CHIEF COMPLAINT: fever, malaise

PRESENT ILLNESS: Ms. [**Known lastname 122**] is a 64F with a history of COPD (not on home O2) and
recent spinal fusion with hardware at [**Hospital6 17390**] on [**2165-6-27**] who presented with back pain, fever and
malaise. She had been recovering well from her recent surgery at
rehab ([**Hospital3 **]) until a few days ago when she began to
experience increasing back pain. She did not have bowel or
bladder dysfunction. She did have weakness in her left lower
extremity however she reports this is chronic. She did not
notice any drainage from the surgical site. Because of her
increasing pain she was seen by her orthopedic surgeon in clinic
this morning. Records from that encounter are not available at
this time. The patient reports that she was told that the top of
her wound "looked infected" but she was not given antibiotics.
After she went back to rehab she began to experience fevers and
malaise and therefore she was sent to the [**Hospital1 18**] ED.

MEDICAL HISTORY: -CAD
-COPD/Asthma
-Pulmonary HTN
-Bipolar D/O
-T2DM
-Diabetic Neuropathy
-Hypothyroidism
-OSA on CPAP
-HTN
-HLD
-Stress Urinary Incontinence
-Diverticulosis
-IBS
-Osteoarthritis
-Spinal Stenosis
-Chronic Peripheral Edema
-GERD
-3 cm right renal cyst found incidentally [**6-/2165**], needs further
workup

MEDICATION ON ADMISSION: Preadmissions medications listed are incomplete and require
futher investigation.  Information was obtained from  [**Last Name (un) **]
note.
1. MetFORMIN (Glucophage) 1000 mg PO BID
2. Furosemide 20 mg PO DAILY
3. Omeprazole 40 mg PO BID
4. Gemfibrozil 600 mg PO BID
5. Gabapentin 1200 mg PO TID
6. Simvastatin 20 mg PO DAILY
7. Valsartan 80 mg PO DAILY
8. Tiotropium Bromide 1 CAP IH DAILY
9. Montelukast Sodium 10 mg PO DAILY
10. Lidocaine 5% Patch 1 PTCH TD DAILY
11. traZODONE 200 mg PO HS:PRN sleep
12. Levothyroxine Sodium 150 mcg PO DAILY
13. DiCYCLOmine 20 mg PO TID
14. Hydrocodone-Acetaminophen (5mg-500mg [**11-19**] TAB PO Q6H:PRN pain

ALLERGIES: Sulfa(Sulfonamide Antibiotics) / Ace Inhibitors /
hydrochlorothiazide / Macrolide Antibiotics / Penicillins

PHYSICAL EXAM: On Admission:
Vitals: T:102.1  BP: 92/52 P: 127 R: 29 O2: 91% 4L NC
General: Alert, oriented
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL
Neck: right IJ
CV:  Tachycardic
Lungs: Bibasilar crackles
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, trace pitting edema in LE
bilaterally
Neuro: CNII-XII intact, moving all extremities, grossly normal
sensation
Back: there is a midline spinal incision extending down the
thoracic and lumbar spine. There is a large area of erythema,
warmth, and fluctuance surrounding the top part of the incision.
It is tender to palpation. No active drainage.

FAMILY HISTORY: Mother died at age 70 due to cardiac disease and
complications of diabetes.  Father died at age 66 due to
congestive heart failure.  Sister died at age 64 due to
emphysema.  Brother died of cancer.  Numerous other family
members with diabetes and neuropathy.

SOCIAL HISTORY: Lives alone. Quit smoking several years ago. No drugs or
alcohol.
Infection and inflammatory reaction due to other internal orthopedic device, implant, and graft,Unspecified septicemia,Severe sepsis,Septic shock,Infected postoperative seroma,Acute posthemorrhagic anemia,Pulmonary collapse,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Abnormal coagulation profile,Chronic obstructive asthma, unspecified,Hypoxemia,Obesity, unspecified,Body Mass Index 39.0-39.9, adult,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Unspecified acquired hypothyroidism,Unspecified essential hypertension,Obstructive sleep apnea (adult)(pediatric),Other and unspecified hyperlipidemia,Edema,Esophageal reflux,Candidiasis of vulva and vagina
React-oth int ortho dev,Septicemia NOS,Severe sepsis,Septic shock,Infected postop seroma,Ac posthemorrhag anemia,Pulmonary collapse,Abn react-artif implant,MRSA elsewhere/NOS,Abnrml coagultion prfile,Chronic obst asthma NOS,Hypoxemia,Obesity NOS,BMI 39.0-39.9,adult,DMII neuro nt st uncntrl,Neuropathy in diabetes,Hypothyroidism NOS,Hypertension NOS,Obstructive sleep apnea,Hyperlipidemia NEC/NOS,Edema,Esophageal reflux,Candidal vulvovaginitis
Admission Date:  [**2165-7-19**]              Discharge Date:   [**2165-7-31**]

Date of Birth:  [**2101-3-31**]             Sex:   F

Service: MEDICINE

Allergies:
Sulfa(Sulfonamide Antibiotics) / Ace Inhibitors /
hydrochlorothiazide / Macrolide Antibiotics / Penicillins

Attending:[**Attending Info 8238**]
Chief Complaint:
fever, malaise


Major Surgical or Invasive Procedure:
Washout with I&D of posterior thoracolumbar incision with
removal and reinstrumentation.


History of Present Illness:
Ms. [**Known lastname 122**] is a 64F with a history of COPD (not on home O2) and
recent spinal fusion with hardware at [**Hospital6 17390**] on [**2165-6-27**] who presented with back pain, fever and
malaise. She had been recovering well from her recent surgery at
rehab ([**Hospital3 **]) until a few days ago when she began to
experience increasing back pain. She did not have bowel or
bladder dysfunction. She did have weakness in her left lower
extremity however she reports this is chronic. She did not
notice any drainage from the surgical site. Because of her
increasing pain she was seen by her orthopedic surgeon in clinic
this morning. Records from that encounter are not available at
this time. The patient reports that she was told that the top of
her wound "looked infected" but she was not given antibiotics.
After she went back to rehab she began to experience fevers and
malaise and therefore she was sent to the [**Hospital1 18**] ED.

In the ED initial VS were 102.7 117 110/47 20 99% 4L. An EKG was
performed which showed sinus tach and right bundle branch block
which is old. CK-MB was negative. Lactate was 1.8. She was given
3 liters of fluid and a right IJ was placed. She was started
empirically on Vancomycin, Levofloxacin, and Flagyl. A CTA of
the chest/abdomen/pelvis was performed which was (prelim)
negative for PE but showed a very large fluid collection
posterior to the thoraco-lumbar fusion hardware. Orthopedics was
consulted in the ED and recommended admission to the MICU for
fever workup.

On arrival to the MICU, the patient immediately spiked to 102.
She was alert and oriented and able to recount details of recent
events. She reported that her back pain was well controlled.

Of note the patient was admitted between [**6-27**] and [**7-4**] to [**Hospital1 **] for a thoracolumbar spinal fusion.
Post-op course was complicated by leukocytosis. Initially a PNA
was suspected and she was treated with levofloxacin. However
cdif subsequently came back positive and levofloxacin was
stopped and she was started on PO vancomycin(course completed
[**2165-7-14**]). She was transferred to rehab after discharge. She has
not had diarrhea in several days.

Review of systems:
(+) Per HPI
(-) Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough. Denies chest pain, chest pressure, palpitations.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.

Past Medical History:
-CAD
-COPD/Asthma
-Pulmonary HTN
-Bipolar D/O
-T2DM
-Diabetic Neuropathy
-Hypothyroidism
-OSA on CPAP
-HTN
-HLD
-Stress Urinary Incontinence
-Diverticulosis
-IBS
-Osteoarthritis
-Spinal Stenosis
-Chronic Peripheral Edema
-GERD
-3 cm right renal cyst found incidentally [**6-/2165**], needs further
workup

PAST SURGICAL HISTORY:
-L2-3, [**1-20**] laminoforaminotomy [**9-/2164**]
-Spinal Surgery [**2165-6-27**]
----Revision of L3, 4 and 5 laminectomy
----Bilateral T10, T11, T12, L1, L2, L3, L4 and S1 and pelvic
posterolateral instrumentation as well as right-sided L5 pedicle
screw
placement
----Arthrodesis at T10-11, T11-12, T12-L1, L1-2, L2-3, L3-4,
L4-5, L5-S1 and S1 and pelvis
-Bilateral cataracts
-Appendectomy
-left mastoid surgery
-left knee surgery


Social History:
Lives alone. Quit smoking several years ago. No drugs or
alcohol.


Family History:
Mother died at age 70 due to cardiac disease and
complications of diabetes.  Father died at age 66 due to
congestive heart failure.  Sister died at age 64 due to
emphysema.  Brother died of cancer.  Numerous other family
members with diabetes and neuropathy.


Physical Exam:
On Admission:
Vitals: T:102.1  BP: 92/52 P: 127 R: 29 O2: 91% 4L NC
General: Alert, oriented
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL
Neck: right IJ
CV:  Tachycardic
Lungs: Bibasilar crackles
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, trace pitting edema in LE
bilaterally
Neuro: CNII-XII intact, moving all extremities, grossly normal
sensation
Back: there is a midline spinal incision extending down the
thoracic and lumbar spine. There is a large area of erythema,
warmth, and fluctuance surrounding the top part of the incision.
It is tender to palpation. No active drainage.

On Discharge:
Vitals - 97.7 133/83 87 20 97%2L
GENERAL - obese, very pleasant, NAD, comfortable
HEENT - sclerae anicteric, MMM
LUNGS - Good air entry b/l
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND
EXTREMITIES - + PICC, WWP, no c/c/e, 2+ peripheral pulses
(radials, DPs). L>R LE edema
BACK - wound vac on and surgical site

Pertinent Results:
Labs on Admission
[**2165-7-19**] 03:15PM BLOOD WBC-15.6* RBC-3.33* Hgb-9.4* Hct-30.3*
MCV-91 MCH-28.4 MCHC-31.2 RDW-16.9* Plt Ct-400
[**2165-7-19**] 03:15PM BLOOD Neuts-90.8* Lymphs-3.7* Monos-4.7 Eos-0.6
Baso-0.3
[**2165-7-20**] 05:01AM BLOOD PT-18.6* PTT-38.1* INR(PT)-1.8*
[**2165-7-20**] 05:01AM BLOOD Fibrino-677*
[**2165-7-19**] 03:15PM BLOOD Glucose-170* UreaN-17 Creat-0.9 Na-139
K-4.8 Cl-104 HCO3-25 AnGap-15
[**2165-7-19**] 03:15PM BLOOD ALT-5 AST-11 LD(LDH)-210 CK(CPK)-30
AlkPhos-161* TotBili-0.2
[**2165-7-20**] 05:01AM BLOOD CK-MB-2 cTropnT-0.08*
[**2165-7-20**] 12:42AM BLOOD Calcium-6.7* Phos-2.7 Mg-0.9*
[**2165-7-19**] 03:15PM BLOOD Albumin-3.3*
[**2165-7-19**] 03:15PM BLOOD CRP-197.0*
[**2165-7-19**] 11:57PM BLOOD Type-MIX Temp-38.9 pO2-41* pCO2-50*
pH-7.30* calTCO2-26 Base XS--1
[**2165-7-19**] 03:37PM BLOOD Lactate-1.8
[**2165-7-19**] 11:57PM BLOOD O2 Sat-65
[**2165-7-20**] 02:43PM BLOOD freeCa-0.99*

Labs on Discharge:
[**2165-7-30**] 05:15AM BLOOD WBC-10.6 RBC-3.19* Hgb-9.3* Hct-28.9*
MCV-91 MCH-29.2 MCHC-32.2 RDW-16.8* Plt Ct-408
[**2165-7-30**] 05:15AM BLOOD Glucose-141* UreaN-6 Creat-0.5 Na-138
K-4.0 Cl-99 HCO3-35* AnGap-8
[**2165-7-29**] 04:32AM BLOOD calTIBC-183* Ferritn-157* TRF-141*
[**2165-7-31**] 04:55AM BLOOD Vanco-17.0

Reports:

CT Abdomen - IMPRESSION: 1.  No pulmonary embolism detected to
the proximal segmental levels.  More distal evaluation is
limited by patient motion. 2.  Very large fluid collection
posterior to thoracolumbar fusion hardware, extending superiorly
to T6. The differential includes, seroma, abscess, and
pseudomenigocele. 3.  Widening of the L3-L4 disc space for which
correation with operative note and prior imaging is suggested.
4.  Moderate lingular atelectasis.

ECHO - IMPRESSION: Mild symmetric left ventricular hypertrophy
with preserved global systolic function. Right ventricular
dilation and mild global hypokinesis. At least moderate
pulmonary hypertension.

Brief Hospital Course:
Ms. [**Known lastname 122**] is a 64 year-old woman with a history of COPD and
recent spinal fusion with hardware at [**Hospital6 17390**] on [**2165-6-27**] who presented with back pain, fever and
malaise, and found to have a MRSA infecton of surgical site. Now
s/p surgical washout, hardware extraction and replacement on
[**2165-7-20**].

ACTIVE ISSUES
-------------
#. MRSA wound infection: The patient underwent spinal fusion on
[**2165-6-27**] at [**Hospital6 **] and subseqeuntly developed
worsening back pain. Seen in the ED where she was febrile. A CTA
torso was performed which showed a large fluid collection
posterior to the thoraco-lumbar fusion hardware. Patient was
transferred to the MICU for fever work-up. On [**2165-7-20**], the
patient went to the OR for wash-out. During the operation, the
previously placed hardware was found to be unstable and was
replaced. Transferred back to the ICU where the patient was
started on vancomycin with ID following. Initially on pressors
but these were weaned. Remained normotensive and transferred to
the floor. On the floor, the patient did well. Wound vac
remained in place due to poor wound healing. Able to tolerate
physical therapy. Will be discharged to rehab with plans for
continued physical therapy (needs to wear TLSO brace w/ PT) and
IV antibioitics. Will need infectious disease follow-up.

#. Hypoxemia: The patient has a known h/o COPD and OSA. She is
not on home oxygen. In the setting of active infection the
patient was hypoxemic. An echo was done showing moderate pulm
HTN but no loss of LV systolic function. CTA negative for PE>
The patient's respiratory status was stable on the floor. Used
CPAP at night.

#. Anemia:  The patient lost ~1L of blood during her operation
here. She required 4 units of PRBCs during her hospital stay.

#. Recent C. diff infection: During her prior hospitalization
the patient developed C. Diff. She underwent therapy with PO
vanc. The patient was initially placed on PO vanc again in the
setting of broad spectrum abx, but this was stopped when her abx
were narrowed to vancomycin only. She remained diahrrea free in
house.

#. Lower Extremity Edema: The patient developed siginificant LE
edema after her surgery. She was treated with IV lasix and
continued on her home PO lasix. Due to some asymetry of the
swelling (L>R), an ultrasound was done showing a possible
ruptured bakers cyst. No DVT was found.

CHRONIC CONDITIONS
------------------
#. COPD/Asthma: Continued spiriva and singulair

#. Diabetes (IDDM): Held oral diabetic medications during
admission. Placed on IHSS. Restarted orals on discharge.

#. Hypothyroidism: Continued on synthroid

#. Hypertension: The patient's home antihypertensives were held
in the setting of active infection. These were restarted over
the course of her hospital stay.

#. Vaginal yeast infection: Received 1 dose of fluconazole

TRANSITIONAL ISSUES:
#. Continue anti-biotics for 4-6 weeks as will be determined by
infectious disease
#. Monitor electrolytes as patient has intermittently required
repletion

Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation.  Information was obtained from  [**Last Name (un) **]
note.
1. MetFORMIN (Glucophage) 1000 mg PO BID
2. Furosemide 20 mg PO DAILY
3. Omeprazole 40 mg PO BID
4. Gemfibrozil 600 mg PO BID
5. Gabapentin 1200 mg PO TID
6. Simvastatin 20 mg PO DAILY
7. Valsartan 80 mg PO DAILY
8. Tiotropium Bromide 1 CAP IH DAILY
9. Montelukast Sodium 10 mg PO DAILY
10. Lidocaine 5% Patch 1 PTCH TD DAILY
11. traZODONE 200 mg PO HS:PRN sleep
12. Levothyroxine Sodium 150 mcg PO DAILY
13. DiCYCLOmine 20 mg PO TID
14. Hydrocodone-Acetaminophen (5mg-500mg [**11-19**] TAB PO Q6H:PRN pain



Discharge Medications:
1. Furosemide 20 mg PO DAILY
2. Omeprazole 40 mg PO BID
3. Gabapentin 1200 mg PO TID
4. Gemfibrozil 600 mg PO BID
5. Simvastatin 20 mg PO DAILY
6. Valsartan 80 mg PO DAILY
7. Montelukast Sodium 10 mg PO DAILY
8. Tiotropium Bromide 1 CAP IH DAILY
9. Lidocaine 5% Patch 1 PTCH TD DAILY
10. traZODONE 200 mg PO HS:PRN sleep
11. Levothyroxine Sodium 150 mcg PO DAILY
12. DiCYCLOmine 20 mg PO TID
13. Docusate Sodium 100 mg PO BID
14. Senna 1 TAB PO BID:PRN Constipation
15. Vancomycin 1000 mg IV Q 12H
16. Hydrocodone-Acetaminophen (5mg-500mg [**11-19**] TAB PO Q4H:PRN pain

17. Acetaminophen 1000 mg PO Q 8H
18. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Wheezing
19. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN Wheezing
20. Lorazepam 1 mg PO TID Anxiety
21. MetFORMIN (Glucophage) 1000 mg PO BID


Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
Infected spinal instrumentation


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 at [**Hospital1 18**]!

In the hospital you were treated for an infection around your
spine. You went to the operating room so that the infection
could be washed out and the hardware replaced. Afterwards, you
were treated with intra-venous antibioitcs and you will need to
continue these after discharge.

New Medications:
- Please START Vancomycin and continue until instructed
otehrwise by infectious disease
- Please START Colace and Senna as you are on higher doses of
opiod medications
- Please START albuterol and ipratropium as needed for wheezing
- Please START Magnesium every other day
- Please START Long acting morphine and reduce the dose as your
pain improves

Please see below for instructions regarding follow-up care.

Followup Instructions:
With Dr. [**Last Name (STitle) 363**] in 10 days.  Please call [**Telephone/Fax (1) **] for an
appointment.

Department: INFECTIOUS DISEASE
When: TUESDAY [**2165-8-13**] at 10:15 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 456**], 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: INFECTIOUS DISEASE
When: MONDAY [**2165-9-2**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 27625**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage



Completed by:[**2165-7-31**]
{'Infection and inflammatory reaction due to other internal orthopedic device, implant, and graft,Unspecified septicemia,Severe sepsis,Septic shock,Infected postoperative seroma,Acute posthemorrhagic anemia,Pulmonary collapse,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Abnormal coagulation profile,Chronic obstructive asthma, unspecified,Hypoxemia,Obesity, unspecified,Body Mass Index 39.0-39.9, adult,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Unspecified acquired hypothyroidism,Unspecified essential hypertension,Obstructive sleep apnea (adult)(pediatric),Other and unspecified hyperlipidemia,Edema,Esophageal reflux,Candidiasis of vulva and vagina'}


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: fever, malaise

PRESENT ILLNESS: Ms. [**Known lastname 122**] is a 64F with a history of COPD (not on home O2) and
recent spinal fusion with hardware at [**Hospital6 17390**] on [**2165-6-27**] who presented with back pain, fever and
malaise. She had been recovering well from her recent surgery at
rehab ([**Hospital3 **]) until a few days ago when she began to
experience increasing back pain. She did not have bowel or
bladder dysfunction. She did have weakness in her left lower
extremity however she reports this is chronic. She did not
notice any drainage from the surgical site. Because of her
increasing pain she was seen by her orthopedic surgeon in clinic
this morning. Records from that encounter are not available at
this time. The patient reports that she was told that the top of
her wound "looked infected" but she was not given antibiotics.
After she went back to rehab she began to experience fevers and
malaise and therefore she was sent to the [**Hospital1 18**] ED.

MEDICAL HISTORY: -CAD
-COPD/Asthma
-Pulmonary HTN
-Bipolar D/O
-T2DM
-Diabetic Neuropathy
-Hypothyroidism
-OSA on CPAP
-HTN
-HLD
-Stress Urinary Incontinence
-Diverticulosis
-IBS
-Osteoarthritis
-Spinal Stenosis
-Chronic Peripheral Edema
-GERD
-3 cm right renal cyst found incidentally [**6-/2165**], needs further
workup

MEDICATION ON ADMISSION: Preadmissions medications listed are incomplete and require
futher investigation.  Information was obtained from  [**Last Name (un) **]
note.
1. MetFORMIN (Glucophage) 1000 mg PO BID
2. Furosemide 20 mg PO DAILY
3. Omeprazole 40 mg PO BID
4. Gemfibrozil 600 mg PO BID
5. Gabapentin 1200 mg PO TID
6. Simvastatin 20 mg PO DAILY
7. Valsartan 80 mg PO DAILY
8. Tiotropium Bromide 1 CAP IH DAILY
9. Montelukast Sodium 10 mg PO DAILY
10. Lidocaine 5% Patch 1 PTCH TD DAILY
11. traZODONE 200 mg PO HS:PRN sleep
12. Levothyroxine Sodium 150 mcg PO DAILY
13. DiCYCLOmine 20 mg PO TID
14. Hydrocodone-Acetaminophen (5mg-500mg [**11-19**] TAB PO Q6H:PRN pain

ALLERGIES: Sulfa(Sulfonamide Antibiotics) / Ace Inhibitors /
hydrochlorothiazide / Macrolide Antibiotics / Penicillins

PHYSICAL EXAM: On Admission:
Vitals: T:102.1  BP: 92/52 P: 127 R: 29 O2: 91% 4L NC
General: Alert, oriented
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL
Neck: right IJ
CV:  Tachycardic
Lungs: Bibasilar crackles
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, trace pitting edema in LE
bilaterally
Neuro: CNII-XII intact, moving all extremities, grossly normal
sensation
Back: there is a midline spinal incision extending down the
thoracic and lumbar spine. There is a large area of erythema,
warmth, and fluctuance surrounding the top part of the incision.
It is tender to palpation. No active drainage.

FAMILY HISTORY: Mother died at age 70 due to cardiac disease and
complications of diabetes.  Father died at age 66 due to
congestive heart failure.  Sister died at age 64 due to
emphysema.  Brother died of cancer.  Numerous other family
members with diabetes and neuropathy.

SOCIAL HISTORY: Lives alone. Quit smoking several years ago. No drugs or
alcohol. 

### Response:
{'Infection and inflammatory reaction due to other internal orthopedic device, implant, and graft,Unspecified septicemia,Severe sepsis,Septic shock,Infected postoperative seroma,Acute posthemorrhagic anemia,Pulmonary collapse,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Abnormal coagulation profile,Chronic obstructive asthma, unspecified,Hypoxemia,Obesity, unspecified,Body Mass Index 39.0-39.9, adult,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Unspecified acquired hypothyroidism,Unspecified essential hypertension,Obstructive sleep apnea (adult)(pediatric),Other and unspecified hyperlipidemia,Edema,Esophageal reflux,Candidiasis of vulva and vagina'}
