CHIEF COMPLAINT: Pacemaker wound infection

PRESENT ILLNESS: 87 year old female with past medical history of atrial
fibrillation s/p PPM in approximately [**2116**], with recent
generator replacement [**2134-5-26**]. She reports erosion of the
skin overlying the pacer pocket on her left shoulder for
approximately 1 month. Now noticing erythema and mild pain. She
was brought to [**Hospital1 18**] ED by her daughter after being seen by her
cardiologist. She does not report fever but notes possible
chills a few weeks ago while in [**State 1727**] which she attributed to
cold weather
.
In the ED, initial VS: 97.9 80 124/61 97%RA. EKG showed V paced
rhythm with underlying afib/flutter. She was given 1 gm of
vancomycin after blood cultures were drawn and admitted to
cardiology for futher management.
.
On the floor, she has been comfortable. She denies chest pain,
SOB, fever, chills, NVD, or abdominal pain. She has no other
complaints.

MEDICAL HISTORY: -Atrial fibrillation s/p PPM approximately [**2116**]
-Skin cancer, BCC [**9-25**]; SCC10/06
-Cholelithiasis
-Hysterectomy
-Neuropathy
-NPH with intracranial shunt
-Urge incontinence
-CLL/SLL, in remission. Currently on rituximab maintence q3
months, last dose [**2134-5-20**]
-Polio dx [**2071**]
-CHF
-Gait disturbance
-Fatigue
-Osteoporosis

MEDICATION ON ADMISSION: Coumadin 6 mg po qdaily
Pilocarpine 1% eye drops tid glaucoma
Detrol unsure dose
Vitamin B12
alendronate 35 qwk monday
Rituximab q 3month for CLL maintenance
MVI

ALLERGIES: Penicillins / Scopolamine / glaucoma drops / Strawberry /
Demerol / Quinaglute Dura-Tabs

PHYSICAL EXAM: FEX ON ADMISSION
VS:95.2 144/85 81 18 100%RA
GENERAL: Female in no acute distress
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
NECK: Supple, no JVD.
HEART: RRR. 2/6 SEM noted over RUSB
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Does not smoke, drink or use illicit drugs. Spends most of her
summertime in [**State 1727**]. Married. Husband with severe Alzheimer's.
Infection and inflammatory reaction due to cardiac device, implant, and graft,Cellulitis and abscess of trunk,Atrioventricular block, complete,Idiopathic normal pressure hydrocephalus (INPH),Other disorders of neurohypophysis,Sinoatrial node dysfunction,Chronic lymphoid leukemia, in remission,Unspecified hereditary and idiopathic peripheral neuropathy,Pulmonary collapse,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms,Abnormal coagulation profile,Rash and other nonspecific skin eruption,Late effects of acute poliomyelitis,Osteoporosis, unspecified,Urinary incontinence, unspecified,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Long-term (current) use of anticoagulants,Presence of cerebrospinal fluid drainage device,Personal history of other malignant neoplasm of skin,Aortic valve disorders
React-cardiac dev/graft,Cellulitis of trunk,Atriovent block complete,Norml pressure hydroceph,Neurohypophysis dis NEC,Sinoatrial node dysfunct,Chr lym leuk w rmsion,Idio periph neurpthy NOS,Pulmonary collapse,Oth gram negatv bacteria,Abnrml coagultion prfile,Nonspecif skin erupt NEC,Late effect acute polio,Osteoporosis NOS,Urinary incontinence NOS,Abn react-artif implant,Long-term use anticoagul,Ventricular shunt status,Hx-skin malignancy NEC,Aortic valve disorder
Admission Date:  [**2134-7-8**]              Discharge Date:   [**2134-7-26**]


Service: MEDICINE

Allergies:
Penicillins / Scopolamine / glaucoma drops / Strawberry /
Demerol / Quinaglute Dura-Tabs

Attending:[**Attending Info 11308**]
Chief Complaint:
Pacemaker wound infection

Major Surgical or Invasive Procedure:
Pacemaker explantation [**7-15**]
Pacemaker reimplantation [**7-20**]
Wound revision [**7-22**]


History of Present Illness:
87 year old female with past medical history of atrial
fibrillation s/p PPM in approximately [**2116**], with recent
generator replacement [**2134-5-26**]. She reports erosion of the
skin overlying the pacer pocket on her left shoulder for
approximately 1 month. Now noticing erythema and mild pain. She
was brought to [**Hospital1 18**] ED by her daughter after being seen by her
cardiologist. She does not report fever but notes possible
chills a few weeks ago while in [**State 1727**] which she attributed to
cold weather
.
In the ED, initial VS: 97.9 80 124/61 97%RA. EKG showed V paced
rhythm with underlying afib/flutter. She was given 1 gm of
vancomycin after blood cultures were drawn and admitted to
cardiology for futher management.
.
On the floor, she has been comfortable. She denies chest pain,
SOB, fever, chills, NVD, or abdominal pain. She has no other
complaints.

Past Medical History:
-Atrial fibrillation s/p PPM approximately [**2116**]
-Skin cancer, BCC [**9-25**]; SCC10/06
-Cholelithiasis
-Hysterectomy
-Neuropathy
-NPH with intracranial shunt
-Urge incontinence
-CLL/SLL, in remission. Currently on rituximab maintence q3
months, last dose [**2134-5-20**]
-Polio dx [**2071**]
-CHF
-Gait disturbance
-Fatigue
-Osteoporosis


Social History:
Does not smoke, drink or use illicit drugs. Spends most of her
summertime in [**State 1727**]. Married. Husband with severe Alzheimer's.

Family History:
Noncontributory

Physical Exam:
FEX ON ADMISSION
VS:95.2 144/85 81 18 100%RA
GENERAL: Female in no acute distress
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
NECK: Supple, no JVD.
HEART: RRR. 2/6 SEM noted over RUSB
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored.

ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
SKIN: No rashes or lesions.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3, CNs II-XII intact, muscle grossly intact

FEX ON DISCHARGE
No significant changes except:
GENERAL: Decreased ambulation requiring 1 person assist.
SKIN. Surgical wound over left chest bandaged. New pacer site on
right chest bandaged. Significant dermatitis from tape across
chest. 3-4 cm erythmatous patch over sacrum. Blanchable with
healthy skin overlying.


Pertinent Results:
LABS ON ADMISSION

[**2134-7-8**] 06:33AM   GLUCOSE-96 UREA N-10 CREAT-0.7 SODIUM-140
POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-28 ANION GAP-13
[**2134-7-8**] 06:33AM   CALCIUM-8.4 PHOSPHATE-3.0 MAGNESIUM-2.0
[**2134-7-8**] 06:33AM   WBC-4.5 RBC-4.08* HGB-12.8 HCT-37.8 MCV-93
MCH-31.3 MCHC-33.8 RDW-13.6
[**2134-7-8**] 06:33AM   NEUTS-52.1 LYMPHS-30.9 MONOS-8.3 EOS-6.7*
BASOS-2.0
[**2134-7-8**] 06:33AM   PT-26.8* INR(PT)-2.6*
[**2134-7-7**] 09:10PM   GLUCOSE-162* UREA N-12 CREAT-0.8 SODIUM-139
POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-26 ANION GAP-15
[**2134-7-7**] 09:10PM   WBC-4.5 RBC-4.31 HGB-13.9 HCT-40.3 MCV-94
MCH-32.2* MCHC-34.4 RDW-13.6
[**2134-7-7**] 09:10PM   NEUTS-60.1 LYMPHS-26.6 MONOS-7.3 EOS-4.2*
BASOS-1.9

PERTINENT LABS

[**2134-7-12**] 07:30AM BLOOD WBC-5.6 RBC-4.21 Hgb-13.9 Hct-39.0 MCV-93
MCH-33.1* MCHC-35.7* RDW-13.5 Plt Ct-213
[**2134-7-21**] 07:50AM BLOOD WBC-8.0 RBC-3.57* Hgb-11.3* Hct-33.5*
MCV-94 MCH-31.7 MCHC-33.8 RDW-14.7 Plt Ct-253

[**2134-7-9**] 06:50AM BLOOD PT-24.1* PTT-40.5* INR(PT)-2.3*
[**2134-7-11**] 06:40AM BLOOD PT-14.4* PTT-38.5* INR(PT)-1.2*
[**2134-7-12**] 07:30AM BLOOD PT-14.3* PTT-150* INR(PT)-1.2*
[**2134-7-16**] 06:41AM BLOOD PT-13.5* PTT-35.4* INR(PT)-1.1
[**2134-7-24**] 09:50AM BLOOD PT-13.4* INR(PT)-1.1

[**2134-7-8**] 06:33AM BLOOD Glucose-96 UreaN-10 Creat-0.7 Na-140
K-3.7 Cl-103 HCO3-28 AnGap-13
[**2134-7-15**] 06:50AM BLOOD Glucose-105* UreaN-22* Creat-0.7 Na-132*
K-3.9 Cl-97 HCO3-28 AnGap-11
[**2134-7-16**] 06:41AM BLOOD Glucose-181* UreaN-23* Creat-0.8 Na-129*
K-4.4 Cl-99 HCO3-19* AnGap-15
[**2134-7-18**] 07:15AM BLOOD Glucose-116* UreaN-16 Creat-0.6 Na-130*
K-4.1 Cl-96 HCO3-26 AnGap-12
[**2134-7-21**] 07:50AM BLOOD Glucose-89 UreaN-13 Creat-0.7 Na-138
K-4.0 Cl-101 HCO3-28 AnGap-13

[**2134-7-9**] 06:50AM BLOOD Calcium-8.6 Phos-3.0 Mg-2.1
[**2134-7-21**] 07:50AM BLOOD Calcium-8.6 Phos-3.9 Mg-1.9

[**2134-7-24**] 09:50AM BLOOD WBC-7.7 RBC-3.32* Hgb-10.6* Hct-31.3*
MCV-94 MCH-32.0 MCHC-34.0 RDW-14.6 Plt Ct-268
[**2134-7-24**] 09:50AM BLOOD UreaN-17 Creat-0.8 Na-135 K-4.1 Cl-100
HCO3-27 AnGap-12

REPORTS
[**Known lastname **], [**Known firstname **]       [**Hospital1 18**] [**Numeric Identifier 89143**]TTE
(Complete) Done [**2134-7-22**] at 10:20:50 AM      FINAL

Echocardiographic Measurements
Results  Measurements  Normal Range
Left Atrium - Long Axis Dimension:  3.5 cm  <= 4.0 cm
Left Atrium - Four Chamber Length:  *6.1 cm  <= 5.2 cm
Right Atrium - Four Chamber Length:  *6.1 cm  <= 5.0 cm
Left Ventricle - Septal Wall Thickness:  *1.2 cm  0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness:  *1.2 cm  0.6 - 1.1 cm

Left Ventricle - Diastolic Dimension:  3.4 cm  <= 5.6 cm
Left Ventricle - Systolic Dimension:  2.1 cm
Left Ventricle - Fractional Shortening:  0.38  >= 0.29
Left Ventricle - Ejection Fraction:  60% to 65%  >= 55%
Left Ventricle - Lateral Peak E':  *0.08 m/s  > 0.08 m/s
Left Ventricle - Septal Peak E':  0.15 m/s  > 0.08 m/s
Left Ventricle - Ratio E/E':  8  < 15
Aorta - Sinus Level:  2.6 cm  <= 3.6 cm
Aorta - Ascending:  3.1 cm  <= 3.4 cm
Aorta - Arch:  2.4 cm  <= 3.0 cm
Aortic Valve - Peak Velocity:  *3.8 m/sec  <= 2.0 m/sec
Aortic Valve - Peak Gradient:  *59 mm Hg  < 20 mm Hg
Aortic Valve - Mean Gradient:  30 mm Hg
Aortic Valve - LVOT VTI:  17
Aortic Valve - Valve Area:  *0.8 cm2  >= 3.0 cm2
Aortic Valve - Pressure Half Time:  651 ms
Mitral Valve - E Wave:  0.9 m/sec
Mitral Valve - E Wave deceleration time:  181 ms  140-250 ms
TR Gradient (+ RA = PASP):  22 mm Hg  <= 25 mm Hg
Pulmonic Valve - Peak Velocity:  0.8 m/sec  <= 1.5 m/sec

Findings
s/p perm pacemaker insertion with removal of prior pacemaker
infected lead.
LEFT ATRIUM: Elongated LA.

RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler. Normal IVC diameter (<=2.1cm) with >50% decrease with
sniff (estimated RA pressure (0-5 mmHg).

LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
regional/global systolic function (LVEF>55%). No resting LVOT
gradient.

RIGHT VENTRICLE: Normal RV chamber size. Borderline normal RV
systolic function. Paradoxic septal motion consistent with
conduction abnormality/ventricular pacing.

AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels. No 2D or Doppler evidence of distal arch coarctation.

AORTIC VALVE: Moderately thickened aortic valve leaflets. No
masses or vegetations on aortic valve. Severe AS (area
0.8-1.0cm2). Mild to moderate ([**12-27**]+) AR.

MITRAL VALVE: Moderately thickened mitral valve leaflets. No
mass or vegetation on mitral valve. Mild mitral annular
calcification. Mild thickening of mitral valve chordae. Mild
(1+) MR.

TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Probable vegetation on tricuspid valve. Moderate [2+] TR.
Borderline PA systolic hypertension.

PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.

PERICARDIUM: Trivial/physiologic pericardial effusion.

GENERAL COMMENTS: Left pleural effusion.
Conclusions
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. The estimated right atrial pressure is 0-5
mmHg. There is mild symmetric left ventricular hypertrophy with
normal cavity size and regional/global systolic function
(LVEF>55%). Right ventricular chamber size is normal. with
borderline normal free wall function. The diameters of aorta at
the sinus, ascending and arch levels are normal. The aortic
valve leaflets are moderately thickened. No masses or
vegetations are seen on the aortic valve. There is severe aortic
valve stenosis (valve area 0.8-1.0cm2). Mild to moderate ([**12-27**]+)
aortic regurgitation is seen. The mitral valve leaflets are
moderately thickened. No mass or vegetation is seen on the
mitral valve. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is a small,
independently moving echodense structure measuring 0.2 x 0.4
centimeters in greatest dimension (clip [**Clip Number (Radiology) **], 104) on the
?posterior leaflet of the tricuspid valve concerning for
possible vegetation vs a torn chordae. At least moderate [2+]
tricuspid regurgitation is seen. There is borderline pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion.

IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and preserved global and regional left
ventricular systolic function. Possible tricuspid valve
vegetation with at least moderate tricuspid regurgitation as
described above. Severe aortic stenosis with mild to moderate
aortic regurgitation.

To futher characterize the possible tricuspid valve vegetation a
transesophageal echocardiogram may be considered.

Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] notified of the results by phone.
  Electronically signed by [**Name6 (MD) **] [**Name8 (MD) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2134-7-22**] 12:48
Radiology Report CHEST (PA & LAT) Study Date of [**2134-7-21**] 8:36 AM



[**Date Range 163**],[**Date Range **] [**Hospital Unit Name 53630**] [**2134-7-21**] 8:36 AM
CHEST (PA & LAT)   Clip # [**Clip Number (Radiology) 89144**]
Reason: s/p right-sided permanent pacemaker implant. ? lead
placemen



[**Hospital 93**] MEDICAL CONDITION:
   87 year old woman with h/o chb s/p right-sided ppm placement.

REASON FOR THIS EXAMINATION:
   s/p right-sided permanent pacemaker implant. ? lead placement


Radiology Report CHEST (PA & LAT) Study Date of [**2134-7-21**] 8:36 AM

Final Report
INDICATION: Patient with right-sided permanent pacemaker
placement. Please
assess lead placement and pneumothorax.

COMPARISON: Chest radiograph from [**7-7**], [**7-15**] and [**7-16**].

FINDINGS: Pacemaker is observed in the right axillary area with
leads ending
in standard positions in the right atrium and the right
ventricle. No
evidence of pneumothorax. Good lung volumes without focal
radiopacities.
Mild-to-moderate cardiomegaly is present. New small bilateral
pleural
effusions with concurrent mild left basilar atelectasis has
developed since
prior exam. A ventriculoperitoneal shunt is seen tracking along
the midline.

IMPRESSION: Interval development of small bilateral pleural
effusions with
left base atelectasis. New pacemaker with leads in standard
position.

Radiology Report CHEST (PORTABLE AP) Study Date of [**2134-7-16**] 7:15
AM


[**Date Range 163**],[**Date Range **] [**Hospital Unit Name 61932**] [**2134-7-16**] 7:15 AM
CHEST (PORTABLE AP)   Clip # [**Clip Number (Radiology) 89145**]
Reason: bleed?



[**Hospital 93**] MEDICAL CONDITION:
   87 year old woman with pacer pocket infection s/p explant
with wire removal and
   temporary pacemaker placement
REASON FOR THIS EXAMINATION:
   bleed?

Final Report
AP CHEST, 8:38 A.M., [**7-16**]

HISTORY: Pacer pocket infection following explant with wire
removal and now
temporary pacemaker.

IMPRESSION: AP chest compared to [**7-15**]:

There is no pneumothorax, appreciable pleural effusion, or
mediastinal
widening. Transvenous lead extends from the left supraclavicular
pacemaker to the right ventricular apex. Moderately enlarged
cardiac silhouette is
slightly smaller today, with a configuration indicating a very
dilated left atrium, but there is no pulmonary vascular
congestion or edema. Shunt
catheter traverses the right neck, chest, and upper abdomen.

DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: FRI [**2134-7-16**] 1:31 PM
Radiology Report CHEST (PA & LAT) Study Date of [**2134-7-7**] 10:48
PM


[**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3239**] EU   [**2134-7-7**] 10:48 PM
CHEST (PA & LAT)   Clip # [**Clip Number (Radiology) 89146**]
Reason: ? wire placement



[**Hospital 93**] MEDICAL CONDITION:
   87 year old woman with pacer eroding through her chest wall
REASON FOR THIS EXAMINATION:
   ? wire placement

Final Report
INDICATION: Pacer eroding through the chest wall, question wire
placement.

TECHNIQUE: PA and lateral radiographs of the chest.

COMPARISONS: None available.

FINDINGS: Pacer box is seen in the left anterior chest wall
which is tilted, is compatible with clinical exam, findings
which demonstrate the lateral portion of the box is eroding
through the skin. The wires appear slightly coiled near the box
with abnormal appearance of the right atrial lead which appears
to be retracted and projecting superiorly and anteriorly. The
left ventricular pacer lead appears in appropriate position. The
lungs are clear without focal opacity, pleural effusion, or
pneumothorax. The heart is normal in size. Normal
cardiomediastinal silhouette, and VP shunt is noted coursing
along the anterior soft tissues of the chest.

IMPRESSION: Slightly aberrant positioning of the right atrial
lead could
relate to retraction secondary to pacer box eroding through
skin.
Cardiology Report ECG Study Date of [**2134-7-7**]  9:35:20 PM


Ventricularly paced rhythm. Underlying rhythm is probably atrial
fibrillation.
No previous tracing available for comparison.


Read by: [**Last Name (LF) **],[**First Name3 (LF) **] D.

  Intervals Axes
Rate PR QRS QT/QTc P QRS T
80 0 138 416/451 0 -77 83

OPERATIVE REPORT

[**Last Name (LF) **],[**First Name3 (LF) 2053**] J.
**NOT REVIEWED BY ATTENDING**

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

Service:                          Date:  [**2134-7-22**]


Surgeon: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **],MD


PREOPERATIVE DIAGNOSIS:  Left chest wound status post device
explantation.

POSTOPERATIVE DIAGNOSIS:  Left chest wound status post device
explantation.

PROCEDURE PERFORMED AT:
1. Surgical preparation of left upper chest 5 x 3 cm wound.
2. Irrigation and debridement of wound.
3. Local tissue advancement and rearrangement area of 20 sq
    cm for closure of wound.

ASSISTANT SURGEON:  [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 38742**], MD

ANESTHESIA:  General.

COMPLICATIONS:  None.

CONDITION:  Stable to the recovery room.

HISTORY OF PRESENT ILLNESS:  The patient is an 88-year-old
female with history of having a left chest wound after
previous device placement.  She has had an infection in this
area and the wound has been open for several days. She
presents for debridement as well as closure of wound. Risks
and benefits of the procedure were explained to the patient.
They included risks of bleeding, infection, need for
additional surgery, flap loss, graft loss, asymmetry, delayed
healing, poor scar formation, hypertrophic scar, keloid scar,
delayed healing and need for additional procedures.  All
questions were answered.  She understands this and wished to
proceed.

OPERATIVE COURSE:  The patient was then seen, identified and
brought to the operating room and placed in the supine
position.  After Venodyne boots were placed as well as
intravenous antibiotics were given, the patient was then
prepped and draped in the usual sterile fashion for truncal
surgery.  The wound was inspected.  There was fibrinous
debris. This was debrided. A portion of heterotopic scar was
also debrided. The wound was pulse lavaged  with several
liters of orthopedic solution.  Following irrigation and
debridement of the area, skin flaps were elevated using [**Last Name (un) 4161**]
electrocautery over this area of 20 cm2 and Penrose drain was
also placed. The skin and subcutaneous areas medially was
advanced to close the wound and this was closed with several
3-0 Monocryl sutures in interrupted fashion as well as
several 2-0 nylon sutures in interrupted fashion.  Penrose
drain was also secured.  Sponge and needle counts were
correct at the end of the case.  Anesthesia was then
discontinued.  The patient was then extubated and brought to
recovery room in stable condition.

                        [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 89147**]


Brief Hospital Course:
87 year old woman with atrial fibrillation s/p PPM ([**2116**]), s/p
generator replacement [**2134-5-26**] who was admitted to [**Hospital1 18**] for
pocket infection at pacer site wound growing pan sensitive
acinetobacter. Now s/p explantation with reimplantation on right
side with left chest wound revision.

ACTIVE PROBLEMS
1. Pacemaker pocket infection: Patient presented with several
weeks of progressive skin erosion over pacer site with
increasing pain, erythema and drainage. Empiric antiobiotic
therapy with vancomycin was started, but when wound cultures
grew pansensitive acinetobacter patient was switched
Ciprofloxacin 500 mg po bid per ID. Patient underwent pacer
explantation with temporary pacer placement on [**7-15**].
Reimplantation of PPM was performed on [**7-20**] and wound revision
and drainage of former pacer pocket was performed [**7-22**]. Patient
is to continue Cipro through [**2134-8-12**] for four weeks total
treatment from pacer explantation. Patient will follow up with
ID, cardiology, and plastic surgery as outpatient. Blood Cx from
[**7-16**] and [**7-17**] were negative, culture from temporary pacer lead
extracted [**7-20**] was negative, and blood cultures from [**7-22**] were
pending with no growth at discharge.

2. Atrial Fibrillation: Patient with history of longstanding
chronic slow atrial fibrillation on coumadin therapy. Patient is
pacer dependent and remained so her entire stay. We started her
on metoprolol 12.5 [**Hospital1 **] during her stay which she tolerated well.
INR was therapeutic on admission at 2.6. Coumadin was held for
most of her stay considering her frequent procedures. Coumadin
was restarted on [**7-22**] following revision and drainage of wound.
Of note, due to interaction with Cipro, dose of coumadin was
decreased to 3mg from home dose of 6mg.  Upon discharge her INR
remained at 1.3 and decision was made to increase coumadin to 5
mg. Patient is to follow up INR after discharge and have results
faxed to her cardiologist.

3. Severe AS (0.8-1.0cm2): Incidental finding on
echocardiography. Previously patient has been asymptomatic,
although now she does note significant DOE. TTE on [**7-22**] showed
preserved LVEF with mild LVH.

4. Triscupid Regurgitation: TTE on [**7-22**] showed a small,
independently moving echodense structure measuring on the
posterior leaflet of the tricuspid valve concerning for possible
vegetation vs a torn chordae. After discussion with ID and EP it
was decided it was torn fibrinous material from pacer
explantation. At least moderate [2+] tricuspid regurgitation was
seen and may be compounding her DOE.

4. Hyponatreamia.  Patient's Na dropped from [**7-15**] to [**7-18**]
hitting a nadir of 129 on [**7-16**]. She was asymptomatic this entire
time. Urine osms were low and was suspected to be due to
dehydration. Patient responded well to IVF's and Na corrected by
[**7-18**].

CHRONIC ISSUES

1. CLL/SLL. In remission. Blood counts stable during admission.
Patient recieves rituximab therapy every three months. Will
follow up with hematologist as previously scheduled.  She did
not receive rituximab while at [**Hospital1 18**].

2. NPH. Patient with chronic urinary incontinence which
continued during stay. Continued on home detrol without much
relief.  Additionally, patient had increasing difficulty with
ambulation during her stay after several procedures. Worked with
PT during stay and recommended inpatient rehabilitation to aid
in ambulation. VPS noted on imaging and appeared stable. Mental
status remained clear and appropriate throughout stay.

3. Osteoporosis. Stable. Continued on alendronate 35 qweek.

OUTSTANDING LABS
1. Blood Cx from [**7-22**] still pending with no growth to date.

TRANSITIONAL ISSUES
-F/U INR as outpatient. Note cipro and coumadin interation.
-Will need continued wound care and removal of stitches.
-Will require 3-4 weeks of PT to improve deconditioning.

Medications on Admission:
Coumadin 6 mg po qdaily
Pilocarpine 1% eye drops tid glaucoma
Detrol unsure dose
Vitamin B12
alendronate 35 qwk monday
Rituximab q 3month for CLL maintenance
MVI


Discharge Medications:
1. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 3 weeks: Take through [**8-12**].
Disp:*35 Tablet(s)* Refills:*0*
2. tolterodine 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
5. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
6. alendronate 70 mg Tablet Sig: 0.5 Tablet PO QTUES (every
Tuesday).
7. Outpatient Lab Work
Please obtain INR before [**2134-7-28**] and send results to:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 89148**]
8. cyanocobalamin (vitamin B-12) 50 mcg Tablet Sig: One (1)
Tablet PO once a day. Tablet(s)
9. hydrocortisone 0.5 % Cream Sig: One (1) Appl Topical TID (3
times a day) as needed for Rash.
Disp:*1 tube* Refills:*2*
10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
11. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
12. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. rituximab  Intravenous


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 979**] - [**Location (un) 246**]

Discharge Diagnosis:
1. Cellulitis with abscess over PMM generator
2. Pacemaker explantation and replacement
3. Aortic stenosis


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:
Dear Ms. [**Known lastname **],

You were admitted to the hospital because you developed an
infection over your pacemaker. Infections on or around the
pacemaker are very serious because of the chance it could spread
to your heart. We treated you with antibiotics, and took out the
old pacemaker. We then inserted a new pacemaker on the other
side of your chest. Additionally, plastic surgery took you to
the OR to help your wound heal. You will need to take
antiobiotics for a few weeks to clear the infection.

Additionally, while you were here, we found that one of the
valves in your heart isn't opening up as well as it should,
causing your heart to work harder to pump out blood (called
aortic stenosis). You should have this followed up with your PCP
and cardiologist.

Please note the following changes to your medications, and
follow up with the appointments we have scheduled for you.

CHANGES TO YOUR MEDICATIONS
START Ciprofloxacin 500mg twice daily through [**2134-8-12**]
START Aspirin 81mg daily
START Metoprolol succinate 25mg daily
DECREASE Coumadin to 5mg daily due to interaction with
antibiotic and we are requesting that you follow up to measure
your INR within 3 days of discharge.

It has been a pleasure taking care of you.

Followup Instructions:
Please schedule a follow up appointment with your PCP [**Name Initial (PRE) 176**] 1
week of discharge from rehab.

Name: [**Last Name (LF) 89149**],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 4094**]: INTERNAL MEDICINE
Address: 131 ORNAC, [**Apartment Address(1) 89150**], [**Location (un) **],[**Numeric Identifier 15215**]
Phone: [**Telephone/Fax (1) 89151**]
Please discuss with the staff at the facility the need for a
follow up appointment with your PCP when you are ready for
discharge.

Cardiology: Thursday, [**8-5**] at 10:45am
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 89152**], MD
Location: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] BLDG
Address: 131 ORNAC, [**Apartment Address(1) 88875**], [**Location (un) **],[**Numeric Identifier 17125**]
Phone: [**Telephone/Fax (1) 88876**]

Department: DIV OF PLASTIC SURGERY
When: TUESDAY [**2134-8-10**] at 11:45 AM
With: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern1) 6751**], MD [**Telephone/Fax (1) 6742**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: INFECTIOUS DISEASE
When: THURSDAY [**2134-8-19**] at 11:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) 32437**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage


                             [**Name6 (MD) **] [**Name8 (MD) 163**] MD [**MD Number(2) 11313**]
{'Infection and inflammatory reaction due to cardiac device, implant, and graft,Cellulitis and abscess of trunk,Atrioventricular block, complete,Idiopathic normal pressure hydrocephalus (INPH),Other disorders of neurohypophysis,Sinoatrial node dysfunction,Chronic lymphoid leukemia, in remission,Unspecified hereditary and idiopathic peripheral neuropathy,Pulmonary collapse,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms,Abnormal coagulation profile,Rash and other nonspecific skin eruption,Late effects of acute poliomyelitis,Osteoporosis, unspecified,Urinary incontinence, unspecified,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Long-term (current) use of anticoagulants,Presence of cerebrospinal fluid drainage device,Personal history of other malignant neoplasm of skin,Aortic valve disorders'}


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: Pacemaker wound infection

PRESENT ILLNESS: 87 year old female with past medical history of atrial
fibrillation s/p PPM in approximately [**2116**], with recent
generator replacement [**2134-5-26**]. She reports erosion of the
skin overlying the pacer pocket on her left shoulder for
approximately 1 month. Now noticing erythema and mild pain. She
was brought to [**Hospital1 18**] ED by her daughter after being seen by her
cardiologist. She does not report fever but notes possible
chills a few weeks ago while in [**State 1727**] which she attributed to
cold weather
.
In the ED, initial VS: 97.9 80 124/61 97%RA. EKG showed V paced
rhythm with underlying afib/flutter. She was given 1 gm of
vancomycin after blood cultures were drawn and admitted to
cardiology for futher management.
.
On the floor, she has been comfortable. She denies chest pain,
SOB, fever, chills, NVD, or abdominal pain. She has no other
complaints.

MEDICAL HISTORY: -Atrial fibrillation s/p PPM approximately [**2116**]
-Skin cancer, BCC [**9-25**]; SCC10/06
-Cholelithiasis
-Hysterectomy
-Neuropathy
-NPH with intracranial shunt
-Urge incontinence
-CLL/SLL, in remission. Currently on rituximab maintence q3
months, last dose [**2134-5-20**]
-Polio dx [**2071**]
-CHF
-Gait disturbance
-Fatigue
-Osteoporosis

MEDICATION ON ADMISSION: Coumadin 6 mg po qdaily
Pilocarpine 1% eye drops tid glaucoma
Detrol unsure dose
Vitamin B12
alendronate 35 qwk monday
Rituximab q 3month for CLL maintenance
MVI

ALLERGIES: Penicillins / Scopolamine / glaucoma drops / Strawberry /
Demerol / Quinaglute Dura-Tabs

PHYSICAL EXAM: FEX ON ADMISSION
VS:95.2 144/85 81 18 100%RA
GENERAL: Female in no acute distress
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
NECK: Supple, no JVD.
HEART: RRR. 2/6 SEM noted over RUSB
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Does not smoke, drink or use illicit drugs. Spends most of her
summertime in [**State 1727**]. Married. Husband with severe Alzheimer's. 

### Response:
{'Infection and inflammatory reaction due to cardiac device, implant, and graft,Cellulitis and abscess of trunk,Atrioventricular block, complete,Idiopathic normal pressure hydrocephalus (INPH),Other disorders of neurohypophysis,Sinoatrial node dysfunction,Chronic lymphoid leukemia, in remission,Unspecified hereditary and idiopathic peripheral neuropathy,Pulmonary collapse,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms,Abnormal coagulation profile,Rash and other nonspecific skin eruption,Late effects of acute poliomyelitis,Osteoporosis, unspecified,Urinary incontinence, unspecified,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Long-term (current) use of anticoagulants,Presence of cerebrospinal fluid drainage device,Personal history of other malignant neoplasm of skin,Aortic valve disorders'}
