CHIEF COMPLAINT: Back wound

PRESENT ILLNESS: 61 yo male w/o significant past medical history
transferred from [**Hospital 3844**] hosp for wound evaluation. Pt has
large back wound, which he has never actually seen, but has
noticed over past 1-2mo draining fluid. Pt states that he fell
backwards ten feet into the foundation of a home in [**9-15**] and
developed a wound in the back. Since his fall, he has been
packing the wound w/ a cut out square of a T shirt, paper
towels, and Neosporin. He has noticed pus dripping from the
wound for the last month. He decided to go the
hospital today in NH when it started to smell bad. Given the
complexity of the wound and exposure of spinous processes, he
was brought to [**Hospital1 18**] for further management.
.
In [**Name (NI) **], pt febrile to 101.8 w/ "labile" BP w/ SBP in the 80's.
Code sepsis initiated. Pt given 5L IVF, central line (R IJ
placed) and pressors started. Plastics & spine consults were
obtained. Given vanco/zosyn. Admitted to the MICU for HD
monitoring & stabilization.
.
In the MICU, the patient was maintained on empiric abx and
aggressive IVF repletion. Plastics and spine still following.
Once hemodynamically stable and afebrile, the patient was
transferred out to the floor.
.
Currently, the patient denies pain (although visibly in distress
when laying back in bed), and denies f/c/n/v/dizziness.
.
On ROS, the patient denies parasthesias/weakness in his
extremities, no changes in bowel or bladder function. He admits
to a 20lb weight loss over 1 year but attributes this to new
retirement. He denies any other B symptoms. He denies
diarrhea/nightsweats/palpitations.

MEDICAL HISTORY: pt has not seen a physician [**Name Initial (PRE) 14169**] [**2098**]

MEDICATION ON ADMISSION: None

ALLERGIES: Cortisone

PHYSICAL EXAM: Vitals: T 98.5; BP 81/39; P 82; RR 18; 98% RA
General: lying in bed NAD
HEENT: NCAT, moist mucous membranes
Neck: supple, no carotid bruit
Pulmonary: CTA b/l
Cardiac: regular rate and rhythm, with no m/r/g
Carotids: no blood flow murmur
Abdomen: soft, nontender, non distended, normal bowel sounds
Skin: ulcerating skin wound from ~ C7-T6 eroded through
paraspinal muscles and exposes necrotic spinous processes. 22 cm

FAMILY HISTORY: mom - cancer of unclear etiology

SOCIAL HISTORY: Worked as a electrician, retired one year ago.
Lives alone, estranged from family.  Has two children who moved
away with mother.  [**Name (NI) **] brother nearby, but not in close contact
with him. Remote history of tobacco/ETOH.
Acute osteomyelitis, other specified sites,Secondary malignant neoplasm of bone and bone marrow,Malignant neoplasm of other parts of bronchus or lung,Pressure ulcer, other site,Acute kidney failure, unspecified,Cellulitis and abscess of trunk,Anemia of other chronic disease,Surgical or other procedure not carried out because of patient's decision,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Diarrhea
Ac osteomyelitis NEC,Secondary malig neo bone,Mal neo bronch/lung NEC,Pressure ulcer, site NEC,Acute kidney failure NOS,Cellulitis of trunk,Anemia-other chronic dis,No proc/patient decision,Pseudomonas infect NOS,Diarrhea
Admission Date:  [**2135-6-15**]              Discharge Date:   [**2135-7-22**]

Date of Birth:  [**2073-8-16**]             Sex:   M

Service: MEDICINE

Allergies:
Cortisone

Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Back wound

Major Surgical or Invasive Procedure:
Debridement of back wound by Neurosurgery and Plastic Surgery
Flap placement and closure by Plastic Surgery
Flap revision by Plastic Surgery
multpile PICC line placements


History of Present Illness:
 61 yo male w/o significant past medical history
transferred from [**Hospital 3844**] hosp for wound evaluation. Pt has
large back wound, which he has never actually seen, but has
noticed over past 1-2mo draining fluid. Pt states that he fell
backwards ten feet into the foundation of a home in [**9-15**] and
developed a wound in the back. Since his fall, he has been
packing the wound w/ a cut out square of a T shirt, paper
towels, and Neosporin. He has noticed pus dripping from the
wound for the last month. He decided to go the
hospital today in NH when it started to smell bad. Given the
complexity of the wound and exposure of spinous processes, he
was brought to [**Hospital1 18**] for further management.
.
In [**Name (NI) **], pt febrile to 101.8 w/ "labile" BP w/ SBP in the 80's.
Code sepsis initiated. Pt given 5L IVF, central line (R IJ
placed) and pressors started. Plastics & spine consults were
obtained. Given vanco/zosyn. Admitted to the MICU for HD
monitoring & stabilization.
.
In the MICU, the patient was maintained on empiric abx and
aggressive IVF repletion. Plastics and spine still following.
Once hemodynamically stable and afebrile, the patient was
transferred out to the floor.
.
Currently, the patient denies pain (although visibly in distress
when laying back in bed), and denies f/c/n/v/dizziness.
.
On ROS, the patient denies parasthesias/weakness in his
extremities, no changes in bowel or bladder function. He admits
to a 20lb weight loss over 1 year but attributes this to new
retirement. He denies any other B symptoms. He denies
diarrhea/nightsweats/palpitations.

Past Medical History:
pt has not seen a physician [**Name Initial (PRE) 14169**] [**2098**]

Social History:
Worked as a electrician, retired one year ago.
Lives alone, estranged from family.  Has two children who moved
away with mother.  [**Name (NI) **] brother nearby, but not in close contact
with him. Remote history of tobacco/ETOH.


Family History:
 mom - cancer of unclear etiology

Physical Exam:
Vitals: T 98.5; BP 81/39; P 82; RR 18; 98% RA
General: lying in bed NAD
HEENT: NCAT, moist mucous membranes
Neck: supple, no carotid bruit
Pulmonary: CTA b/l
Cardiac: regular rate and rhythm, with no m/r/g
Carotids: no blood flow murmur
Abdomen: soft, nontender, non distended, normal bowel sounds
Skin: ulcerating skin wound from ~ C7-T6 eroded through
paraspinal muscles and exposes necrotic spinous processes. 22 cm

at greatest width.
Extremities: no c/c/e.
Neuro: CNII-XII in tact, strength in tact UE/LE equal
bilaterally, sensation in tact. No clonus, DTR's 2+, Babinski
down b/l.

Pertinent Results:
[**2135-6-15**] 07:00PM   WBC-11.7* RBC-3.74* HGB-9.6* HCT-28.1*
MCV-75* MCH-25.5* MCHC-34.0 RDW-14.8
[**2135-6-15**] 07:00PM   NEUTS-79.7* LYMPHS-14.4* MONOS-5.4 EOS-0.4
BASOS-0.1
[**2135-6-15**] 07:00PM   PLT COUNT-715*
[**2135-6-15**] 07:00PM   GLUCOSE-102 UREA N-16 CREAT-0.8 SODIUM-127*
POTASSIUM-5.9* CHLORIDE-97 TOTAL CO2-19* ANION GAP-17
[**2135-6-15**] 07:18PM   LACTATE-1.3
.
[**2135-6-16**]: CXR: IMPRESSION: 1. Standard position of the right
internal jugular line with no evidence of complications. 2. New
large left lower lobe consolidation might be accompanied by
pleural effusion. Given its fast appearance, it might represent
aspiration. 3. Questionable left upper lobe nodule. Repeated PA
and lateral chest radiographs are recommended for precise
evaluation of these findings.
.
[**2135-6-16**]: TTE: Conclusions:
The left atrium is mildly dilated. Left ventricular wall
thicknesses are
normal. The left ventricular cavity size is normal. Left
ventricular systolic
function is hyperdynamic (EF 80%). Tissue Doppler imaging
suggests an
increased left ventricular filling pressure (PCWP>18mmHg). There
is no
ventricular septal defect. The right ventricular cavity is
dilated. Right
ventricular systolic function is normal. The ascending aorta is
mildly
dilated. There are focal calcifications in the aortic arch. The
aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No
aortic regurgitation is seen. The mitral valve appears
structurally normal
with trivial mitral regurgitation. There is no mitral valve
prolapse. There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
[**2135-6-16**]: CT abd/pelvis: IMPRESSION:
1. Multiple lung nodules, which may represent metastases or
infection. However, no definite primary cancer identified.
2. Open wound in left upper back and over the thoracic spine.
However, no drainable collection identified.
3. Bilateral pleural effusions, left greater than right and left
loculated.
4. Ascites.
5. No suspicious sclerotic lesions seen in the bones. However,
CT is not specific for evaluating bony metastases.
.
[**2135-6-17**]: CT Head: IMPRESSION: No evidence of intracranial
metastatic disease.
.
[**2135-6-17**]: MR [**Name13 (STitle) 2854**] - FINDINGS: There are extensive signal
intensity abnormalities of all of the visualized vertebral
bodies. This finding is most strongly suggestive of diffuse
metastatic disease. There is no definite evidence of rupture of
tumor through the cortex. However, as noted below, there are
areas where it is difficult to distinguish tumor from the
infection.
There is a large defect in the skin and musculature posterior to
the spine. The superior extent of this defect appears to be
located at approximately T1. This appears to extend to
approximately T11. At the greatest depth of the defect, it
appears to extend to the spinous processes and lamina. There is
extensive soft tissue abnormality, with enhancement, surrounding
the thecal sac, most prominent from approximately T2 to T6.
Throughout these levels, there also appears to be abnormal
enhancement of the vertebral bodies themselves. The spinous
processes and lamina at T2 through T4 appear markedly
hypointense on the MR images suggesting sclerosis due to chronic
osteomyelitis.
There are large bilateral pleural effusions, larger on the left
than right. A right lung nodule is identified in the limited
views of the lung included in this study.
There is a protrusion of the T7-8 intervertebral disc with
indentation on the spinal cord. This is incompletely visualized
on these images.
The findings described above suggest both infectious and
neoplastic pathology with the diffuse vertebral body signal
intensity abnormalities, and the right lung nodule,
characteristic of metastatic disease. The large ulceration of
the posterior soft tissues and the enhancement surrounding the
thecal sac presumably represent infection. However, this
intraspinal soft tissue may also contain tumor. There may well
be an intraspinal epidural abscess or phlegmon. No drainable
fluid collection is noted within the spinal canal.
CONCLUSION: Findings suggesting both metastatic disease and
chronic infection with intraspinal enhancement most suspicious
for epidural abscess or phlegmon.
Right lung nodule.
Bilateral pleural effusions.
T7-8 disc protrusion.
.
[**2135-6-19**]: MR L/C spine:
IMPRESSION:
1. Epidural abnormality which could represent phlegmon or early
abscess, from the T3 through T5 level. At the T4-T5 level, this
deforms the dorsal surface of the thecal sac.
2. Foci of increased signal on the T1 post-gadolinium sequence
at the T3-T4 level within the thecal sac which could represent
enhancing nerve roots, vessels, or artifact. It is unlikely to
be intrathecal extension of infection.
3. Erosion of the spinous processes of T2 through T8 with
extensive posterior soft tissue phlegmon and inflammation. At
T3-T4, T4-T5 and T5-T6, this soft tissue extends into the neural
foramina, and into the epidural space.
4. No cervical or lumbar epidural abnormalities, and no cervical
or lumbar cord signal abnormalities.
5. Bilateral pleural effusions and multiple lung nodules, which
are better assessed on the recent CT of the torso.
6. Multifocal signal changes within vertebral bodies in the
cervical, thoracic and lumbar spine are most suggestive of
multifocal osseous metastatic disease.
Overall, the study of the thoracic spine does not demonstrate
significant change since [**2135-6-17**].
.
[**2135-6-20**]- pathology report:
SPECIMEN SUBMITTED: SPINOUS PROCESS (BONE) (1).
Procedure date    	Tissue received    	Report Date   	Diagnosed
by
[**2135-6-20**]	[**2135-6-21**]	[**2135-6-29**]	DR. [**Last Name (STitle) **]. LOMO/lxl??????
DIAGNOSIS:
Spinous process bone:
.
    Metastatic carcinoma with squamous features (see Note).
.
    Acute osteomyelitis with necrosis.
.
Note: Immunostains will be performed and the results reported in
an addendum.
.
[**2135-6-20**]: EKG: Sinus rhythm. Left atrial abnormality. No previous
tracing available for comparison.
.
[**2135-6-21**]: Pleural Fluid Cytology:  Pleural fluid: NEGATIVE FOR
MALIGNANT CELLS.
.
SWAB      THORAC BACK.
.
                            **FINAL REPORT [**2135-6-22**]**
.
   GRAM STAIN (Final [**2135-6-15**]):
      3+  (5-10 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      3+  (5-10 per 1000X FIELD):   GRAM NEGATIVE ROD(S).
      2+   (1-5 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND CLUSTERS.
.
   WOUND CULTURE (Final [**2135-6-19**]):
      Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
      workup is performed appropriate to the isolates recovered
from the
      site (including a screen for Pseudomonas aeruginosa,
Staphylococcus
      aureus and beta streptococcus).
      STAPH AUREUS COAG +.    MODERATE GROWTH.
         OF TWO COLONIAL MORPHOLOGIES.
         PENICILLIN SENSITIVITY AVAILABLE ON REQUEST.
         Staphylococcus species may develop resistance during
prolonged
         therapy with quinolones.   Therefore, isolates that are
initially
         susceptible may become resistant within three to four
days after
         initiation of therapy.  Testing of repeat isolates may
be
         warranted.
         Trimethoprim/Sulfa sensitivity testing performed by
[**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
      GRAM NEGATIVE ROD(S).    SPARSE GROWTH.
         OF TWO COLONIAL MORPHOLOGIES.
      PSEUDOMONAS AERUGINOSA.    SPARSE GROWTH.
      PSEUDOMONAS AERUGINOSA.    SPARSE GROWTH.  SECOND STRAIN.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |          PSEUDOMONAS AERUGINOSA
                             |          |          PSEUDOMONAS
AERUGINOSA
                             |          |          |
CEFEPIME--------------                4 S        2 S
CEFTAZIDIME-----------                4 S      <=1 S
CIPROFLOXACIN---------              0.5 S   <=0.25 S
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S        4 S      <=1 S
IMIPENEM--------------              <=1 S      <=1 S
LEVOFLOXACIN----------<=0.12 S
MEROPENEM-------------           <=0.25 S   <=0.25 S
OXACILLIN-------------<=0.25 S
PIPERACILLIN----------                8 S      <=4 S
PIPERACILLIN/TAZO-----                8 S      <=4 S
TOBRAMYCIN------------              <=1 S      <=1 S
TRIMETHOPRIM/SULFA----       S

   ANAEROBIC CULTURE (Final [**2135-6-22**]):
      BACTEROIDES FRAGILIS GROUP.    MODERATE GROWTH.
         BETA LACTAMASE POSITIVE.
.
[**2135-6-20**] 6:00 pm TISSUE      LUMBAR INFECTION.

                            **FINAL REPORT [**2135-6-26**]**

   GRAM STAIN (Final [**2135-6-20**]):
      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
      1+    (<1 per 1000X FIELD):   GRAM POSITIVE COCCI.

   TISSUE (Final [**2135-6-26**]):
      REPORTED BY PHONE TO [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 72682**] ([**6-23**]).
      STAPH AUREUS COAG +.    RARE GROWTH.
         Trimethoprim/Sulfa sensitivity testing performed by
[**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
      PSEUDOMONAS AERUGINOSA.    RARE GROWTH.
         sensitivity testing performed by Microscan.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |          PSEUDOMONAS AERUGINOSA
                             |          |
CEFEPIME--------------                4 S
CEFTAZIDIME-----------                8 S
CIPROFLOXACIN---------            <=0.5 S
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S      <=1 S
IMIPENEM--------------              <=1 S
LEVOFLOXACIN----------     4 R
MEROPENEM-------------                  S
OXACILLIN-------------   0.5 S
PENICILLIN------------ =>0.5 R
PIPERACILLIN----------               64 S
PIPERACILLIN/TAZO-----              <=8 S
TOBRAMYCIN------------              <=1 S
TRIMETHOPRIM/SULFA----       S

   ANAEROBIC CULTURE (Final [**2135-6-24**]):    NO ANAEROBES ISOLATED.



Brief Hospital Course:
61yo M estranged from medical care for >35yr who presents w/
extensive back wound, pentrating to spinous processes, and
smaller L back/axillary wound.  Pt septic on admission.
.
# Sepsis: When the patient was initially admitted, he was
hypotensive with the obvious source being the large infected
back wound with associated chronic vertebral osteomyelitis and
possible epidural abscess.  Additionally, blood cultures from
OSH grew pseudomonas, though blood cultures here were without
growth (except for cornybacterium, which is presumed
contamination). The patient was started on broad antibiotic
coverage with vancomycin and zosyn.  He was aggressively fluid
resuscitated (>12L) and required pressors for approximately
24hrs.  Thereafter, he was hemodynamically stable and afebrile.
Workup of his hypotension was unrevealing for adrenal
insufficiency or cardiogenic source (EF>80%).  Likewise, TTE
showed no gross evidence of endocarditis. His wound swab
ultimately grew MSSA and pseudomonas. Antibiotics were changed
to naficillin/cipro/flagyl given sensitivities of cultures. Pt
was changed to high-dose Levaquin and Flagyl to complete 6 week
course. Stop date [**2135-8-18**].
.
# Back wounds: wound culture grew MSSA and pan-sensitive
pseudomonas.  Patient was treated initially in the MICU with
vancomycin & zosyn, and ultimately tailored to nafcillin, cipro,
flagyl on the floor. Plastic surgery and neurosurgery took the
patient to the OR together on [**2135-6-20**] for initial debridement
and was thereafter followed by plastic surgery who took him back
to the OR on [**6-27**] for flap closure. He was kept on a wound vac.
It was taken down on [**2135-7-2**], and because the flap didn't take,
he needed to be taken back to the OR on [**7-6**] for a wound
wash-out and another vac dressing. Plastic surgery recommending
that patient is able to be d/c'ed with [**Hospital1 **] dressing changes and
outpatient follow-up, with plan to consider another skin graft
in the future.
.
# Osteomyelitis: because the wound had exposed vertebral
processes (by definition osteomyelitis), ID recommended several
weeks of IV antibiotics. Pt received IV naficillin until
discharge. Medication changed to high-dose Levaquin and Flagyl
on discharge to complete 6 week course on [**2135-8-18**]. Acute care as
outlined above.
.
# Question of malignancy: MRI revealed extensive vertebral body
changes throughout the thoracic spine that were suggestive of
malignancy/metastatic disease.  The patient has no known prior
malignancy, although he did not have any medical care for over 3
decades.  Pan-CT scan notable for multiple lung nodules as well
as left sided pleural effusion. This effusion was tapped by
Interventional Pulmonary, which showed predominant lymphocytosis
with cytology negative for evidence of malignancy. A specimen of
the spinous process was sent to pathology and under special
staining revealed likely non-small cell lung cancer, stage IV.
Hematology/oncology was consulted who felt that the prognosis
was likely poor with an estimated lifespan of 8 months; they
offered the patient palliative chemotherapy (which would not be
able to be initiated until the ulcers healed) and the patient
has initially refused but will arrange follow up in New
[**Location (un) **] if patient is amenable.
.
# ARF: On presentation, the patient had a slight bump in his
creatinine, thought to be prerenal azotemia versus contrast
nephropathy versus ATN secondary to either medication or
hypovolemic insult during sepsis and then again with second
hypotensive episode following incomplete fluid resuscitation in
the PACU following his second surgery. Urine electrolytes
indicated a FENa of 2.2, which indicates a more likely intrinsic
mechanism for renal failure, such as ATN. He was treated with
IVF and all medications were renally dosed. Subsequent to these
events, the patients renal funtion returned to [**Location 213**] and has
remained normal through discharge.
.
# FEN: tolerates a regular diet, although has refused most meals
since [**7-4**] since complaining that his pills (specifically
cipro/flagyl) were altering his sensation of taste. Cipro and
flagyl were switched to IV, but the patients po intake continues
to be poor so medications were restarted po. Pt. only accepted
cans of Ensure.
.
# Access: pt initially had R IJ, then PICC placed on [**2135-6-19**] for
long-term access.PICC DC'd prior to discharge.
.
# However, despite multiple attempts by PT to encourage exercise
and OOB activity, he has become deconditioned and at this point
will need PT services at home.


Medications on Admission:
None

Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Bismuth Subsalicylate 262 mg/15 mL Suspension Sig: Fifteen
(15) ML PO TID (3 times a day).
3. Levaquin 750 mg Tablet Sig: One (1) Tablet PO once a day for
27 days.
Disp:*27 Tablet(s)* Refills:*0*
4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 27 days.
Disp:*81 Tablet(s)* Refills:*0*
5. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed.


Discharge Disposition:
Home With Service

Facility:
[**Hospital **] Home Health and Hospice

Discharge Diagnosis:
Primary:
1. Stage IV Non-small cell lung cancer.
2. Metastasis and osteomyelitis of thoracic spine.
3. Malignant back ulcer with superinfection - MSSA, Pseudomonas


Discharge Condition:
Stable

Discharge Instructions:
You were admitted with a large back ulcer that involved the
bones of your spine. You were initially taken to the ICU, as
bacteria had entered your bloodstream, and you were taken to the
operating room three times, first by neurosurgery and
subsequently, by plastic surgery, to clean and then close the
wound. You were maintained on intravenous antibiotics throughout
the admission.
.
Additionally, on imaging it was noted that you had evidence of
malignancy in the bones of your spine. A sample of bone was
taken for analysis during surgery, which came back as non-small
cell lung cancer metastasized to the bone. Hematology/Oncology
has offered palliative chemotherapy and will arrange follow up
for you in [**Location (un) 3844**] if you are amenable.
.
You have been accepted as a patient at the [**Location (un) **] Family
Practice. Please follow-up with your PCP after your discharge
from the hospital.


Followup Instructions:
It is recommended that you be followed by hematology/oncology,
infectious diseases and plastic surgery upon discharge. Your PCP
can arrange appointments with these specialty services for you.
{"Acute osteomyelitis, other specified sites,Secondary malignant neoplasm of bone and bone marrow,Malignant neoplasm of other parts of bronchus or lung,Pressure ulcer, other site,Acute kidney failure, unspecified,Cellulitis and abscess of trunk,Anemia of other chronic disease,Surgical or other procedure not carried out because of patient's decision,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Diarrhea"}


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: Back wound

PRESENT ILLNESS: 61 yo male w/o significant past medical history
transferred from [**Hospital 3844**] hosp for wound evaluation. Pt has
large back wound, which he has never actually seen, but has
noticed over past 1-2mo draining fluid. Pt states that he fell
backwards ten feet into the foundation of a home in [**9-15**] and
developed a wound in the back. Since his fall, he has been
packing the wound w/ a cut out square of a T shirt, paper
towels, and Neosporin. He has noticed pus dripping from the
wound for the last month. He decided to go the
hospital today in NH when it started to smell bad. Given the
complexity of the wound and exposure of spinous processes, he
was brought to [**Hospital1 18**] for further management.
.
In [**Name (NI) **], pt febrile to 101.8 w/ "labile" BP w/ SBP in the 80's.
Code sepsis initiated. Pt given 5L IVF, central line (R IJ
placed) and pressors started. Plastics & spine consults were
obtained. Given vanco/zosyn. Admitted to the MICU for HD
monitoring & stabilization.
.
In the MICU, the patient was maintained on empiric abx and
aggressive IVF repletion. Plastics and spine still following.
Once hemodynamically stable and afebrile, the patient was
transferred out to the floor.
.
Currently, the patient denies pain (although visibly in distress
when laying back in bed), and denies f/c/n/v/dizziness.
.
On ROS, the patient denies parasthesias/weakness in his
extremities, no changes in bowel or bladder function. He admits
to a 20lb weight loss over 1 year but attributes this to new
retirement. He denies any other B symptoms. He denies
diarrhea/nightsweats/palpitations.

MEDICAL HISTORY: pt has not seen a physician [**Name Initial (PRE) 14169**] [**2098**]

MEDICATION ON ADMISSION: None

ALLERGIES: Cortisone

PHYSICAL EXAM: Vitals: T 98.5; BP 81/39; P 82; RR 18; 98% RA
General: lying in bed NAD
HEENT: NCAT, moist mucous membranes
Neck: supple, no carotid bruit
Pulmonary: CTA b/l
Cardiac: regular rate and rhythm, with no m/r/g
Carotids: no blood flow murmur
Abdomen: soft, nontender, non distended, normal bowel sounds
Skin: ulcerating skin wound from ~ C7-T6 eroded through
paraspinal muscles and exposes necrotic spinous processes. 22 cm

FAMILY HISTORY: mom - cancer of unclear etiology

SOCIAL HISTORY: Worked as a electrician, retired one year ago.
Lives alone, estranged from family.  Has two children who moved
away with mother.  [**Name (NI) **] brother nearby, but not in close contact
with him. Remote history of tobacco/ETOH. 

### Response:
{"Acute osteomyelitis, other specified sites,Secondary malignant neoplasm of bone and bone marrow,Malignant neoplasm of other parts of bronchus or lung,Pressure ulcer, other site,Acute kidney failure, unspecified,Cellulitis and abscess of trunk,Anemia of other chronic disease,Surgical or other procedure not carried out because of patient's decision,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Diarrhea"}
