CHIEF COMPLAINT: Hip pain and drainage from prior surgical site

PRESENT ILLNESS: Patient is a 76yoF with multiple medical problems including CAD
s/p CABG, DM2, AS s/p bovine AVR, HTN, HLD and a left hip
hemiarthroplasty s/p infection/abx/washout/suppressive abx over
the last year, who was admitted [**7-29**] with a several week history
of left hip pain, which evolved to include edema, pain, and
finally mucopurulent drainage from her previous surgical
incision site. She underwent abscess drainage, washout, hardware
removal, and antibiotic spacer placement in the OR late on [**7-30**],
complicated by an intraoperative blood loss estimated at 1000cc.
She received 2 units PRBC. Tissue culture is having sparse coagu
negaitve sptaph. Last year tissue culture grew a coag negative
staph lugdunensis. Wound vac and drain were placed in the site.
ID is seeing her and has her on vancomycin 750mg Q12.
.
Post-operatively, she developed a dense delirium last night,
accusing staff of trying to kill her, pulling at IV lines and
her wound vac. Took a few swings at staff. Received IV haldol
0.5mg x 2 with good effect. QTC at 410. She has suffered post-op
delirium in previous surgeries, tends to wane in 2 days.
.
She has numerous metabolic derangements: hyperglycemic with AM
glucose 576 (though FSG shortly thereafter was 300 without any
interval insulin administered). Hyperkalemic with K=5.7 (no EKG
change). Hypomagnesemic. Tachycardic and dry-appearing with HCT
25ish. Complaining of some left hip pain.

MEDICAL HISTORY: - Coronary artery disease s/p 4 vessel CABG [**2190**]: LIMA to LAD,
reverse saphenous vein graft from aorta separately to ramus
intermedius, obtuse marginal, and posterolateral branch of RCA.
- Re-do sternotomy for AVR ([**1-6**]) for critical symptomatic
critical aortic stenosis with bovine AVR
- Carcinoid tumor of right middle lung lobe s/p resection.
- Diabetes mellitus, type 2
- Hypertension
- Hyperlipidemia
- Deep venous thrombosis, [**2176**], on Coumadin X6 months. Stopped
Coumadin, had another DVT,[**2176**] placed on Coumadin since, s/p IVC

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver[**Name (NI) 581**].
1. Atorvastatin 40 mg PO DAILY
2. Carvedilol 3.125 mg PO BID
3. MetFORMIN (Glucophage) 1000 mg PO BID
4. Senna 1 TAB PO DAILY:PRN Constipation
5. Docusate Sodium 100 mg PO DAILY Contipation
6. Multivitamins 1 TAB PO DAILY
7. Calcium 500 With D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit Oral Twice daily
8. Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q6H:PRN Pain
9. Aspirin 81 mg PO DAILY
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. NPH 10 Units Breakfast
NPH 8 Units Dinner
12. Bromday *NF* (bromfenac) 0.09 % OU daily
13. Doxycycline Hyclate 100 mg PO Q12H

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

PHYSICAL EXAM: Physical Exam on Tranfer to Medicine Team
Vitals: T: 100.1  99.1  96/53  85 16 97%RA
General: Alert able to converse, lying flat on bed.
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear,
pupils reactive to light bilaterally, EOMI.  Right pupil
slightly elongated
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally in the anterioc hest
wall, no wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, [**3-4**]
crescendo-decresedo murmur at LUSB radiating to carotids.
Abdomen: soft, non-tender, distended, no rebound tenderness or
guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin:  Surgical site appears clean without erythema.  Tender to
touch.  Wound wac in place.  Poor skin turgor.
Neuro:  Alert and oreinted x2 (name and place).  Able to have
conversation.  CNII-XII intack.
.
Discharged Physical Exam
97.9 96/54  64  18  100% on 2L
Gen: NAD
CV: RRR with systolic murmur ([**3-4**]) radiating to carotids
Resp: CTAB no w/r/r
Abd: mild distention, withough ttp or guarding, improved from
prior
Extr: bandaged ulcer on left heel, left hip wound bandage c/d/i
with ttp but no visible erythema, induration, or hematoma
Neuro: A&Ox2, appropriate, grossly nonfocal

FAMILY HISTORY: Denies any family history of blood clot.  REports vague family
history o heart attacks.

SOCIAL HISTORY: Patient is originally from [**Country 5881**].  Moved to U.S long time ago.
Currently live with husband and son in [**Name (NI) 77913**] plane.  Denies any
tobacco, alcohol and drugs.
Infection and inflammatory reaction due to internal joint prosthesis,Metabolic encephalopathy,Hemorrhage complicating a procedure,Acute kidney failure, unspecified,Cellulitis and abscess of leg, except foot,Pyogenic arthritis, pelvic region and thigh,Hematemesis,Paralytic ileus,Pulmonary collapse,Chronic combined systolic and diastolic heart failure,Hip joint replacement,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Heart valve replaced by transplant,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Hyperpotassemia,Disorders of magnesium metabolism,Personal history of venous thrombosis and embolism,Obstructive sleep apnea (adult)(pediatric),Anemia of other chronic disease,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus,Constipation, unspecified,Synovitis and tenosynovitis, unspecified,Long-term (current) use of insulin,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Hypoxemia
React-inter joint prost,Metabolic encephalopathy,Hemorrhage complic proc,Acute kidney failure NOS,Cellulitis of leg,Pyogen arthritis-pelvis,Hematemesis,Paralytic ileus,Pulmonary collapse,Chr syst/diastl hrt fail,Joint replaced hip,Abn react-artif implant,Cor ath unsp vsl ntv/gft,Aortocoronary bypass,Heart valve transplant,Hypertension NOS,Hyperlipidemia NEC/NOS,Hyperpotassemia,Dis magnesium metabolism,Hx-ven thrombosis/embols,Obstructive sleep apnea,Anemia-other chronic dis,Other staphylococcus,Constipation NOS,Synovitis NOS,Long-term use of insulin,DMII wo cmp uncntrld,Hypoxemia
Admission Date:  [**2205-7-29**]              Discharge Date:   [**2205-8-9**]

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

Service: MEDICINE

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

Attending:[**First Name3 (LF) 8928**]
Chief Complaint:
Hip pain and drainage from prior surgical site

Major Surgical or Invasive Procedure:
Abscess drainage, washout, hardware removal, and antibiotic
spacer placement in the OR in the left hip.


History of Present Illness:
Patient is a 76yoF with multiple medical problems including CAD
s/p CABG, DM2, AS s/p bovine AVR, HTN, HLD and a left hip
hemiarthroplasty s/p infection/abx/washout/suppressive abx over
the last year, who was admitted [**7-29**] with a several week history
of left hip pain, which evolved to include edema, pain, and
finally mucopurulent drainage from her previous surgical
incision site. She underwent abscess drainage, washout, hardware
removal, and antibiotic spacer placement in the OR late on [**7-30**],
complicated by an intraoperative blood loss estimated at 1000cc.
She received 2 units PRBC. Tissue culture is having sparse coagu
negaitve sptaph. Last year tissue culture grew a coag negative
staph lugdunensis. Wound vac and drain were placed in the site.
ID is seeing her and has her on vancomycin 750mg Q12.
.
Post-operatively, she developed a dense delirium last night,
accusing staff of trying to kill her, pulling at IV lines and
her wound vac. Took a few swings at staff. Received IV haldol
0.5mg x 2 with good effect. QTC at 410. She has suffered post-op
delirium in previous surgeries, tends to wane in 2 days.
.
She has numerous metabolic derangements: hyperglycemic with AM
glucose 576 (though FSG shortly thereafter was 300 without any
interval insulin administered). Hyperkalemic with K=5.7 (no EKG
change). Hypomagnesemic. Tachycardic and dry-appearing with HCT
25ish. Complaining of some left hip pain.


Past Medical History:
- Coronary artery disease s/p 4 vessel CABG [**2190**]: LIMA to LAD,
reverse saphenous vein graft from aorta separately to ramus
intermedius, obtuse marginal, and posterolateral branch of RCA.
- Re-do sternotomy for AVR ([**1-6**]) for critical symptomatic
critical aortic stenosis with bovine AVR
- Carcinoid tumor of right middle lung lobe s/p resection.
- Diabetes mellitus, type 2
- Hypertension
- Hyperlipidemia
- Deep venous thrombosis, [**2176**], on Coumadin X6 months. Stopped
Coumadin, had another DVT,[**2176**] placed on Coumadin since, s/p IVC

filter, [**2197**] reports being off of coumadin now
- Oxygen dependent since lung surgery and for obstructive sleep
apnea, uses 2L nasal cannula 02 only at night at home. No Bpap
for obstructive sleep apnea.
- Restrictive lung disease
- carpel tunnel syndrome b/l, [**2179**] s/p decompression
- Chronic Diastolic heart failure (left atrium is mildly
dilated.
LVEF 67%/[**2199**])
- Anemia of Chronic disease, baseline Hct=26-31.0

Social History:
Patient is originally from [**Country 5881**].  Moved to U.S long time ago.
Currently live with husband and son in [**Name (NI) 77913**] plane.  Denies any
tobacco, alcohol and drugs.


Family History:
Denies any family history of blood clot.  REports vague family
history o heart attacks.

Her mother was diagnosed with diabetes.

Physical Exam:
Physical Exam on Tranfer to Medicine Team
Vitals: T: 100.1  99.1  96/53  85 16 97%RA
General: Alert able to converse, lying flat on bed.
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear,
pupils reactive to light bilaterally, EOMI.  Right pupil
slightly elongated
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally in the anterioc hest
wall, no wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, [**3-4**]
crescendo-decresedo murmur at LUSB radiating to carotids.
Abdomen: soft, non-tender, distended, no rebound tenderness or
guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin:  Surgical site appears clean without erythema.  Tender to
touch.  Wound wac in place.  Poor skin turgor.
Neuro:  Alert and oreinted x2 (name and place).  Able to have
conversation.  CNII-XII intack.
.
Discharged Physical Exam
97.9 96/54  64  18  100% on 2L
Gen: NAD
CV: RRR with systolic murmur ([**3-4**]) radiating to carotids
Resp: CTAB no w/r/r
Abd: mild distention, withough ttp or guarding, improved from
prior
Extr: bandaged ulcer on left heel, left hip wound bandage c/d/i
with ttp but no visible erythema, induration, or hematoma
Neuro: A&Ox2, appropriate, grossly nonfocal

Pertinent Results:
Admission
[**2205-7-29**] 01:08PM BLOOD WBC-6.0 RBC-3.21* Hgb-8.9* Hct-27.5*
MCV-86 MCH-27.6 MCHC-32.2 RDW-15.8* Plt Ct-274
[**2205-7-29**] 01:08PM BLOOD Neuts-75.4* Lymphs-17.7* Monos-5.4
Eos-1.2 Baso-0.2
[**2205-7-29**] 01:08PM BLOOD Glucose-197* UreaN-43* Creat-1.1 Na-138
K-4.5 Cl-101 HCO3-27 AnGap-15
[**2205-8-1**] 06:40AM BLOOD ALT-9 AST-11 AlkPhos-61 TotBili-0.4
[**2205-7-30**] 05:10AM BLOOD Calcium-8.9 Mg-1.5*
[**2205-7-29**] 01:07PM BLOOD Lactate-0.7
Blood Culture, Routine (Final [**2205-8-4**]):    NO GROWTH.

Pertinent
[**2205-8-5**] 05:53AM BLOOD Glucose-45* UreaN-43* Creat-1.9* Na-130*
K-5.0 Cl-100 HCO3-23 AnGap-12
[**2205-8-2**] 10:18PM BLOOD CK-MB-2 cTropnT-<0.01
[**2205-8-3**] 03:22AM BLOOD CK-MB-4 cTropnT-0.12*
[**2205-8-3**] 01:11PM BLOOD CK-MB-4 cTropnT-0.06*
[**2205-8-5**] 12:13PM BLOOD cTropnT-0.04*
[**2205-8-5**] 04:44PM BLOOD CK-MB-3 cTropnT-0.04*
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2205-8-7**]):
      POSITIVE BY EIA.
Blood Culture, Routine (Final [**2205-8-9**]):    NO GROWTH.
GRAM STAIN (Final [**2205-7-31**]):
      2+   (1-5 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.

   TISSUE (Final [**2205-8-4**]):
      STAPHYLOCOCCUS LUGDUNENSIS.    SPARSE GROWTH.
         IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
350-0974S
         [**2205-7-31**].
      STAPHYLOCOCCUS LUGDUNENSIS.    RARE GROWTH.  SECOND
MORPHOLOGY.
         IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
350-0974S
         [**2205-7-31**].

Discharge
[**2205-8-9**] 04:48AM BLOOD WBC-7.0 RBC-2.66* Hgb-7.9* Hct-24.3*
MCV-91 MCH-29.8 MCHC-32.7 RDW-16.0* Plt Ct-296
[**2205-8-9**] 04:48AM BLOOD Glucose-71 UreaN-27* Creat-1.1 Na-136
K-4.4 Cl-103 HCO3-26 AnGap-11
[**2205-8-9**] 04:48AM BLOOD Calcium-8.1* Phos-3.3 Mg-1.9
[**2205-8-9**] 04:48AM BLOOD Vanco-22.9* (not true trough as dose was
given at 8pm night prior)
[**2205-7-29**] 01:08PM BLOOD WBC-6.0 RBC-3.21* Hgb-8.9* Hct-27.5*
MCV-86 MCH-27.6 MCHC-32.2 RDW-15.8* Plt Ct-274
[**2205-8-3**] 03:22AM BLOOD WBC-10.3 RBC-3.01* Hgb-9.1* Hct-26.8*
MCV-89 MCH-30.2 MCHC-33.8 RDW-15.3 Plt Ct-173
[**2205-8-3**] 03:22AM BLOOD Neuts-88.0* Lymphs-5.9* Monos-4.7 Eos-1.1
Baso-0.3
[**2205-8-3**] 03:22AM BLOOD PT-12.7* PTT-27.5 INR(PT)-1.2*
[**2205-7-30**] 05:10AM BLOOD ESR-84*
[**2205-7-29**] 01:08PM BLOOD Glucose-197* UreaN-43* Creat-1.1 Na-138
K-4.5 Cl-101 HCO3-27 AnGap-15
[**2205-8-3**] 03:22AM BLOOD Glucose-119* UreaN-24* Creat-1.0 Na-132*
K-4.9 Cl-103 HCO3-21* AnGap-13
[**2205-8-2**] 10:18PM BLOOD CK-MB-2 cTropnT-<0.01
[**2205-8-3**] 03:22AM BLOOD CK-MB-4 cTropnT-0.12*
[**2205-8-3**] 03:22AM BLOOD Calcium-7.8* Phos-2.7 Mg-1.8
.
Pelvis and dedicated left Hip X-Ray: [**2205-7-29**]
FINDINGS: AP view of the pelvis and three dedicated views of the
left hip obtained. Long stem left hip bipolar hemiarthroplasty,
cerclage wire, and greater trochanter hook device are in similar
position to prior. Lucencies surrounding the cement-bone
interfaces of the intertrochanteric region and proximal femur
are similar to prior, accounting for positioning. No evidence of
new osseous fracture. Diffuse demineralization is again seen.
Vascular calcifications and radiopaque pills in the right lower
quadrant are similar to prior. Numerous metallic clips over the
medial thigh soft tissues.
IMPRESSION: Stable position of left femoral hardware with
cement-bone.Preliminary Reportinterface lucencies similar to
prior.
.
CXR: [**2205-7-29**]
FINDINGS: The patient is status post aortic valve replacement
and probably coronary artery bypass graft surgery as well as
placement of fixation plates along the sternum. The cardiac,
mediastinal and hilar contours appear unchanged. There is no
pleural effusion or pneumothorax. A mild background interstitial
abnormality appears unchanged. The bones appear demineralized.
Mild superior endplate compression deformity along an upper
thoracic vertebral body with sclerosis is also unchanged.
IMPRESSION: No evidence of acute cardiopulmonary disease.
.
Left Pelvis X-ray: [**2205-7-31**]
FINDINGS: Since the previous study, there has been removal of
the hemiarthroplasty on the left side.  There has been placement
of an antibiotic spacer within the hip joint as well as within
the femoral shaft.  Lateral surgical skin staples are seen.
There is soft tissue swelling and gas consistent with the recent
surgery.  Some generalized demineralization.
.
Echo [**2205-8-3**]
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is mild regional left ventricular systolic
dysfunction with basal to mid septal hypokinesis (the anterior
wall is not well seen). The aortic root is mildly dilated at the
sinus level. A bioprosthetic aortic valve prosthesis is present.
The aortic valve prosthesis appears well seated, with normal
leaflet/disc motion and transvalvular gradients. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is severe mitral annular calcification. There
is mild functional mitral stenosis (mean gradient 7 mmHg) due to
mitral annular calcification. Mild to moderate ([**1-28**]+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.

CTA chest [**2205-8-2**]
1.  No pulmonary embolus.
2.  Enlarged main pulmonary artery, suggesting pulmonary
arterial
hypertension.
3.  Cardiomegaly, unchanged.Chronic small bilateral
non-hemorrhagic pleural
effusions with loculated components, with only very mild
component of
pulmonary edema.


Brief Hospital Course:
76yoF with CAD s/p 4v CABG, DM2, AS s/p bovine valve, HTN, HLD
and a left hip hemiarthroplasty with recurrent prosthetic joint
infection s/p washout, abscess drainage, hardware removal, and
antibiotic spacer placment on [**7-30**] with post-op delirium and
cultures which coagu negative staph.

# Prostethic Joint Infection: Patient presented with hip pain
and found to have mucopurulent drainage from her previous
surgical incision site. She underwent abscess drainage, washout,
hardware removal, and antibiotic spacer placement in the OR on
[**7-30**], complicated by an intraoperative blood loss estimated at
1000cc. She received 3 units PRBC with stablization of her
hematocrit. Tissue culture grew coagulase negative staph,
staphylococcus Lugdunesis, the same organism found in her prior
hip infections. She remained afebfile without any signs of
sepsis. She was started on IV vancomycin and had PICC line
placed.  Her vancomycin dose was adjusted in the setting of her
acute renal failure but has been now established by ID to be 750
q 24 hrs.  She continues to experience pain which is well
controoled with PO oxycodone 2.5.  She will need to follow up
with orthopedics next week for staple removal and infectious
disease and further management.

# Post-operative respiratory distress: Post-op, was noted to
have be hypoxemic, which was rapidly weaned back to nasal
cannula with SpO2 in high 90s. Unclear etiology. Transferred to
ICU.  CTA negative for PE.  Troponin was elevated to 0.12 but
decreased to 0.06 there after.  EKG was unchanged.  [**Month (only) 116**] have
been [**2-28**] to narcotic effects in setting of OSA.  Should obtain
sleep study given questionable history of OSA.

# Systolic CHF/CAD:  s/p 4V CABG [**2190**].  Noted on echo which was
obtained because of episode of hypoxia and chest pain.  EF 45%
with presumed ischemic cardiomyopathy.  Newly diagnosed.
Carvedilol was increased to 6.25 [**Hospital1 **].  ASA 81 continued.  Unable
to add ACEI because it was not tolerated due to hypotension.
F/U with cardiology.

# Post Operative delirium: Patient was at high risk for delirium
given her history of previous post-op delirium, pain, immobility
and anesthesia.  She was given haldol 0.5mgx2 with good effect.
She was transferred to the ICU very delirious in the setting of
hypoxia and was given additional doses of Haldol IV. Within 8
hours of transfer to ICU, patient's delirium had cleared. On
transfer to medicine team, patient was awake, alert and oriented
and did not have any further episodes of delirium.  She remained
A&Ox2 for the remainder of her stay.

# Anemia: Patient has history of iron deficiency anemia with
baseline HCT 25-30. Colonoscopy from [**2198**] showed diverticulosis
of the colon and grade 3 internal hemorrhoids. During her
orthopedic surgery this admission, she lost aproximately 1000cc
of blood and recieved eunits of blood transfusions.  She denied
hemoptysis, hematamesis and hemmatochezia.  Her hematocrit
remained stable around 25% after procedure.  Patient will need
to follow up with PCP for further evaluation/management of her
anemia.

# GI bleed: Pt had questionable episode of coffee ground emesis.
 She was started in IV pantoprazole [**Hospital1 **].  HCT and pressures were
stable during this event and during the remainder of her stay.
Her enoxaparin was initially held but then restarted in setting
of hemodynamic instability.  She was transitioned to
pantoprazole PO BID.   GI was consulted and did not recommend
EGD but will see her as outpatient.  H Pylori antibody was
positive and she was started on metronidazole and clarithromycin
for a course of 10 days of treatment.  She will need to follow
up with gastorenterology to have stool antigen testing or urea
breath test to confirm erridication.

# Constipation: pt was profoundly constipated in the post
operative period with evidence of dilated loops of bowel on abd
xray.  An aggressive bowel regimen was instituted with
combinations of senna, docusate, miralax, milk of mag,
lactulose, and pr bisacodyl.  She ultimated had several large
bowel movements and improvement was noted in abdominal
distention on exam and on bowel dilation on xray.  She is now on
senna and docusate and miralax with bisacodyl prn.

# [**Last Name (un) **]: Pt creatinine rose from baseline of 1->1.9 in the
postoperative/post CTA period.  It was initially unresponsive to
NS bolus.  Renal US was normal.  Prior to discharge, her
creatine downtrended to 1.1.  Etiology, while unclear was likely
secondary to prerenal azotemia.

# Hx of recurrent DVT: Patient is s/p IVC filter.  She was kept
on lovenox given she is at risk for DVT/PE from orthopedic
surgery and immnobilization. She will continue lovenox for 19
more days after d/c for a total of 4 weeks.

Chronic
# Hypertension: Blood pressure was well controlled during this
admission. Uptitrated Carvedilol.  Unable to add ACEI because of
soft pressures.

# Diabetes Type 2: Patient was kept on 10NPH in the morning and
8NPH at dinner consistent with home dose.  ISS was added as
well.  Metformin was held while in house.  She was discharged on
her home NPH dose and her home metformin.

# Hyperlipdiema: Continued atorvastain.

TRANSITIONAL ISSUES:
# Unable to start ACEI because it was not tolerated by blood
pressure->should be considered in setting of systolic CHF
# Would likely benefit from outpatient sleep study to further
define severity of OSA and need for nocturnal O2
# Will need vancomycin trough on sunday with goal between 15-20.
Results to be faxed to the Infectious Disease R.N.s at [**Hospital1 18**] fax
([**Telephone/Fax (1) 4591**]
# She will need weekly CBC, Creatinine, LFTs checked weekly and
faxed to the Infectious Disease R.N.s at [**Hospital1 18**] fax ([**Telephone/Fax (1) 4591**]




Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver[**Name (NI) 581**].
1. Atorvastatin 40 mg PO DAILY
2. Carvedilol 3.125 mg PO BID
3. MetFORMIN (Glucophage) 1000 mg PO BID
4. Senna 1 TAB PO DAILY:PRN Constipation
5. Docusate Sodium 100 mg PO DAILY Contipation
6. Multivitamins 1 TAB PO DAILY
7. Calcium 500 With D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit Oral Twice daily
8. Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q6H:PRN Pain
9. Aspirin 81 mg PO DAILY
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. NPH 10 Units Breakfast
NPH 8 Units Dinner
12. Bromday *NF* (bromfenac) 0.09 % OU daily
13. Doxycycline Hyclate 100 mg PO Q12H


Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Senna 1 TAB PO DAILY:PRN Constipation
3. Docusate Sodium 100 mg PO DAILY Contipation
4. MetFORMIN (Glucophage) 1000 mg PO BID
5. Multivitamins 1 TAB PO DAILY
6. Calcium 500 With D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit Oral Twice daily
7. Bromday *NF* (bromfenac) 0.09 % OU daily
8. Atorvastatin 40 mg PO DAILY
9. Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q6H:PRN Pain
10. Carvedilol 6.25 mg PO BID
Hold for BP<90 or HR<60.
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. Bisacodyl 10 mg PR HS:PRN Constipation
13. Clarithromycin 500 mg PO Q12H Duration: 9 Days
14. Enoxaparin Sodium 40 mg SC DAILY Duration: 19 Days
15. MetRONIDAZOLE (FLagyl) 500 mg PO BID Duration: 9 Days
16. Ondansetron 4 mg IV Q8H:PRN nausea
17. OxycoDONE (Immediate Release)  2.5-5 mg PO Q4H:PRN pain
Hold for excessive sedation.
RX *oxycodone 5 mg 0.5 (One half) capsule(s) by mouth q6hrs Disp
#*30 Capsule Refills:*0
18. Pantoprazole 40 mg PO Q12H
19. Vancomycin 750 mg IV Q 24H
20. NPH 10 Units Breakfast
NPH 8 Units Dinner
Insulin SC Sliding Scale using HUM Insulin


Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
Primary Diagnosis:  Prostethic Joint Infection

Secondary Diagnosis: Delirium, Type II Diabetes, systolic heart
failure, acute kidney injury, constipation


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair due to
surgical pain.


Discharge Instructions:
Dear Mrs. [**Known lastname 32737**], it was a pleasure taking care of you during
your hospitalization at [**Hospital1 18**].  You were admitted because you
had left hip pain which was draining pus from previous surgical
incision site. You were taken to the operating room where you
had drainage of the pus, removal of the hardware in the hip, and
antibiotic  placement in your hip. Tissue culture from your hip
grew bacteria similar to your past joint infections.  Infectious
disease specialist were also involved in your care who started
you on intravenous antibtioics.  In order to treat your
infection outside the hospital you had a PICC line placed for
antibiotic adminstration in your rehab/home.  You also had some
shortness of breath and chest pain during your stay.  However,
it was determined that you did not have a heart attack.  It was
noted that your heart did not squeeze as hard as it should and
we have started some new medications to treat this problem. we
recommend that you see a cardiologist to help manage this
problem.

You will need follow up with gastroenterology, cardiology,
infectious disease, and orthopedic doctors

Followup Instructions:
Department: [**Hospital3 249**]
When: WEDNESDAY [**2205-8-14**] at 10:40 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: ORTHOPEDICS
When: THURSDAY [**2205-8-15**] at 3:00 PM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: ORTHOPEDICS
When: TUESDAY [**2205-8-20**] at 10:40 AM
With: [**Year (4 digits) **] XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: ORTHOPEDICS
When: TUESDAY [**2205-8-20**] at 11:00 AM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Name: [**Last Name (LF) **],[**First Name3 (LF) **] P.
Department: Cardiology
Location: [**Hospital **] HOSPITAL
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 38978**]
Phone: [**Telephone/Fax (1) 77385**]
Appointment: Thursday [**2205-8-22**] 11:30am

Department: DIV. OF GASTROENTEROLOGY
When: THURSDAY [**2205-8-29**] at 1 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST     Best Parking: Main Garage


                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 8931**]
{'Infection and inflammatory reaction due to internal joint prosthesis,Metabolic encephalopathy,Hemorrhage complicating a procedure,Acute kidney failure, unspecified,Cellulitis and abscess of leg, except foot,Pyogenic arthritis, pelvic region and thigh,Hematemesis,Paralytic ileus,Pulmonary collapse,Chronic combined systolic and diastolic heart failure,Hip joint replacement,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Heart valve replaced by transplant,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Hyperpotassemia,Disorders of magnesium metabolism,Personal history of venous thrombosis and embolism,Obstructive sleep apnea (adult)(pediatric),Anemia of other chronic disease,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus,Constipation, unspecified,Synovitis and tenosynovitis, unspecified,Long-term (current) use of insulin,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Hypoxemia'}


You are an AI assistant analyzing clinical admission notes from the MIMIC III dataset. Your task is to map symptoms mentioned in the notes to a list of provided ICD-9 LONG_TEXT.



### Clinical text :
CHIEF COMPLAINT: Hip pain and drainage from prior surgical site

PRESENT ILLNESS: Patient is a 76yoF with multiple medical problems including CAD
s/p CABG, DM2, AS s/p bovine AVR, HTN, HLD and a left hip
hemiarthroplasty s/p infection/abx/washout/suppressive abx over
the last year, who was admitted [**7-29**] with a several week history
of left hip pain, which evolved to include edema, pain, and
finally mucopurulent drainage from her previous surgical
incision site. She underwent abscess drainage, washout, hardware
removal, and antibiotic spacer placement in the OR late on [**7-30**],
complicated by an intraoperative blood loss estimated at 1000cc.
She received 2 units PRBC. Tissue culture is having sparse coagu
negaitve sptaph. Last year tissue culture grew a coag negative
staph lugdunensis. Wound vac and drain were placed in the site.
ID is seeing her and has her on vancomycin 750mg Q12.
.
Post-operatively, she developed a dense delirium last night,
accusing staff of trying to kill her, pulling at IV lines and
her wound vac. Took a few swings at staff. Received IV haldol
0.5mg x 2 with good effect. QTC at 410. She has suffered post-op
delirium in previous surgeries, tends to wane in 2 days.
.
She has numerous metabolic derangements: hyperglycemic with AM
glucose 576 (though FSG shortly thereafter was 300 without any
interval insulin administered). Hyperkalemic with K=5.7 (no EKG
change). Hypomagnesemic. Tachycardic and dry-appearing with HCT
25ish. Complaining of some left hip pain.

MEDICAL HISTORY: - Coronary artery disease s/p 4 vessel CABG [**2190**]: LIMA to LAD,
reverse saphenous vein graft from aorta separately to ramus
intermedius, obtuse marginal, and posterolateral branch of RCA.
- Re-do sternotomy for AVR ([**1-6**]) for critical symptomatic
critical aortic stenosis with bovine AVR
- Carcinoid tumor of right middle lung lobe s/p resection.
- Diabetes mellitus, type 2
- Hypertension
- Hyperlipidemia
- Deep venous thrombosis, [**2176**], on Coumadin X6 months. Stopped
Coumadin, had another DVT,[**2176**] placed on Coumadin since, s/p IVC

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver[**Name (NI) 581**].
1. Atorvastatin 40 mg PO DAILY
2. Carvedilol 3.125 mg PO BID
3. MetFORMIN (Glucophage) 1000 mg PO BID
4. Senna 1 TAB PO DAILY:PRN Constipation
5. Docusate Sodium 100 mg PO DAILY Contipation
6. Multivitamins 1 TAB PO DAILY
7. Calcium 500 With D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit Oral Twice daily
8. Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q6H:PRN Pain
9. Aspirin 81 mg PO DAILY
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. NPH 10 Units Breakfast
NPH 8 Units Dinner
12. Bromday *NF* (bromfenac) 0.09 % OU daily
13. Doxycycline Hyclate 100 mg PO Q12H

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

PHYSICAL EXAM: Physical Exam on Tranfer to Medicine Team
Vitals: T: 100.1  99.1  96/53  85 16 97%RA
General: Alert able to converse, lying flat on bed.
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear,
pupils reactive to light bilaterally, EOMI.  Right pupil
slightly elongated
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally in the anterioc hest
wall, no wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, [**3-4**]
crescendo-decresedo murmur at LUSB radiating to carotids.
Abdomen: soft, non-tender, distended, no rebound tenderness or
guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin:  Surgical site appears clean without erythema.  Tender to
touch.  Wound wac in place.  Poor skin turgor.
Neuro:  Alert and oreinted x2 (name and place).  Able to have
conversation.  CNII-XII intack.
.
Discharged Physical Exam
97.9 96/54  64  18  100% on 2L
Gen: NAD
CV: RRR with systolic murmur ([**3-4**]) radiating to carotids
Resp: CTAB no w/r/r
Abd: mild distention, withough ttp or guarding, improved from
prior
Extr: bandaged ulcer on left heel, left hip wound bandage c/d/i
with ttp but no visible erythema, induration, or hematoma
Neuro: A&Ox2, appropriate, grossly nonfocal

FAMILY HISTORY: Denies any family history of blood clot.  REports vague family
history o heart attacks.

SOCIAL HISTORY: Patient is originally from [**Country 5881**].  Moved to U.S long time ago.
Currently live with husband and son in [**Name (NI) 77913**] plane.  Denies any
tobacco, alcohol and drugs. 

### Response:
{'Infection and inflammatory reaction due to internal joint prosthesis,Metabolic encephalopathy,Hemorrhage complicating a procedure,Acute kidney failure, unspecified,Cellulitis and abscess of leg, except foot,Pyogenic arthritis, pelvic region and thigh,Hematemesis,Paralytic ileus,Pulmonary collapse,Chronic combined systolic and diastolic heart failure,Hip joint replacement,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Heart valve replaced by transplant,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Hyperpotassemia,Disorders of magnesium metabolism,Personal history of venous thrombosis and embolism,Obstructive sleep apnea (adult)(pediatric),Anemia of other chronic disease,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus,Constipation, unspecified,Synovitis and tenosynovitis, unspecified,Long-term (current) use of insulin,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Hypoxemia'}
