CHIEF COMPLAINT: Non healing sternal wound

PRESENT ILLNESS: Mrs. [**Known lastname 77879**] is a 73 yo F well known to cardiac surgery, ID and
plastics. Was last discharged back to rehab on [**2137-9-4**]. Was seen
in cardiac surgery clinic on [**2137-9-19**]. Wound vac was changed and
wound was clean.
She presented to the ER today from Rehab w/ fever, chills, sore
throat, and buring with urination which started 24 hrs ago.

MEDICAL HISTORY: s/p cabg x2 with reversed saphenous vein graft to the ramus
intermedius artery and a free left internal mammary artery graft
to the obtuse marginal artery Y'd to the vein graft  [**2137-7-18**]
PMH:
coronary artery disease, dyspnea on exertion, bilateral knee
replacement [**2132**], sleep apnea, hiatal hernia, GERD, diabetes
mellitus, hypertension, Hyperlipidemia, Restless leg syndrome,
s/p stent to LAD in [**2126**], Stent to RCA and OM in [**2128**],
appendectomy, hysterectomy, CTR left wrist, laser surgery OU,
cataract

MEDICATION ON ADMISSION: CEFEPIME 2gm/12H,LIPITOR 80mg daily,SQH
5000unitTID,HYDROMORPHONE 2-4mg Q4prn,Humalog SSI,LISINOPRIL5mg
daily, Lopressor 50 TID, PANTOPRAZOLE 40mg daily,KCl10mEq [**Hospital1 **],
PRAMIPEXOLE 0.5 mg HS,ecASA81mg daily, CHOLECALCIFEROL 400 unit
DAILY, FISH OIL-DHA-EPA 1,200 mg-144 mg 1 Capsule TID,
MULTIVITAMIN 1 DAILY, NPH INSULIN HUMAN RECOMB [HUMULIN N] - 100
unit/mL Suspension - 72 units twice a day
ID/Plastics,Vanco.Continue Cefipime

ALLERGIES: Morphine / Baclofen / adhesive bandage / penicillin G / Aldomet

PHYSICAL EXAM: Physical Exam

FAMILY HISTORY: Premature coronary artery disease- Brother with CABG at age 65
Race:Caucasian

SOCIAL HISTORY: Occupation:retired
Cigarettes: denies
Other Tobacco use:denies
ETOH: denies
Illicit drug use:denies
Lives with: alone in a senior complex, Ambulates with
a four wheel walker.
Contact:[**Name (NI) **] and [**Name (NI) **] (son and daughter-in-law)
Non-healing surgical wound,Acute kidney failure, unspecified,Infection and inflammatory reaction due to other internal orthopedic device, implant, and graft,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Knee joint replacement,Unspecified sleep apnea,Diaphragmatic hernia without mention of obstruction or gangrene,Esophageal reflux,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Restless legs syndrome (RLS),Cardiac pacemaker in situ,Obesity, unspecified,Body Mass Index 37.0-37.9, adult
Non-healing surgcl wound,Acute kidney failure NOS,React-oth int ortho dev,Pseudomonas infect NOS,Cor ath unsp vsl ntv/gft,Aortocoronary bypass,Joint replaced knee,Sleep apnea NOS,Diaphragmatic hernia,Esophageal reflux,DMII wo cmp nt st uncntr,Hypertension NOS,Hyperlipidemia NEC/NOS,Restless legs syndrome,Status cardiac pacemaker,Obesity NOS,BMI 37.0-37.9,adult
Admission Date:  [**2137-9-21**]              Discharge Date:   [**2137-10-1**]

Date of Birth:  [**2063-12-24**]             Sex:   F

Service: CARDIOTHORACIC

Allergies:
Morphine / Baclofen / adhesive bandage / penicillin G / Aldomet

Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Non healing sternal wound

Major Surgical or Invasive Procedure:
Removal of hardware, bilateral pectoralis flap advancement.


History of Present Illness:
Mrs. [**Known lastname 77879**] is a 73 yo F well known to cardiac surgery, ID and
plastics. Was last discharged back to rehab on [**2137-9-4**]. Was seen
in cardiac surgery clinic on [**2137-9-19**]. Wound vac was changed and
wound was clean.
She presented to the ER today from Rehab w/ fever, chills, sore
throat, and buring with urination which started 24 hrs ago.

Longterm plan was to remain at rehabilitation for 2-3 weeks and
return for sternal closure device removal and flap closure with
plastic surgery in 3 weeks.
She will remain on antibiotics until that time. Discharged on IV
Cefepime. Currently feels well. No fevers with good appetite.
Remains active at rehab. Patient has improved energy.


Past Medical History:
s/p cabg x2 with reversed saphenous vein graft to the ramus
intermedius artery and a free left internal mammary artery graft
to the obtuse marginal artery Y'd to the vein graft  [**2137-7-18**]
PMH:
coronary artery disease, dyspnea on exertion, bilateral knee
replacement [**2132**], sleep apnea, hiatal hernia, GERD, diabetes
mellitus, hypertension, Hyperlipidemia, Restless leg syndrome,
s/p stent to LAD in [**2126**], Stent to RCA and OM in [**2128**],
appendectomy, hysterectomy, CTR left wrist, laser surgery OU,
cataract

Social History:
Occupation:retired
Cigarettes: denies
Other Tobacco use:denies
ETOH: denies
Illicit drug use:denies
Lives with: alone in a senior complex, Ambulates with
a four wheel walker.
Contact:[**Name (NI) **] and [**Name (NI) **] (son and daughter-in-law)


Family History:
Premature coronary artery disease- Brother with CABG at age 65
Race:Caucasian



Physical Exam:
Physical Exam

temp 98.5 Pulse:72  Resp:18  O2 sat: 97% RA
B/P  Right:140/70    Height:     Weight:

General:
Obese female in NAD lying on stretcher in ER
Skin: Dry [x] intact []- sternal wound vac in place
HEENT: PERRLA [] EOMI [x]
Neck:  Supple [x] Full ROM [x]- no lymph adenopathy
Chest: Lungs clear bilaterally [x]
Sternal incision: on [**2137-9-19**] wound bed with healthy granulation
tissue, no exudate, no erythema.  Wound measures 7 inches long
by
1.5 inches wide by [**2-15**] deep
Heart: RRR [x]  Irregular []  Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x]  bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]  Edema []none____
Lesser Saph incision: clean, dry and intact
Left Picc line site w/o drainage or erythema
Varicosities: None [x]
Neuro: Grossly intact [x]


Pertinent Results:
[**2137-9-21**] 07:25PM URINE  RBC-1 WBC-17* BACTERIA-NONE YEAST-NONE
EPI-1 TRANS EPI-<1 RENAL EPI-<1
[**2137-9-21**] 04:00PM   GLUCOSE-206* UREA N-20 CREAT-0.8 SODIUM-136
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-22 ANION GAP-16

ECHO:
No spontaneous echo contrast is seen in the body of the left
atrium or left atrial appendage. There is mild symmetrical
hypertrophy of the left ventricle. The left ventricular cavity
is mildly dilated. There is mild regional left ventricular
systolic dysfunction with anteroseptal wall hypokinesis. Overall
left ventricular systolic function is mildly depressed (LVEF=
40-45 %). Right ventricular chamber size and free wall motion
are normal. There are simple atheroma in the aortic arch. The
descending thoracic aorta is mildly dilated. There are complex
(>4mm) atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis. There is no aortic valve
stenosis. No aortic regurgitation is seen. Mild (1+) mitral
regurgitation is seen. Moderate [2+] tricuspid regurgitation is
seen. There is no pericardial effusion. Dr. [**First Name (STitle) **] was notified
in person of the results at time of surgery.
  I certify that I was present for this procedure in compliance
with HCFA regulations.

Electronically signed by [**First Name8 (NamePattern2) **] [**Name8 (MD) 17792**], MD, Interpreting physician [**Last Name (NamePattern4) **]
[**2137-9-27**] 19:19

Chest CT:
IMPRESSION: No evidence for discrete fluid collection. However,
there is a
slightly increasing gap along the manubrium and faintly
increased sclerosis,
so subacute osteomyelitis would represent a differential
consideration.


Brief Hospital Course:
Mrs. [**Known lastname 77879**] is a 73 yo F well known to cardiac surgery, ID and
plastics. Was last discharged back to rehab on [**2137-9-4**]. Was seen
in cardiac surgery clinic on [**2137-9-19**]. Wound vac was changed and
wound was clean.

She presented to the ER [**2137-9-21**] from Rehab w/ fever, chills,
sore throat, and buring with urination which started 24 hrs ago.

Fever w/u revealed 1 out of 4 BC positive- possible contaminant.
Her Picc was d/c'd and sent for culture which was neg. A new
PICC was placed. Chest CT revealed no fluid colection. She was
followed by ID and treated with vanco thru [**11-8**] and cefepime
thru [**10-11**]. Her wound vac was changed and the wound bed was
clean. She was taken to the OR for removal of hardware and
bilateral pectoralis flap advancement
with Dr. [**First Name (STitle) **] (see operative note). She has 2 JP drains left
in place which will be managed byDr. [**Location (un) **]. [**9-30**] OR wound
culture showed coag-negative staph - rare growth. ID service had
followed patient and she is to be continued on Vanco/Cefepime
for 6 week total course of each antibiotic. Her blood sugars had
been elevated pre and postoperatively but were controlled on NPH
at the time of discharge. She was in stable condition and was
discharged to [**Hospital 31183**] Nursing and Rehab in [**Hospital1 1474**] on POD #3.


Medications on Admission:
CEFEPIME 2gm/12H,LIPITOR 80mg daily,SQH
5000unitTID,HYDROMORPHONE 2-4mg Q4prn,Humalog SSI,LISINOPRIL5mg
daily, Lopressor 50 TID, PANTOPRAZOLE 40mg daily,KCl10mEq [**Hospital1 **],
PRAMIPEXOLE 0.5 mg HS,ecASA81mg daily, CHOLECALCIFEROL 400 unit
DAILY, FISH OIL-DHA-EPA 1,200 mg-144 mg 1 Capsule TID,
MULTIVITAMIN 1 DAILY, NPH INSULIN HUMAN RECOMB [HUMULIN N] - 100
unit/mL Suspension - 72 units twice a day
ID/Plastics,Vanco.Continue Cefipime


Discharge Medications:
1. vancomycin 1,000 mg Recon Soln Sig: One (1)  Intravenous
every twenty-four(24) hours for 6 weeks: Check trough daily and
dose for level <20 - end date [**2137-11-8**].
2. cefepime 2 gram Recon Soln Sig: One (1)  Injection every
twenty-four(24) hours for 6 weeks: End date [**2137-10-11**].
3. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. pramipexole 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
7. multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

8. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
12. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain for 2 weeks.
Disp:*65 Tablet(s)* Refills:*0*
13. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for rash.
14. Insulin
NPH 85 units Q AM and NPH 80 units Q dinnner.

RISS - see attached or use own facilites SS
15. Cepacol Sore Throat 15-2.6 mg Lozenge Sig: One (1)  Mucous
membrane once a day as needed for sore throat.
16. picc line care and flushes
Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline Sodium
Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
followed by Heparin as above daily and PRN per lumen.
17. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
18. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15)
ML Mucous membrane [**Hospital1 **] (2 times a day).
19. hydrochlorothiazide 50 mg Tablet Sig: One (1) Tablet PO once
a day: for lower extermity edema- stop when resolved.


Discharge Disposition:
Extended Care

Facility:
[**Hospital 2971**] Rehabilitation and Nursing Center - [**Hospital1 1474**]

Discharge Diagnosis:
Non healing sternal wound


Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Dilaudid
Incisions:
Sternal - healing well, no erythema or drainage - JP's in place
- Keep JP's in place until follow up with Dr [**First Name (STitle) **]
Leg 2+ Edema - teds in place


Discharge Instructions:
1. Clean around the drain site(s), where the tubing exits the
skin, with soap and water.
2. Strip drain tubing, empty bulb(s), and record output(s) [**1-17**]
times per day.
3. A written record of the daily output from each drain should
be brought to every follow-up appointment. your drains will be
removed as soon as possible when the daily output tapers off to
an acceptable amount.
4. You may shower daily. No baths until instructed to do so by
Dr. [**First Name (STitle) **].
6. Keep your surgibra in place at all times except when
showering.
7. Do not lift your arms out to the side to prevent stress on
your midline incision.

Activity:
1. You may resume your regular diet.
2. DO NOT lift anything heavier than 5 pounds or engage in
strenuous activity until instructed by Dr. [**First Name (STitle) **].

Medications:
1. You may take your prescribed pain medication for moderate to
severe pain. You may switch to Tylenol or Extra Strength Tylenol
for mild pain as directed on the packaging. Please note that
Percocet and Vicodin have Tylenol as an active ingredient so do
not take these meds with additional Tylenol.
4. Take prescription pain medications for pain not relieved by
tylenol.
5. Take your antibiotic as prescribed.
6. Take Colace, 100 mg by mouth 2 times per day, while taking
the prescription pain medication. You may use a different
over-the-counter stool softerner if you wish.
7. Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.

.
DRAIN DISCHARGE INSTRUCTIONS
You are being discharged with drains in place. Drain care is a
clean procedure. Wash your hands thoroughly with soap and warm
water before performing drain care. Perform drainage care twice
a day. Try to empty the drain at the same time each day. Pull
the stopper out of the drainage bottle and empty the drainage
fluid into the measuring cup. Record the amount of drainage
fluid on the record sheet. Reestablish drain suction.


Followup Instructions:
You are scheduled for the following appointments

Surgeon: Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] on 10/27th at 1:00 PM in the [**Hospital **]
medical office building [**Hospital Unit Name **], [**Last Name (NamePattern1) **]
Plastic surgery: Dr [**First Name (STitle) **] on [**10-8**] at 9:45 am
Needs follow up with [**Hospital **] clinic  - Clinic to call rehab with
appointment

Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 17918**] in [**3-19**] weeks [**Telephone/Fax (1) 17919**]

PLEASE CHECK VANCO TROUGH, BUN/CREA/K in AM [**10-2**] and then
weekly labs: CBC with diff, BMP, LFT's, ESR, CRP, VANCO TROUGH Q
WEEK - PLEASE FAX ALL LAB RESULTS TO [**Telephone/Fax (1) 1419**]

**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**



Completed by:[**2137-10-1**]
{'Non-healing surgical wound,Acute kidney failure, unspecified,Infection and inflammatory reaction due to other internal orthopedic device, implant, and graft,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Knee joint replacement,Unspecified sleep apnea,Diaphragmatic hernia without mention of obstruction or gangrene,Esophageal reflux,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Restless legs syndrome (RLS),Cardiac pacemaker in situ,Obesity, unspecified,Body Mass Index 37.0-37.9, adult'}


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: Non healing sternal wound

PRESENT ILLNESS: Mrs. [**Known lastname 77879**] is a 73 yo F well known to cardiac surgery, ID and
plastics. Was last discharged back to rehab on [**2137-9-4**]. Was seen
in cardiac surgery clinic on [**2137-9-19**]. Wound vac was changed and
wound was clean.
She presented to the ER today from Rehab w/ fever, chills, sore
throat, and buring with urination which started 24 hrs ago.

MEDICAL HISTORY: s/p cabg x2 with reversed saphenous vein graft to the ramus
intermedius artery and a free left internal mammary artery graft
to the obtuse marginal artery Y'd to the vein graft  [**2137-7-18**]
PMH:
coronary artery disease, dyspnea on exertion, bilateral knee
replacement [**2132**], sleep apnea, hiatal hernia, GERD, diabetes
mellitus, hypertension, Hyperlipidemia, Restless leg syndrome,
s/p stent to LAD in [**2126**], Stent to RCA and OM in [**2128**],
appendectomy, hysterectomy, CTR left wrist, laser surgery OU,
cataract

MEDICATION ON ADMISSION: CEFEPIME 2gm/12H,LIPITOR 80mg daily,SQH
5000unitTID,HYDROMORPHONE 2-4mg Q4prn,Humalog SSI,LISINOPRIL5mg
daily, Lopressor 50 TID, PANTOPRAZOLE 40mg daily,KCl10mEq [**Hospital1 **],
PRAMIPEXOLE 0.5 mg HS,ecASA81mg daily, CHOLECALCIFEROL 400 unit
DAILY, FISH OIL-DHA-EPA 1,200 mg-144 mg 1 Capsule TID,
MULTIVITAMIN 1 DAILY, NPH INSULIN HUMAN RECOMB [HUMULIN N] - 100
unit/mL Suspension - 72 units twice a day
ID/Plastics,Vanco.Continue Cefipime

ALLERGIES: Morphine / Baclofen / adhesive bandage / penicillin G / Aldomet

PHYSICAL EXAM: Physical Exam

FAMILY HISTORY: Premature coronary artery disease- Brother with CABG at age 65
Race:Caucasian

SOCIAL HISTORY: Occupation:retired
Cigarettes: denies
Other Tobacco use:denies
ETOH: denies
Illicit drug use:denies
Lives with: alone in a senior complex, Ambulates with
a four wheel walker.
Contact:[**Name (NI) **] and [**Name (NI) **] (son and daughter-in-law) 

### Response:
{'Non-healing surgical wound,Acute kidney failure, unspecified,Infection and inflammatory reaction due to other internal orthopedic device, implant, and graft,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Knee joint replacement,Unspecified sleep apnea,Diaphragmatic hernia without mention of obstruction or gangrene,Esophageal reflux,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Restless legs syndrome (RLS),Cardiac pacemaker in situ,Obesity, unspecified,Body Mass Index 37.0-37.9, adult'}
