CHIEF COMPLAINT: Right lower extremity wound dehiscence

PRESENT ILLNESS: On admission ([**2190-11-2**], by Plastic Surgery): Mrs. [**Known lastname **] is an 88
year old woman with history of right femur/tibial plateau
fracture ([**2173**]) complicated by multiple revisions/repairs, most
recently with right total knee arthroplasty on [**9-27**],
complicated by wound dehiscence, who was now admitted for right
knee gastroc muscle flap reconstruction.

MEDICAL HISTORY: - Hypertension
- Hyperlipidemia
- Hypothyroidism
- Thyroid nodules
- Glaucoma
- History of bilateral femur fracture and pelvic fracture after
motor vehicle collision ([**2173**])

MEDICATION ON ADMISSION: -alendronate 70 mg by mouth weekly
-atorvastatin 10 mg by mouth once a day
-cephalexin 500 mg by mouth four times a day take with food
-diltiazem HCl 90 mg Extended Release by mouth once a day
-hydrocodone-acetaminophen 5 mg-500 mg by mouth at night as
needed for pain
-latanoprost eye drops
-levothyroxine 75 mcg by mouth once a day
-aspirin 81 mg by mouth once a day
-B complex vitamins daily
-calcium/vitamin D3 by mouth twice a day
-cholecalciferol 1,000 unit by mouth once a day
-hydrochlorothiazide 50 mg by mouth once a day
-multivitamin by mouth once a day

ALLERGIES: Iodine-Iodine Containing

PHYSICAL EXAM: Discharge Exam:
96.8, 115/47, 82, 18, 98%RA
GA: AOx3, elderly woman resting comfortably in bed in NAD
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: RRR S1/S2 heard. no murmurs/gallops/rubs.
Pulm:  bronchial breath sounds bilaterally, worse at left base.
No wheezes or rales. somewhat increased rate of breathing, good
resp effort
Abd: with pink healthy looking ostomy in LLQ, and large linear
stapled scar down midline abdomen, soft, NT, ND, +BS. no g/rt.
neg HSM.
GU: foley in place, minimal dark urine
Extremities: wwp, 1+ edema bilaterally. PTs 2+.
Neuro/Psych: CNs II-XII grossly intact. sensation intact to LT
in toes bilaterally, though decreased on the right

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: She is a retired secretary and does not currently smoke or
drink.
Disruption of internal operation (surgical) wound,Acute vascular insufficiency of intestine,Unspecified septicemia,Severe sepsis,Septic shock,Unspecified pleural effusion,Other ascites,Hyposmolality and/or hyponatremia,Acute kidney failure, unspecified,Other digestive system complications,Paralytic ileus,Precipitous drop in hematocrit,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Unspecified acquired hypothyroidism,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Unspecified glaucoma,Encounter for change or removal of surgical wound dressing,Accidental cut, puncture, perforation or hemorrhage during surgical operation,Accidents occurring in residential institution,Peritoneal adhesions (postoperative) (postinfection),Retention of urine, unspecified,Anemia of other chronic disease,Osteoporosis, unspecified,Altered mental status
Disrup internal op wound,Ac vasc insuff intestine,Septicemia NOS,Severe sepsis,Septic shock,Pleural effusion NOS,Ascites NEC,Hyposmolality,Acute kidney failure NOS,Oth digestv system comp,Paralytic ileus,Drop, hematocrit, precip,Abn react-artif implant,Hypothyroidism NOS,Hyperlipidemia NEC/NOS,Hypertension NOS,Glaucoma NOS,Attn rem surg dressing,Acc cut/hem in surgery,Accid in resident instit,Peritoneal adhesions,Retention urine NOS,Anemia-other chronic dis,Osteoporosis NOS,Altered mental status
Admission Date:  [**2190-11-2**]              Discharge Date:   [**2190-11-21**]


Service: MEDICINE

Allergies:
Iodine-Iodine Containing

Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Right lower extremity wound dehiscence

Major Surgical or Invasive Procedure:
[**2190-11-4**] Right lower extremity gastrocnemius flap reconstruction
[**2190-11-8**] Exploratory laparotomy with left hemicolectomy and
splenorrhaphy with transverse end-colostomy and Hartmann's
pouch, for ischemic colon

History of Present Illness:
On admission ([**2190-11-2**], by Plastic Surgery): Mrs. [**Known lastname **] is an 88
year old woman with history of right femur/tibial plateau
fracture ([**2173**]) complicated by multiple revisions/repairs, most
recently with right total knee arthroplasty on [**9-27**],
complicated by wound dehiscence, who was now admitted for right
knee gastroc muscle flap reconstruction.

On transfer to medicine ([**2190-11-18**]), 88F with HTN,
hyperlipidemia, and hypothyroidism, s/p TKR [**2190-9-27**], who was
initially admitted on [**2190-11-2**] for non-healing right knee wound.
She underwent gastrocnemius flap reconstruction, with
split-thickness skin graft [**2190-11-4**]. Her post-operative course
was complicated by septic shock (thought initially to be from
C.diff given high WBC and daughter with h/o recent c.diff) from
necrotic splenic flexure, for which she underwent resection of
the splenic flexure with colostomy on [**2190-11-8**]. This was
complicated by splenic laceration which was repaired
intraoperatively. Given sepsis, patient was started on
flagyl/vanc/cefe/cipro which were peeled off on [**11-12**] (cefepime
d/c'd [**11-8**]). The patient had return of bowel function on [**11-13**],
at which point her diet was advanced. She had persistent
leukocytosis, which was investigated with CT abdomen/pelvis on
[**11-15**]. This showed no evidence of intraabdominal abscess. U/A
showed WBC 8, with negative nitrates. Of note, the CT
abdomen/pelvis also showed ascites and anasarca. Currently, the
patient is tachypneic to about 30 but not dyspneic, O2 sat
95%/RA. Exam notable for bronchial breath sounds at left base
and trace bilateral LE edema. CXR shows large left pleural
effusion with smaller right pleural effusion and patient is
complaining of persistent cough.
.
Upon transfer, vitals were 97.3, 139/60, 88, 22, 95%RA. Looking
comfortable, breathing slightly fast but denies any dyspnea.
States knee pain is well controlled. Bothered only by persistent
cough. Denies recent fevers, chills, abdominal pain, changes in
bowel movements, subjective dyspnea.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.

Past Medical History:
- Hypertension
- Hyperlipidemia
- Hypothyroidism
- Thyroid nodules
- Glaucoma
- History of bilateral femur fracture and pelvic fracture after
motor vehicle collision ([**2173**])


Social History:
She is a retired secretary and does not currently smoke or
drink.

Family History:
Non-contributory

Physical Exam:
Discharge Exam:
96.8, 115/47, 82, 18, 98%RA
GA: AOx3, elderly woman resting comfortably in bed in NAD
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: RRR S1/S2 heard. no murmurs/gallops/rubs.
Pulm:  bronchial breath sounds bilaterally, worse at left base.
No wheezes or rales. somewhat increased rate of breathing, good
resp effort
Abd: with pink healthy looking ostomy in LLQ, and large linear
stapled scar down midline abdomen, soft, NT, ND, +BS. no g/rt.
neg HSM.
GU: foley in place, minimal dark urine
Extremities: wwp, 1+ edema bilaterally. PTs 2+.
Neuro/Psych: CNs II-XII grossly intact. sensation intact to LT
in toes bilaterally, though decreased on the right


Pertinent Results:
Admission Labs:
[**2190-11-2**] 04:10PM BLOOD WBC-9.7 RBC-3.71* Hgb-11.0* Hct-33.4*
MCV-90 MCH-29.5 MCHC-32.8 RDW-16.2* Plt Ct-395
[**2190-11-2**] 04:10PM BLOOD PT-10.4 PTT-30.2 INR(PT)-1.0
[**2190-11-2**] 04:10PM BLOOD Glucose-98 UreaN-16 Creat-0.8 Na-131*
K-4.6 Cl-95* HCO3-29 AnGap-12
[**2190-11-2**] 04:10PM BLOOD Albumin-4.1 Calcium-9.1 Phos-4.1 Mg-2.0
Iron-44
[**2190-11-2**] 04:10PM BLOOD calTIBC-311 Ferritn-452* TRF-239

Labs on [**11-8**] (day of abdominal surgery):
[**2190-11-8**] 04:23AM BLOOD WBC-19.0* RBC-3.47* Hgb-10.2* Hct-31.0*
MCV-89 MCH-29.4 MCHC-32.9 RDW-15.5 Plt Ct-365
[**2190-11-8**] 04:23AM BLOOD Neuts-77* Bands-3 Lymphs-8* Monos-12*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2190-11-8**] 05:12PM BLOOD PT-13.9* PTT-50.2* INR(PT)-1.3*
[**2190-11-8**] 09:46AM BLOOD Glucose-135* UreaN-36* Creat-1.9* Na-130*
K-5.8* Cl-98 HCO3-15* AnGap-23*
[**2190-11-8**] 04:23AM BLOOD Calcium-9.9 Phos-6.1* Mg-3.9*
[**2190-11-8**] 01:43PM BLOOD Type-ART pO2-264* pCO2-32* pH-7.42
calTCO2-21 Base XS--2 Intubat-INTUBATED
[**2190-11-8**] 04:39AM BLOOD Lactate-4.0*
[**2190-11-8**] 01:43PM BLOOD Glucose-126* Lactate-3.2* Na-128* K-4.2
Cl-101
[**2190-11-8**] 03:30PM BLOOD Glucose-109* Lactate-2.5* Na-129*
[**2190-11-8**] 04:37PM BLOOD Glucose-118* Lactate-2.6* Na-129*
[**2190-11-8**] 08:29PM BLOOD Lactate-3.2*
[**2190-11-8**] 01:43PM BLOOD Hgb-8.0* calcHCT-24
[**2190-11-8**] 03:30PM BLOOD freeCa-1.09*

Thoracentesis:
[**2190-11-18**] 10:16PM PLEURAL WBC-3100* RBC-5250* Polys-76* Lymphs-2*
Monos-0 Macro-22*
[**2190-11-18**] 10:16PM PLEURAL TotProt-2.0 Glucose-127 LD(LDH)-312
Amylase-60 Cholest-38

Discharge Labs:
[**2190-11-21**] 05:50AM BLOOD WBC-15.3* RBC-3.07* Hgb-8.4* Hct-27.2*
MCV-89 MCH-27.5 MCHC-31.1 RDW-15.7* Plt Ct-680*
[**2190-11-21**] 05:50AM BLOOD Glucose-84 UreaN-12 Creat-0.5 Na-130*
K-4.5 Cl-95* HCO3-30 AnGap-10
[**2190-11-19**] 05:03AM BLOOD ALT-7 AST-18 LD(LDH)-189 AlkPhos-45
TotBili-0.3
[**2190-11-21**] 05:50AM BLOOD Calcium-7.4* Phos-2.7 Mg-2.3

Microbiology: [**2190-11-18**] blood cultures pending. previous blood,
urine, c.diff cultures negative.

Imagaing:
[**2190-11-7**] ECG: rate 88, Sinus rhythm. Delayed precordial R wave
transition as recorded on [**2190-11-12**] without diagnostic interim
change.
[**2190-11-7**] CXR: Given the decrease in lung volumes, bibasilar
opacification is more likely atelectasis than pneumonia. Upper
lungs are clear. Pleural effusion is minimal if any. Heart size
normal.
[**2190-11-8**] CXR: One supine portable AP view of the chest. Low lung
volumes. The left lower lobe opacity likely represents
atelectasis. There is a small left pleural effusion, if any. No
opacities concerning for pneumonia. Heart size is difficult to
evaluate, but likely normal. Mediastinal and hilar contours are
normal. No pneumothorax.
[**2190-11-9**] ECHO (prelim): Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Overall
left ventricular systolic function is normal (LVEF>55%). A
mid-cavitary gradient is identified. Right ventricular chamber
size and free wall motion are normal. No mitral regurgitation is
seen. No aortic stenosis or regurgitation. IMPRESSION:
Suboptimal image quality. Preserved biventricular function.
[**2190-11-9**] CXR: The ET tube sits 5 cm above the carina. The
endogastric tube side port tip sits well below the GE junction.
A right IJ central line tip sits in the lower SVC. The heart
size is within normal limits. The mediastinal contours
demonstrate calcified atherosclerotic disease of the aortic
knob.  There is a small to moderate left pleural effusion with
associated atelectasis. There is no pneumothorax. Severe
degenerative changes are seen in the left glenohumeral joint.
IMPRESSION: 1. Lines and tubes in place. 2. Small to moderate
left pleural effusion with associated atelectasis.
[**2190-11-11**] CXR: 1. Left pleural effusion appears unchanged and
right pleural effusion is likely increased. Assessment is
slightly limited due to different positioning of patient.  2.
Mild pulmonary vascular congestion.
[**2190-11-11**] LENI: No evidence for DVT.
[**2190-11-12**] KUB: Air filled dilated loops of large and small bowel
are most
consistent with an ileus.
[**2190-11-15**] CT abd: 1. Splenorrhaphy, with mild perisplenic
hemorrhage and Surgicel packing. 2. Small pleural effusions,
mild ascites, and anasarca. No evidence of intra-abdominal
abscess, within limitations of a non-contrast study. 3. Left
colectomy and transverse colostomy, without complications.
[**2190-11-16**] There has been interval removal of the right IJ central
venous
catheter tip. The heart size is large. The mediastinal and hilar
contours
are unchanged. There is a moderate left pleural effusion with
underlying
atelectasis. Mild right basal atelectasis with a small pleural
effusion is
also present. IMPRESSION: Bilateral pleural effusions, left
greater than right, with associated atelectasis.
[**2190-11-18**] CXR: Assessment of the heart size is limited by the
large left and small right pleural effusions with associated
atelectasis; an additional component of pneumonia, particularly
on the left cannot be excluded. Within that limitation, the
heart size likely continues to be enlarged. There is no fluid
overload. There is no pneumothorax.
[**2190-11-18**] Comparison is made with prior study performed the same
day earlier. Moderate left pleural effusion has markedly
decreased. Adjacent atelectases have decreased. There is a new
left basal pigtail catheter. There is no evident pneumothorax.
mild-to-moderate right pleural effusion with adjacent
atelectasis, is unchanged. Cardiomediastinal contours are
partially obscured by pleuroparenchymal abnormalities.
.


Brief Hospital Course:
Hopsital course: Patient admitted to plastic surgery service
[**11-2**] in anticipation of gastrocnemius flap to RLE chronic wound
dehiscence.  Preoperative workup completed 12/6-7 uneventfull
and patient taken to OR for flap procedure [**11-4**].  Tolerated
procedure well and was transferred to CC6 for further
management.  Recovery proceeded uneventfully until [**11-7**] when
patient demonstrated altered mental status, nausea, vomiting and
increasing abdominal distention.  Transferred to MICU [**11-8**] for
these symptoms and surgery consult obtained for concern of
altered mental status and worsening abdominal distention (See
ACS Consult note for further details).  Patient taken to OR by
ACS for colonoscopy with assistance of GI given concern for
sigmoid/cecal volvulus.  Colonoscopy failed to demonstrate
volvulus and exploratory laparotomy was undertaken which
revealed necrotic splenic flexure.  Left colectomy was performed
with mid transverse colon ostomy and long Hartmann's pouch.
Patient tolerated procedure well and was brought to TSICU for
further management under ACS service. Post-operatively, the
patient was brought to the TSICU intubated/sedated.  Patient
extubated successfully [**11-9**] and IV pain regimen initiated prn.
This was carried out with good effect and adequate pain control.
 When tolerating oral intake, the patient was transitioned to
oral pain medications. She was then transfered to the floor on
[**11-11**]. She had urinary retention issues and a foley was placed
which stayed in throughout hospital course as she failed 2
voiding trials. She was given methylnatrexone x1 and was started
on a regular diet. However, she had some emesis and a KUB showed
ileus. She began to produce stool in her ostomy on [**11-13**] and her
diet was advanced to regular which she tolerated well. Her WBC
began to rise so a CT abd/pelvis was performed to r/o abscess
and no intra-abdominal abscesses were identified. She had a
chest x-ray on [**11-16**] which showed bilateral pleural effusions.
She continued to have a cough and medicine was consulted to
evaluate. Thoracentesis was performed and 1.5 liters of
exudative fluid was drained (LDH 312, WBC 3100). Pigtail
catheter was placed which drained minimal serosangeous fluid.
This was thought to be related to the abdominal surgery and
resultant inflammation of the LUQ. Her WBC dropped from 20.8 to
14.5 with the thoracentesis.  Patient remains feeling well
without and is without fevers off all antibiotics.
.
Pulmonary: Pulmonary toilet including incentive spirometry and
early ambulation were encouraged.  The patient was stable from a
pulmonary standpoint; vital signs were routinely monitored. CXR
on [**2190-11-16**] showed bilateral pleural effusions L>R. She
continued to have a cough and will be transferred to the
medicine service for further evaluation and management.
Thoracentesis was performed and 1.5L transudative fluid was
drained, effectively resolving her cough. WBC dropped from 20.8
to 14.5 with the procedure. Patient remained tachypneic, and
given her vascular congestion on xray, she was administered
lasix with good urinary output. No antibiotics were
administered, as there was no clear infection to be treated
(afebrile, feeling well off antibiotics).  Pleural fluid studies
were consistent with effusion secondary to adrenergic state
likley [**12-30**] splenic flexure infarct and splenic laceration.  Rpt
chest X-ray showed improving pleural effusion s/p thoracentesis
and her lung exam continued to improve until the day of
discharge.
.
GI/GU: Post-operatively, the patient was given IV fluids until
tolerating oral intake. Her diet was advanced to sips [**11-10**] and
regular diet [**11-11**].  Patient demonstrated some nausea w emesis
12/15PM and was made NPO.  Advanced from sips to clears [**11-13**]
which was tolerated well. Given methylnaltrexone [**11-12**].  Had gas
and stool in ostomy [**11-13**].  She was also started on a bowel
regimen to encourage bowel movement. She was started on a
regular diet on [**11-13**] which she continued to tolerate well.
.
ID: Post-operatively, the patient was started on IV cefazolin,
then switched to PO cephalexin on POD#2. The patient's
temperature was closely watched for signs of infection. Her WBC
began to slowly uptrend, for which a clear source was not
identified. She was given roughly 4 days of
cipro/flagyl/vanc/cefepime, all of which were discontinued
around [**11-12**]. U/A blood, urine, and c.diff was negative, her
graft site did not appear infected, CT ab/pelvis on [**2190-11-15**] was
negative for any intra-abdominal abscess, and CXR was signficant
only for bilateral pleural effusions L>R. No antibiotics were
administered as patient did not have a clear source of
infection.  All culture data was negative, she continued to be
afebrile and VS were stable.  Her WBC was fluctuating and also
with a reactive thrombocytosis.  Given no objective signs of
infection antibiotics were never started.
.
# Reactive thrombocytosis: likely in relation to inflammatory
state from necrotic bowel, recent operations and pleural
effusions irritating the pleural lining.  This will need to be
trended with repeat CBC within 1 week.
.
# Hyponatremia: Patient admitted with Na+ 129, corrected to 139,
now 129. Thought to be SIADH vs. hypervolemic hyponatremia as
patient appears somewhat overloaded on exam (1+edema with
ascites and large pleural effusion). Serum osm is low (262),
however urine lytes suggested patient was prerenal. Given IV
lasix for fluid overload and sodium initially trended up to 130,
but then decreased to 126.  There was likely a combine picture.
Lasix were stopped and the patient equilibrated to 130 at time
of discharge.  She will need repeat lab work within 1 week to
re-evaluate Na levels.
.
# Urinary Retention: Patient failed trial of voiding twice while
inpatient.  Urology was consulted and they felt that given
recent operations and shock likel state it may take some time
for her bladder to regain function.  She will be discharged with
her Foley in place and follow up with urology within 1-2 weeks
for another trial of voiding.
.
#. [**Last Name (un) **]- Patient had transient [**Last Name (un) **] to 1.9 on [**11-8**], when she was
septic and necrosing her bowel. Creatinine improved with fluids
and was likely prerenal in etiology given her septic physiology.

.
# Anemia: remained at basline over admission (28-31). No signs
of bleeding. Iron borderline low and ferritin high, MCV normal
(89). Possibly anemia of chronic disease. Hct trended.
.
#. HTN: continued HCTZ, lisinopril, diltiazem, ASA
.
#. HL: continued atorvastatin, ASA
.
#. Hypothyroidism: continued levothyroxine
.
#. Glaucoma: continued latanoprost, dorzolamide
.
Transitional Issues:
- At the time of discharge on POD 15, the patient was doing
well, afebrile with stable vital signs, tolerating a regular
diet, ambulating, with foley in place, and pain well controlled.
Patient failed 2 voiding trials, and is being discharged home
with foley in place.  She will have oruology follow up within
1-2weeks of discharge for voiding trial.
- Will also need stitches removed on [**2190-11-26**]
- will need repeat CBC and chem-7 in 1 week to evaluate
leukocytosis, reactive thrombocytosis and sodium level

Medications on Admission:
-alendronate 70 mg by mouth weekly
-atorvastatin 10 mg by mouth once a day
-cephalexin 500 mg by mouth four times a day take with food
-diltiazem HCl 90 mg Extended Release by mouth once a day
-hydrocodone-acetaminophen 5 mg-500 mg by mouth at night as
needed for pain
-latanoprost eye drops
-levothyroxine 75 mcg by mouth once a day
-aspirin 81 mg by mouth once a day
-B complex vitamins daily
-calcium/vitamin D3 by mouth twice a day
-cholecalciferol 1,000 unit by mouth once a day
-hydrochlorothiazide 50 mg by mouth once a day
-multivitamin by mouth once a day

Discharge Medications:
1. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. diltiazem HCl 90 mg Capsule,Extended Release 12 hr Sig: One
(1) Capsule,Extended Release 12 hr PO once a day.
3. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
4. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Vitamin B Complex     Tablet Sig: One (1) Tablet PO once a
day.
7. Calcium 600 + D(3) 600 mg(1,500mg) -400 unit Tablet Sig: One
(1) Tablet PO twice a day.
8. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
9. hydrochlorothiazide 50 mg Tablet Sig: One (1) Tablet PO once
a day.
10. multivitamin     Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
15. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO every four (4)
hours as needed for pain: Hold for RR<12, Sedation.
16. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 100**] Senior Life [**Location (un) 2312**]

Discharge Diagnosis:
Primary Diagnosis:
- Right TKR would dehiscence
- Infarcted large bowel at splenic flexure
- Partially infarcted spleen
- Right sympathetic pleural effusion
- Urinary retention
- Anemia of chronic disease
- Reactive leukocytosis
- Hyponatremia

Surgical Procedures:
- Right lower extremity gastrocnemius flap reconstruction
- Exploratory laparotomy with left hemicolectomy and
splenorrhaphy with transverse end-colostomy and Hartmann's pouch

- Right thoracentesis and pig-tail catheter placement
Secondary Dignosis:
- bilateral femur fracture s/p periprosthetic femur fracture

Secondary diagnosis:
- Traumatic pelvic and bilateral femur fractures
- Osteoporosis
- Hypothyroidism
- Hyperlipidemia
- Hypertension
- Hypothyroidism
- Glaucoma


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


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

It was a pleasure taking care of you at [**Hospital1 827**]. You were initially admitted for a nonhealing
wound for which you had a skin flap reconstruction. This healed
well, however you developed poor perfusion to your bowel and had
to have a colon resection with a colostomy (Hartmann's pouch).
Part of your spleen was additionally resected.  You remained in
the hospital for some time as you had an elevated white blood
count (usually a sign of infection) and fluid around your lungs
that was making you breathe faster than normal.  The fluid was
drained from around your left lung and your white blood count
began to return to normal and your breathing improved.  You are
safe for discharge to [**Hospital **] rehab for further care..
.
The following medications were started:
Docusate 100mg by mouth twice a day
senna 1 tab by mouth twice a day
tylenol 650mg by mouth three times a day
tamsulosin 0.4mg by mouth at bedtime
trazadone 25mg by mouth as needed for sleep.

Followup Instructions:
Please call the number below to schedule an appt with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 1022**] in 2 weeks.
[**Hospital1 18**] Division of Plastic Surgery
[**Hospital Unit Name 11610**]
[**Location (un) 86**], [**Numeric Identifier 11611**]
Phone: [**Telephone/Fax (1) 4652**]
Fax: [**Telephone/Fax (1) 11612**]
.
Please call the number below to schedule an appt with Dr. [**Last Name (STitle) **]
in 2 weeks.
[**Hospital Unit Name 11613**]
[**Location (un) 86**], [**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 6429**]
Fax: [**Telephone/Fax (1) 11614**]
.
Urology appointment:NEEDED
Please arrange new physician appointment with the Urology
Department @ [**Hospital1 69**] within 2 weeks
from your discharge from the hospital
Phone: [**Telephone/Fax (1) 164**]
.
Please call your Primary Care Doctor - Dr. [**Last Name (STitle) 5482**] at
[**Telephone/Fax (1) 5483**] to schedule an appt when you are discharged from
[**Hospital 100**] Rehab.
{'Disruption of internal operation (surgical) wound,Acute vascular insufficiency of intestine,Unspecified septicemia,Severe sepsis,Septic shock,Unspecified pleural effusion,Other ascites,Hyposmolality and/or hyponatremia,Acute kidney failure, unspecified,Other digestive system complications,Paralytic ileus,Precipitous drop in hematocrit,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Unspecified acquired hypothyroidism,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Unspecified glaucoma,Encounter for change or removal of surgical wound dressing,Accidental cut, puncture, perforation or hemorrhage during surgical operation,Accidents occurring in residential institution,Peritoneal adhesions (postoperative) (postinfection),Retention of urine, unspecified,Anemia of other chronic disease,Osteoporosis, unspecified,Altered mental status'}


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: Right lower extremity wound dehiscence

PRESENT ILLNESS: On admission ([**2190-11-2**], by Plastic Surgery): Mrs. [**Known lastname **] is an 88
year old woman with history of right femur/tibial plateau
fracture ([**2173**]) complicated by multiple revisions/repairs, most
recently with right total knee arthroplasty on [**9-27**],
complicated by wound dehiscence, who was now admitted for right
knee gastroc muscle flap reconstruction.

MEDICAL HISTORY: - Hypertension
- Hyperlipidemia
- Hypothyroidism
- Thyroid nodules
- Glaucoma
- History of bilateral femur fracture and pelvic fracture after
motor vehicle collision ([**2173**])

MEDICATION ON ADMISSION: -alendronate 70 mg by mouth weekly
-atorvastatin 10 mg by mouth once a day
-cephalexin 500 mg by mouth four times a day take with food
-diltiazem HCl 90 mg Extended Release by mouth once a day
-hydrocodone-acetaminophen 5 mg-500 mg by mouth at night as
needed for pain
-latanoprost eye drops
-levothyroxine 75 mcg by mouth once a day
-aspirin 81 mg by mouth once a day
-B complex vitamins daily
-calcium/vitamin D3 by mouth twice a day
-cholecalciferol 1,000 unit by mouth once a day
-hydrochlorothiazide 50 mg by mouth once a day
-multivitamin by mouth once a day

ALLERGIES: Iodine-Iodine Containing

PHYSICAL EXAM: Discharge Exam:
96.8, 115/47, 82, 18, 98%RA
GA: AOx3, elderly woman resting comfortably in bed in NAD
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: RRR S1/S2 heard. no murmurs/gallops/rubs.
Pulm:  bronchial breath sounds bilaterally, worse at left base.
No wheezes or rales. somewhat increased rate of breathing, good
resp effort
Abd: with pink healthy looking ostomy in LLQ, and large linear
stapled scar down midline abdomen, soft, NT, ND, +BS. no g/rt.
neg HSM.
GU: foley in place, minimal dark urine
Extremities: wwp, 1+ edema bilaterally. PTs 2+.
Neuro/Psych: CNs II-XII grossly intact. sensation intact to LT
in toes bilaterally, though decreased on the right

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: She is a retired secretary and does not currently smoke or
drink. 

### Response:
{'Disruption of internal operation (surgical) wound,Acute vascular insufficiency of intestine,Unspecified septicemia,Severe sepsis,Septic shock,Unspecified pleural effusion,Other ascites,Hyposmolality and/or hyponatremia,Acute kidney failure, unspecified,Other digestive system complications,Paralytic ileus,Precipitous drop in hematocrit,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Unspecified acquired hypothyroidism,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Unspecified glaucoma,Encounter for change or removal of surgical wound dressing,Accidental cut, puncture, perforation or hemorrhage during surgical operation,Accidents occurring in residential institution,Peritoneal adhesions (postoperative) (postinfection),Retention of urine, unspecified,Anemia of other chronic disease,Osteoporosis, unspecified,Altered mental status'}
