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
at bedtime
3. Bisacodyl 10 mg PO DAILY:PRN constipation
4. Carvedilol 3.125 mg PO BID
5. Docusate Sodium 100 mg PO BID
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Multivitamins 1 TAB PO DAILY
8. Milk of Magnesia 30 mL PO DAILY
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Senna 1 TAB PO BID
11. Vancomycin 750 mg IV Q 24H
6 weeks until [**2205-9-9**]
12. Heparin 5000 UNIT SC TID
13. Vitamin D 1000 UNIT PO DAILY
14. Omeprazole 40 mg PO BID
15. zinc oxide *NF* 20%  Topical [**Hospital1 **]
one application topically [**Hospital1 **]
16. Heparin Flush (10 units/ml) 5 mL IV PRN line maintenance
3 mL IV PRN line maintenance; 2 mL IV line flush to PICC line
17. OxycoDONE (Immediate Release)  5 mg PO BID for pain
18. OxycoDONE (Immediate Release)  5 mg PO Q4H:PRN pain
2.5-5 mg PO Q4H PRN pain
19. NPH insulin human recomb *NF* 100 unit/mL Subcutaneous daily

ALLERGIES: Ampicillin / Ceftin / Bactrim / Zocor / Lopressor / Rezulin

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM
PHYSICAL EXAM:
VITALS: 98.4 116/53 84 18 97% RA
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 [**3-1**] above the clavicle
at 90-degrees. Thyroid barely palpable.
CVS: Regular rate and rhythm, II/VI holosystolic murmur at RUSB,
no rubs or gallops. S1 and S2 normal.
RESP: Decreased breath sounds at bases to auscultation
bilaterally without adventitious sounds. No wheezing, rhonchi or
crackles. Stable inspiratory effort.
ABD: soft, non-tender, non-distended, with normoactive bowel
sounds. No palpable masses or peritoneal signs.
EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses and
warm, well-perfused. Right PICC line without erythema or
drainage.
LEFT HIP: 15-20 cm linear incision cranial to caudal with
staples in place superiorly and inferiorly. No surrounding
erythema. Mid-incision there appears a 5-6 cm area of open wound
with serosanguinous drainage tracking into the fascia.
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: FAMILY HX: Denies significant family history of cardiovascular
disease, early MI, arrhythmia or sudden cardiac death. Father
with a history of lung cancer.

SOCIAL HISTORY: SOCIAL HX: Patient is originally from [**Country 5881**]. Lives at home with
her husband and son in [**Name (NI) 98332**] Plains. Daughter lives in [**Location 86**]
and is very involved. Denies tobacco use or alcohol use; no
recreational substance use. Patient is now dependent in ADLs and
does not ambulate (not since [**2205-6-28**]) given her pain and hip
infection issues.
.
Infection and inflammatory reaction due to internal joint prosthesis,Acute on chronic systolic heart failure,Other postoperative infection,Acute posthemorrhagic anemia,Other iatrogenic hypotension,Coronary atherosclerosis of native coronary artery,Obstructive sleep apnea (adult)(pediatric),Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other and unspecified hyperlipidemia,Other chronic postoperative pain,Other and unspecified Escherichia coli [E. coli],Pressure ulcer, lower back,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Aortocoronary bypass status,Heart valve replaced by transplant,Long-term (current) use of insulin,Hip joint replacement,Personal history of venous thrombosis and embolism
React-inter joint prost,Ac on chr syst hrt fail,Other postop infection,Ac posthemorrhag anemia,Iatrogenc hypotnsion NEC,Crnry athrscl natve vssl,Obstructive sleep apnea,Hypertension NOS,DMII wo cmp nt st uncntr,Hyperlipidemia NEC/NOS,Chronic postop pain NEC,E.coli infection NEC/NOS,Pressure ulcer, low back,Abn react-surg proc NEC,Aortocoronary bypass,Heart valve transplant,Long-term use of insulin,Joint replaced hip,Hx-ven thrombosis/embols
Admission Date:  [**2205-9-10**]              Discharge Date:   [**2205-9-24**]

Date of Birth:  [**2129-3-14**]             Sex:   F

Service: MEDICINE

Allergies:
Ampicillin / Ceftin / Bactrim / Zocor / Lopressor / Rezulin

Attending:[**Doctor First Name 2080**]
Chief Complaint:
hip pain

Major Surgical or Invasive Procedure:
L hip spacer removal, washout, and wound closure


History of Present Illness:
HPI: This is a 76 year-old Female with a PMH significant for
coronary artery disease (4-vessel CABG), critical aortic
stenosis with bovine AVR (s/p re-do sternotomy for wound
dehiscence with rib plating), s/p carcinoid tumor resection,
obstructive sleep apnea (on 2L NC at nighttime), history of deep
venous thrombses (IVC filter currently not on anticoagulation),
hypertension, hyperlipidemia, insulin-dependent diabetes
mellitus, chronic systolic heart failure (LVEF 40%) and anemia
of chronic disease who has a complicated surgical history after
a left subtrochanteric femur fracture repair in [**2197**] with
subsequent opeartive site infection, debridement and irrigation
of a left hip abscess with hardware removal and antibiotic
spacer placement ([**2205-7-30**]) followed by repeat washout and
antibiotic spacer exchange for on-going left septic hip joint
([**2205-8-15**]) now presenting from her rehab facility with persitent
hip pain, spacer dislocation and evidence of a larger open
wound.
.
Her infectious history begins when her left prosthetic joint
speciated S.lugdenesis in [**2-/2204**] requiring washout with a
retention strategy and 6-weeks of IV Vancomycin and Rifampin,
followed by 3-months of Rifampin and Doxycycline.
.
She was subsequently re-admitted on [**2205-7-29**] with on-going left
hip pain and underwent debridement and irrigation of a left hip
abscess, removal of arthroplasty hardware components, antibiotic
spacer placement, with VAC application for wound closure on
[**2205-7-30**]. Tissue cultures at that time again noted S.lugdenesis
and coagulase negative Staphylooccus. Her post-operative course
was complicate by delirium, hypotension and acute renal failure
and episodes of coffee-ground hematemesis without decreased
hematocrit (treated for H. pylori infection) and she was
discharged to rehab on IV Vancomycin for 6-weeks (on [**2205-8-9**]).
.
Her most recent admission to [**Hospital1 18**] was on [**2205-8-12**], at which time
she returned from rehab with a decrease in her hematocrit to 22%
and evidence of sanguinous drainage from her left hip. She was
reportedly hypotensive to the 80s in the ED, but responsive to
IV fluids and 2 units of packed red cells. She underwent an
uncomplicated incision and drainage and placement of
articulating antibiotic spacer on [**2205-8-15**]. Tissue cultures from
her prior debridement had speciated Staphylococcus lugdunensis
(similar to her prior hip infection) and her blood cultures from
[**2205-8-12**] speciated two species of Staphylococcus epidermidis.
Infectious disease was involved and recommended continuing the
extended course of Vancomycin IV. She was discharged to rehab on
[**2205-8-20**] to continue IV antibiotics.
.
She is now being directly admitted from clinic given on-going
hip pains and evidence of a larger open wound. She was
interviewed with her daughter presents. She has been doing
'okay' while at rehab. She has no fevers or chills, ocassional
sweats at nighttime. She is tolearting PO intake with nausea,
emesis or abdominal pain. She has no headaches or vision
changes. She denies chest pain or trouble breathing. No
numbness, paresthesias or new weakness in the lower extremities.
She denies changes in her bowel habits. Her left hip is painful
and has this pain has been escalating while at rehab; she gains
some relief from Oxycodone PO. She has been working with PT at
rehab, but has not ambulated since her first surgery in late
[**2205-6-28**].
.
ROS: Denies headaches or vision changes. No cough or upper
respiratory symptoms. Denies chest pain, dizziness or
lightheadedness; no palpitations. Denies shortness of breath or
exertional dyspnea. No nausea or vomiting; denies abdominal
pain. No dysuria or hematuria. Denies muscle weakness, myalgias
or neurologic complaints. No leg swelling. Denies rashes or
lesions.
.

Past Medical History:
1. Coronary artery disease (4-vessel CABG, [**2190**] - LIMA-LAD,
RSVG-RI, OM and PLA of RCA)
2. Critical, symptomatic aortic stenosis with bovine AVR (re-do
sternotomy for wound dehiscence with rib plating, [**10/2203**])
3. Carcinoid tumor of the lung (right middle lobe, s/p
resection)
4. Obstructive sleep apnea (oxygen-dependent since lung
resection; utilizes 2L nasal cannula O2 only at nighttime; no
BiPAP)
5. History of chronic congestive heart failure
6. History of deep venous thrombosus (in [**2176**] twice, s/p IVC
filter placement; no chronic anticoagulation since [**2197**])
7. Hypertension
8. Hyperlipidemia
9. Insulin-dependent diabetes mellitus
10. Restrictive lung disease
11. Carpel tunnel syndrome (bilateral decompressions, [**2179**])
12. Chronic systolic heart failure (LVEF 40% in [**2205**])
13. Anemia of chronic disease (baseline HCT 26-31%)
.
PAST PERTINENT SURGICAL HISTORY:
1. s/p right middle lobe resection, VATS for carcinoid tumor
([**2195-3-20**])
2. s/p intramedullary rod fixation of left subtrochanteric femur
fracture ([**2197-6-3**])
3. s/p irrigation debridement left hip joint, arthrotomy,
exchange bipolar component left hip hemiarthroplasty ([**2204-3-14**])
4. s/p debridement and irrigation of hip abscess, removal of
arthroplasty hardware components, antibiotic spacer placement,
VAC application for wound closure ([**2205-7-30**])
5. s/p debridement irrigation hip hematoma, removal of
antibiotic spacer and placement of functional antibiotic spacer
and application of surface VAC sponge ([**2205-8-15**]) for left septic
hip joint


Social History:
SOCIAL HX: Patient is originally from [**Country 5881**]. Lives at home with
her husband and son in [**Name (NI) 98332**] Plains. Daughter lives in [**Location 86**]
and is very involved. Denies tobacco use or alcohol use; no
recreational substance use. Patient is now dependent in ADLs and
does not ambulate (not since [**2205-6-28**]) given her pain and hip
infection issues.
.

Family History:
FAMILY HX: Denies significant family history of cardiovascular
disease, early MI, arrhythmia or sudden cardiac death. Father
with a history of lung cancer.

Physical Exam:
ADMISSION PHYSICAL EXAM
PHYSICAL EXAM:
VITALS: 98.4 116/53 84 18 97% RA
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 [**3-1**] above the clavicle
at 90-degrees. Thyroid barely palpable.
CVS: Regular rate and rhythm, II/VI holosystolic murmur at RUSB,
no rubs or gallops. S1 and S2 normal.
RESP: Decreased breath sounds at bases to auscultation
bilaterally without adventitious sounds. No wheezing, rhonchi or
crackles. Stable inspiratory effort.
ABD: soft, non-tender, non-distended, with normoactive bowel
sounds. No palpable masses or peritoneal signs.
EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses and
warm, well-perfused. Right PICC line without erythema or
drainage.
LEFT HIP: 15-20 cm linear incision cranial to caudal with
staples in place superiorly and inferiorly. No surrounding
erythema. Mid-incision there appears a 5-6 cm area of open wound
with serosanguinous drainage tracking into the fascia.
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
GENERAL: NAD, awake, alert, wants to go to rehab
CV: RRR, S1S2, II/VI holosystolic murmur at RUSB
RESP: CTABL, no wheezes or crackles
ABD: soft, NTND, +BS
EXT: 2+ DP pulses. R PICC line.
LEFT HIP: 15-20 cm linear incision cranial to caudal with
staples in place superiorly and inferiorly. No surrounding
erythema.
NEURO: CN II-XII intact throughout. Alert and oriented x 3. DTRs
2+ throughout, strength 5/5 bilaterally, sensation grossly
intact. Gait deferred.

Pertinent Results:
[**2205-9-10**] 07:26PM BLOOD WBC-7.9 RBC-3.25* Hgb-9.8* Hct-29.7*
MCV-92 MCH-30.2 MCHC-33.0 RDW-15.4 Plt Ct-253
[**2205-9-10**] 07:26PM BLOOD Neuts-83.7* Lymphs-10.9* Monos-4.0
Eos-0.9 Baso-0.4
[**2205-9-10**] 07:26PM BLOOD PT-11.9 PTT-29.4 INR(PT)-1.1
[**2205-9-10**] 07:26PM BLOOD Glucose-170* UreaN-32* Creat-0.8 Na-135
K-4.4 Cl-100 HCO3-25 AnGap-14
[**2205-9-10**] 07:26PM BLOOD Calcium-8.4 Phos-3.5 Mg-1.5*
[**2205-9-11**] 05:40AM BLOOD Vanco-13.5

Micro
[**2205-9-13**] 12:30 pm SWAB     Site: HIP      LEFT HIP #3.
   GRAM STAIN (Final [**2205-9-13**]):
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.
   WOUND CULTURE (Preliminary):
      GRAM NEGATIVE ROD(S).    RARE GROWTH.
   ANAEROBIC CULTURE (Preliminary):

[**2205-9-11**] 9:00 pm SWAB     Site: HIP      LEFT HIP SUPERFISCIAL.

   WOUND CULTURE (Preliminary):
      SERRATIA MARCESCENS.    SPARSE GROWTH.
         IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
352-7050S
         [**2205-9-11**].
      ESCHERICHIA COLI.    SPARSE GROWTH.
         Cefazolin interpretative criteria are based on a dosage
regimen of
         2g every 8h.
         Piperacillin/Tazobactam Susceptibility testing
requested by [**First Name4 (NamePattern1) **]
         [**Last Name (NamePattern1) **] #[**Numeric Identifier 98333**] [**2205-9-16**].
      ESCHERICHIA COLI.    SPARSE GROWTH.  SECOND MORPHOLOGY.
         Cefazolin interpretative criteria are based on a dosage
regimen of
         2g every 8h.
         Piperacillin/Tazobactam Susceptibility testing
requested by [**First Name4 (NamePattern1) **]
         [**Last Name (NamePattern1) **] #[**Numeric Identifier 98333**] [**2205-9-16**].

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ESCHERICHIA COLI
                             |          ESCHERICHIA COLI
                             |          |
AMPICILLIN------------    16 I       16 I
AMPICILLIN/SULBACTAM--     4 S        4 S
CEFAZOLIN-------------   <=4 S      <=4 S
CEFEPIME--------------   <=1 S      <=1 S
CEFTAZIDIME-----------   <=1 S      <=1 S
CEFTRIAXONE-----------   <=1 S      <=1 S
CIPROFLOXACIN---------<=0.25 S   <=0.25 S
GENTAMICIN------------   <=1 S      <=1 S
MEROPENEM-------------<=0.25 S   <=0.25 S
TOBRAMYCIN------------     2 S      <=1 S
TRIMETHOPRIM/SULFA----   <=1 S      <=1 S

[**2205-9-11**] 9:00 pm TISSUE     Site: HIP      LEFT HIP #3.

                            **FINAL REPORT [**2205-9-15**]**

   GRAM STAIN (Final [**2205-9-11**]):
      2+   (1-5 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.

   TISSUE (Final [**2205-9-14**]):
      Reported to and read back by DR. [**Last Name (STitle) **] [**2205-9-12**] 11:11AM.
      SERRATIA MARCESCENS.    SPARSE GROWTH.
         This organism may develop resistance to third
generation
         cephalosporins during prolonged therapy. Therefore,
isolates that
         are initially susceptible may become resistant within
three to
         four days after initiation of therapy.  For serious
infections,
         repeat culture and sensitivity testing may therefore be
warranted
         if third generation cephalosporins were used.
         Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
         [**Last Name (NamePattern1) 3060**].

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             SERRATIA MARCESCENS
                             |
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------   <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO-----       S
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----   <=1 S

   ANAEROBIC CULTURE (Final [**2205-9-15**]):    NO ANAEROBES ISOLATED.


DISCHARGE LABS
WBC RBC  Hgb Hct  MCV MCH MCHC RDW Plt Ct
6.2 3.02 9.2 27.3 90 30.5 33.7 14.8 252

Glucose UreaN Creat Na K   Cl HCO3 AnGap
122     17    0.7  134 4.2 101 27 10

FINDINGS:  Two frontal images of the chest demonstrate a right
PICC line in
place with the tip overlying the right atrium.  The catheter
will need to be
pulled back 3 cm for appropriate placement.  No pneumothorax or
other
complications are seen.  There are slightly smaller lung volumes
on this exam
than on previous exam which may account for the slight increase
in vascular
crowding.  There is also some decrease in the distinctness of
vascular vessels
which could be consistent with vascular congestion or low lung
volumes.
Cardiac silhouette is unremarkable.  Again noted is the
orthopedic hardware in
the mid abdomen overlying the mid abdomen.

IMPRESSION:  Right PICC line in place with tip overlying the
right atrium.
Catheter needs to be pulled back 3 cm.


Brief Hospital Course:
IMPRESSION: 76F with a PMH significant for coronary artery
disease (4-vessel CABG), critical aortic stenosis with bovine
AVR (s/p re-do sternotomy for wound dehiscence with rib
plating), s/p carcinoid tumor resection, obstructive sleep apnea
(on 2L NC at nighttime), history of deep venous thromboses (IVC
filter currently not on anticoagulation), hypertension,
hyperlipidemia, insulin-dependent diabetes mellitus, chronic
systolic heart failure (LVEF 40%) and anemia of chronic disease
who has a complicated surgical history after a left
subtrochanteric femur fracture repair in [**2197**] with subsequent
operative site infection, debridement and irrigation of a left
hip abscess with hardware removal and antibiotic spacer
placement ([**2205-7-30**]) followed by repeat washout and antibiotic
spacer exchange for on-going left septic hip joint ([**2205-8-15**]) now
presenting from her rehab facility with persistent left-sided
hip pain, spacer dislocation and evidence of a larger draining
open wound.

#Septic Joint/Left Hip Infection-  The patient went to the OR on
[**2205-9-11**] for an I and D of her left hip, removal of antibiotic
spacer, and placement of wound VAC.   Her post-op course was
complicated by hypotension with BPs 85/50 requiring
phenylephrine and transfer to the TICU from [**Date range (3) 98334**].
She was weaned off pressors, hemodynamically stable, and
transferred to the medical floors on [**2205-9-12**].  She was taken
back to the OR on [**2205-9-13**] for repeat washout and wound VAC
placement. Her post-op course was again c/b by hypotension
(83/39) not on pressors.  She had 750cc blood loss from wound
VAC in the PACU and was transfused 3 units PRBC and given IVFs
with minimal improvement in pressures.  She was transferred to
the MICU and transfused 2 additional units PRBCs and all BP meds
were held given her hypotension. She was called out of the MICU
on [**2205-9-13**].  Her wound VAC was not hooked up to suction, due to
a large hematoma and concern for continued bleeding from wound
She went back to the OR on [**2205-9-16**] for repeat washout and her
post op course was again c/b by hypotension with SBPs in the
70s. In the PACU she had significant bloody VAC output and a Hct
drop from 34 to 28. She received pRBC and FFP x1, vitamin K, and
was admitted to the TSICU for close monitoring. She had repeated
washouts and final closure of her hip wound on [**2205-9-19**].

The patient was continued on her IV Vanc for her previous
Staphylococcus lugdunensis infection. He IV Vanc course was
completed during this admission.  Her wound cultures grew
Serratia marcens and E. Coli, for which she was initially
treated with Zosyn and subsequently narrowed down to IV
ciprofloxacin.  There was concern for possible bacteremia given
the patient's hypotension, however her blood cultures were
negative.  She will continue IV ciprofloxacin for 6 weeks ( last
day of [**First Name9 (NamePattern2) 621**] [**2205-10-24**]). She is to follow up with ortho and ID
in clinic after discharge. Per ID the patient will need weekly
CBC, Chem 7, ESR, CRP faxed to their office at #[**Telephone/Fax (1) 24609**].

#Chronic Sacral and right heel decubitus ulcer- The patient was
evaluated by the Wound Care Team, and their recs were
implemented. The recs are as follows:
 Wound care:
 Site: L heel
 Type:  Pressure ulcer
 Cleansing [**Doctor Last Name 360**]:  Saline
 Dressing:  Gauze - dry
 Change dressing:  qd

Site: Left heel
Description: Necrotic area
Care: Moisturize the periwound tissue with Aloe Vesta Moisture
barrier Ointment left and right heels.  Waffle boots

Site: Coccyx
Description: Pressure ulcer, unstageable, slough at wound base
Care: Irrigate wound w/commercial wound cleanser, pat dry, apply
a thin layer of DuoDerm Gel to the wound bed, cover with Mepilex
Sacral Foam dressing; Change dressing every 3 days or prn
displacement

# ISCHEMIC CARDIOMYOPATHY/ CORONARY DISEASE/CHRONIC DIASTOLIC
CHF ( LVEF 45% FROM [**2205-7-28**])
-Continue home meds: ASA 81 mg PO, atorvastatin 20 mg PO QHS.
Her carvedilol was decreased to 3.125 mg PO BID.  These
medications were confirmed with her outpatient cardiologist. She
was ordered for lisinopril 2.5mg daily while admitted but her
blood pressures tended to be on the low side and this was not
started.  Lasix continued to be held during admission because of
low BPs.  She did not show signs of volume overload.  Of note,
if was confirmed that the patient is NOT on Plavix currently.

#INSULIN-DEPENDENT DIABETES MELLITUS - the patient achieved
optimal glycemic control on 6 units NPH at breakfast and 8 units
at dinner with an insulin sliding scale. and is to  continue
this regimen on discharge.

#HISTORY OF DEEP VENOUS THROMBOSIS - The patient has a history
of deep venous thromboses in the lower extremities in [**2176**]
occurring two times(completed 6-months of Coumadin and had
repeat DVT occurrence off anticoagulation). Now she is s/p IVC
filter placement with no chronic anticoagulation needs since
[**2197**].  Given her high risk for recurrence and immobilization
with her hip surgery she was maintained  on Heparin 5000mg TID
for DVT prophylaxis and this should be continued for 4 weeks
following surgery (last date [**2205-10-17**]).

# OBSTRUCTIVE SLEEP APNEA, PRIOR LUNG RESECTION - History of
obstructive sleep apnea, requiring 2L nasal cannula
supplementation at bedtime only (intermittent use). She does not
use CPAP at home.  She was continued on 2 L Nasal cannula at
bedtime

# HYPERTENSION - The patient was initially hypotensive after OR,
requiring use of pressors. Now, BPs range in the 90-110s/30-50s.
Once pressures were stable her Carvedilol 3.125 mg PO BID was
restarted.

# HYPERLIPIDEMIA - The patient was continued on  Atorvastatin 20
mg PO QHS

# PEPTIC ULCER DISEASE - The patient underwent eradication
therapy after showing positive H. pylori antibodies in the past.
 She was continued on  omeprazole 40mg [**Hospital1 **]

TRANSITIONAL ISSUES
#FOLLOW UP IN [**Hospital **] CLINIC and [**Hospital **] CLINIC
# CONTINUE 6 WEEK COURSE OF IV CIPRO WITH weekly CBC, chem 7 ,
ESR, CRP faxed to [**Hospital **] clinic at [**Telephone/Fax (1) 24609**]

Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Family/Caregiver.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
at bedtime
3. Bisacodyl 10 mg PO DAILY:PRN constipation
4. Carvedilol 3.125 mg PO BID
5. Docusate Sodium 100 mg PO BID
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Multivitamins 1 TAB PO DAILY
8. Milk of Magnesia 30 mL PO DAILY
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Senna 1 TAB PO BID
11. Vancomycin 750 mg IV Q 24H
6 weeks until [**2205-9-9**]
12. Heparin 5000 UNIT SC TID
13. Vitamin D 1000 UNIT PO DAILY
14. Omeprazole 40 mg PO BID
15. zinc oxide *NF* 20%  Topical [**Hospital1 **]
one application topically [**Hospital1 **]
16. Heparin Flush (10 units/ml) 5 mL IV PRN line maintenance
3 mL IV PRN line maintenance; 2 mL IV line flush to PICC line
17. OxycoDONE (Immediate Release)  5 mg PO BID for pain
18. OxycoDONE (Immediate Release)  5 mg PO Q4H:PRN pain
2.5-5 mg PO Q4H PRN pain
19. NPH insulin human recomb *NF* 100 unit/mL Subcutaneous daily

4 units SC at breakfast, 4 units SC at dinner time
20. Calcium Carbonate 750 mg PO BID


Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
at bedtime
3. Carvedilol 3.125 mg PO BID
4. Docusate Sodium 100 mg PO BID
5. Heparin 5000 UNIT SC TID
last day [**2205-10-17**]
6. Multivitamins 1 TAB PO DAILY
7. Omeprazole 40 mg PO BID
8. Senna 1 TAB PO BID
9. Vitamin D 1000 UNIT PO DAILY
10. Acetaminophen 1000 mg PO Q8H:PRN fever/pain
11. Ciprofloxacin 400 mg IV Q12H
last day [**2205-10-24**]
12. NPH 6 Units Breakfast
NPH 8 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
13. Bisacodyl 10 mg PO DAILY:PRN constipation
14. Milk of Magnesia 30 mL PO DAILY
15. OxycoDONE (Immediate Release)  5 mg PO Q4H:PRN pain
2.5-5 mg PO Q4H PRN pain
16. Polyethylene Glycol 17 g PO DAILY:PRN constipation
17. zinc oxide *NF* 20%  Topical [**Hospital1 **]
one application topically [**Hospital1 **]
18. Calcium Carbonate 750 mg PO BID
19. 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.


Discharge Disposition:
Extended Care

Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]

Discharge Diagnosis:
Spacer removal, washout, wound closure L hip


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:
It was a pleasure taking care of you in the hospital.  You were
admitted for a left hip infection and you were taken to the
operating room for washout and removal of hardware.  You will be
going to a rehab facility for further physical therapy.

-Wound Care: You can get the wound wet/take a shower starting
from 3 days post-op. No baths or swimming for at least 4 weeks.
Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment. No dressing is needed
if wound continued to be non-draining.

******WEIGHT-BEARING*******
Touchdown weightbearing on Left lower extremity

******MEDICATIONS***********
**You will need to continue ciprofloxacin for one month until
[**2205-10-24**] and SC heparin for 4 weeks until your follow up
appointment***
- Resume your pre-hospital medications.
- You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink 8-8oz glasses of water daily and take a stool
softener (colace) to prevent this side effect.

-Please speak with your cardiologist regarding a blood pressure
medication called lisinopril.  We tried to start this medication
in the hospital but your blood pressures were on the low side.

Followup Instructions:
Department: ORTHOPEDICS
When: TUESDAY [**2205-10-1**] at 8:25 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

Department: ORTHOPEDICS
When: TUESDAY [**2205-10-1**] at 8:45 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

Please have your staples removed at your rehabilitation facility
at post-operative day 14 ([**2205-10-4**]).

Department: INFECTIOUS DISEASE
When: MONDAY [**2205-10-7**] at 10:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: ORTHOPEDICS
When: TUESDAY [**2205-10-8**] at 2:10 PM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: ORTHOPEDICS
When: TUESDAY [**2205-10-8**] at 2:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Infection and inflammatory reaction due to internal joint prosthesis,Acute on chronic systolic heart failure,Other postoperative infection,Acute posthemorrhagic anemia,Other iatrogenic hypotension,Coronary atherosclerosis of native coronary artery,Obstructive sleep apnea (adult)(pediatric),Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other and unspecified hyperlipidemia,Other chronic postoperative pain,Other and unspecified Escherichia coli [E. coli],Pressure ulcer, lower back,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Aortocoronary bypass status,Heart valve replaced by transplant,Long-term (current) use of insulin,Hip joint replacement,Personal history of venous thrombosis and embolism'}


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: hip pain

PRESENT ILLNESS: HPI: This is a 76 year-old Female with a PMH significant for
coronary artery disease (4-vessel CABG), critical aortic
stenosis with bovine AVR (s/p re-do sternotomy for wound
dehiscence with rib plating), s/p carcinoid tumor resection,
obstructive sleep apnea (on 2L NC at nighttime), history of deep
venous thrombses (IVC filter currently not on anticoagulation),
hypertension, hyperlipidemia, insulin-dependent diabetes
mellitus, chronic systolic heart failure (LVEF 40%) and anemia
of chronic disease who has a complicated surgical history after
a left subtrochanteric femur fracture repair in [**2197**] with
subsequent opeartive site infection, debridement and irrigation
of a left hip abscess with hardware removal and antibiotic
spacer placement ([**2205-7-30**]) followed by repeat washout and
antibiotic spacer exchange for on-going left septic hip joint
([**2205-8-15**]) now presenting from her rehab facility with persitent
hip pain, spacer dislocation and evidence of a larger open
wound.
.
Her infectious history begins when her left prosthetic joint
speciated S.lugdenesis in [**2-/2204**] requiring washout with a
retention strategy and 6-weeks of IV Vancomycin and Rifampin,
followed by 3-months of Rifampin and Doxycycline.
.
She was subsequently re-admitted on [**2205-7-29**] with on-going left
hip pain and underwent debridement and irrigation of a left hip
abscess, removal of arthroplasty hardware components, antibiotic
spacer placement, with VAC application for wound closure on
[**2205-7-30**]. Tissue cultures at that time again noted S.lugdenesis
and coagulase negative Staphylooccus. Her post-operative course
was complicate by delirium, hypotension and acute renal failure
and episodes of coffee-ground hematemesis without decreased
hematocrit (treated for H. pylori infection) and she was
discharged to rehab on IV Vancomycin for 6-weeks (on [**2205-8-9**]).
.
Her most recent admission to [**Hospital1 18**] was on [**2205-8-12**], at which time
she returned from rehab with a decrease in her hematocrit to 22%
and evidence of sanguinous drainage from her left hip. She was
reportedly hypotensive to the 80s in the ED, but responsive to
IV fluids and 2 units of packed red cells. She underwent an
uncomplicated incision and drainage and placement of
articulating antibiotic spacer on [**2205-8-15**]. Tissue cultures from
her prior debridement had speciated Staphylococcus lugdunensis
(similar to her prior hip infection) and her blood cultures from
[**2205-8-12**] speciated two species of Staphylococcus epidermidis.
Infectious disease was involved and recommended continuing the
extended course of Vancomycin IV. She was discharged to rehab on
[**2205-8-20**] to continue IV antibiotics.
.
She is now being directly admitted from clinic given on-going
hip pains and evidence of a larger open wound. She was
interviewed with her daughter presents. She has been doing
'okay' while at rehab. She has no fevers or chills, ocassional
sweats at nighttime. She is tolearting PO intake with nausea,
emesis or abdominal pain. She has no headaches or vision
changes. She denies chest pain or trouble breathing. No
numbness, paresthesias or new weakness in the lower extremities.
She denies changes in her bowel habits. Her left hip is painful
and has this pain has been escalating while at rehab; she gains
some relief from Oxycodone PO. She has been working with PT at
rehab, but has not ambulated since her first surgery in late
[**2205-6-28**].
.
ROS: Denies headaches or vision changes. No cough or upper
respiratory symptoms. Denies chest pain, dizziness or
lightheadedness; no palpitations. Denies shortness of breath or
exertional dyspnea. No nausea or vomiting; denies abdominal
pain. No dysuria or hematuria. Denies muscle weakness, myalgias
or neurologic complaints. No leg swelling. Denies rashes or
lesions.
.

MEDICAL HISTORY: 1. Coronary artery disease (4-vessel CABG, [**2190**] - LIMA-LAD,
RSVG-RI, OM and PLA of RCA)
2. Critical, symptomatic aortic stenosis with bovine AVR (re-do
sternotomy for wound dehiscence with rib plating, [**10/2203**])
3. Carcinoid tumor of the lung (right middle lobe, s/p
resection)
4. Obstructive sleep apnea (oxygen-dependent since lung
resection; utilizes 2L nasal cannula O2 only at nighttime; no
BiPAP)
5. History of chronic congestive heart failure
6. History of deep venous thrombosus (in [**2176**] twice, s/p IVC
filter placement; no chronic anticoagulation since [**2197**])
7. Hypertension
8. Hyperlipidemia
9. Insulin-dependent diabetes mellitus
10. Restrictive lung disease
11. Carpel tunnel syndrome (bilateral decompressions, [**2179**])
12. Chronic systolic heart failure (LVEF 40% in [**2205**])
13. Anemia of chronic disease (baseline HCT 26-31%)
.
PAST PERTINENT SURGICAL HISTORY:
1. s/p right middle lobe resection, VATS for carcinoid tumor
([**2195-3-20**])
2. s/p intramedullary rod fixation of left subtrochanteric femur
fracture ([**2197-6-3**])
3. s/p irrigation debridement left hip joint, arthrotomy,
exchange bipolar component left hip hemiarthroplasty ([**2204-3-14**])
4. s/p debridement and irrigation of hip abscess, removal of
arthroplasty hardware components, antibiotic spacer placement,
VAC application for wound closure ([**2205-7-30**])
5. s/p debridement irrigation hip hematoma, removal of
antibiotic spacer and placement of functional antibiotic spacer
and application of surface VAC sponge ([**2205-8-15**]) for left septic
hip joint

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from Family/Caregiver.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
at bedtime
3. Bisacodyl 10 mg PO DAILY:PRN constipation
4. Carvedilol 3.125 mg PO BID
5. Docusate Sodium 100 mg PO BID
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Multivitamins 1 TAB PO DAILY
8. Milk of Magnesia 30 mL PO DAILY
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Senna 1 TAB PO BID
11. Vancomycin 750 mg IV Q 24H
6 weeks until [**2205-9-9**]
12. Heparin 5000 UNIT SC TID
13. Vitamin D 1000 UNIT PO DAILY
14. Omeprazole 40 mg PO BID
15. zinc oxide *NF* 20%  Topical [**Hospital1 **]
one application topically [**Hospital1 **]
16. Heparin Flush (10 units/ml) 5 mL IV PRN line maintenance
3 mL IV PRN line maintenance; 2 mL IV line flush to PICC line
17. OxycoDONE (Immediate Release)  5 mg PO BID for pain
18. OxycoDONE (Immediate Release)  5 mg PO Q4H:PRN pain
2.5-5 mg PO Q4H PRN pain
19. NPH insulin human recomb *NF* 100 unit/mL Subcutaneous daily

ALLERGIES: Ampicillin / Ceftin / Bactrim / Zocor / Lopressor / Rezulin

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM
PHYSICAL EXAM:
VITALS: 98.4 116/53 84 18 97% RA
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 [**3-1**] above the clavicle
at 90-degrees. Thyroid barely palpable.
CVS: Regular rate and rhythm, II/VI holosystolic murmur at RUSB,
no rubs or gallops. S1 and S2 normal.
RESP: Decreased breath sounds at bases to auscultation
bilaterally without adventitious sounds. No wheezing, rhonchi or
crackles. Stable inspiratory effort.
ABD: soft, non-tender, non-distended, with normoactive bowel
sounds. No palpable masses or peritoneal signs.
EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses and
warm, well-perfused. Right PICC line without erythema or
drainage.
LEFT HIP: 15-20 cm linear incision cranial to caudal with
staples in place superiorly and inferiorly. No surrounding
erythema. Mid-incision there appears a 5-6 cm area of open wound
with serosanguinous drainage tracking into the fascia.
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: FAMILY HX: Denies significant family history of cardiovascular
disease, early MI, arrhythmia or sudden cardiac death. Father
with a history of lung cancer.

SOCIAL HISTORY: SOCIAL HX: Patient is originally from [**Country 5881**]. Lives at home with
her husband and son in [**Name (NI) 98332**] Plains. Daughter lives in [**Location 86**]
and is very involved. Denies tobacco use or alcohol use; no
recreational substance use. Patient is now dependent in ADLs and
does not ambulate (not since [**2205-6-28**]) given her pain and hip
infection issues.
. 

### Response:
{'Infection and inflammatory reaction due to internal joint prosthesis,Acute on chronic systolic heart failure,Other postoperative infection,Acute posthemorrhagic anemia,Other iatrogenic hypotension,Coronary atherosclerosis of native coronary artery,Obstructive sleep apnea (adult)(pediatric),Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other and unspecified hyperlipidemia,Other chronic postoperative pain,Other and unspecified Escherichia coli [E. coli],Pressure ulcer, lower back,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Aortocoronary bypass status,Heart valve replaced by transplant,Long-term (current) use of insulin,Hip joint replacement,Personal history of venous thrombosis and embolism'}
