CHIEF COMPLAINT: Cellulitis with RLE swelling and erythema

PRESENT ILLNESS: 88 yoM with recent history of Right sided groin lymphadenectomy
for metatatic melanoma.  Patient has had difficulty with seroma
and was recently discharged on [**3-22**] home on augmentin after IR
drainage of seroma located just right of
the pudendum.  He was at home, doing relatively well until this
morning when he noted progressive swelling of his right upper
leg / thigh area.  It also was more erythematous and he called
Dr. [**Last Name (STitle) 519**] who asked him to report to the ED.

MEDICAL HISTORY: PMH:
 - metastatic squamous cell carcinoma (unknown primary lesion)
 - CAD s/p MI (remote), EF 50%
 - Aortic stenosis
 - Afib on coumadin
 - HTN
 - BPH
 - L retinal artery occlusion in [**2134**] (secondary to emoblic
disease)

MEDICATION ON ADMISSION: digoxin 250 q OTHER day, ditropan 5'', lasix 20', vicodin 5/500
q6h prn, lisinopril 10', metoprolol 25'', nitroglycerin prn
chest pain, simvastatin 40', flomax 0.4', travatan 0.004% 1 drop
in LEFT eye daily, coumadin (5' except 7.5' Wed), vit B12, ASA
81', colace 100'', vit D, augmentin, coumadin

ALLERGIES: Levsin / Shellfish

PHYSICAL EXAM: EXAM:
Vitals: 97.6  56  99/54  22  97RA
AAO x 3, NAD
RRR, [**4-3**] holosystolic murmur noted on auscultation
CTA B/L no RRW appreciated
soft, NT, ND.  Erythema form RLE extends minimally in to RLQ.
RLE: 4.8 x 1.5 x 4.2 cm and located in the anterior thigh.
Dopplerable signals x 2
LLE: no CCE, palpable pulses throughout.

FAMILY HISTORY: CAD in multiple family members

SOCIAL HISTORY: nonsmoker, lives with wife, no EtOH
Infected postoperative seroma,Subendocardial infarction, initial episode of care,Cellulitis and abscess of leg, except foot,Secondary and unspecified malignant neoplasm of lymph nodes of inguinal region and lower limb,Acute kidney failure, unspecified,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Unspecified essential hypertension,Atrial fibrillation,Aortic valve disorders,Hypotension, unspecified,Coronary atherosclerosis of native coronary artery,Diarrhea,Long-term (current) use of anticoagulants,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Personal history of other malignant neoplasm of skin
Infected postop seroma,Subendo infarct, initial,Cellulitis of leg,Mal neo lymph-inguin/leg,Acute kidney failure NOS,Abn react-surg proc NEC,Hypertension NOS,Atrial fibrillation,Aortic valve disorder,Hypotension NOS,Crnry athrscl natve vssl,Diarrhea,Long-term use anticoagul,Pseudomonas infect NOS,Hx-skin malignancy NEC
Admission Date:  [**2146-3-26**]              Discharge Date:   [**2146-4-8**]


Service: SURGERY

Allergies:
Levsin / Shellfish

Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Cellulitis with RLE swelling and erythema


Major Surgical or Invasive Procedure:
I&D R groin [**2146-4-1**]
picc line x 2
IR guided aspiration [**3-27**] and [**3-29**]


History of Present Illness:
88 yoM with recent history of Right sided groin lymphadenectomy
for metatatic melanoma.  Patient has had difficulty with seroma
and was recently discharged on [**3-22**] home on augmentin after IR
drainage of seroma located just right of
the pudendum.  He was at home, doing relatively well until this
morning when he noted progressive swelling of his right upper
leg / thigh area.  It also was more erythematous and he called
Dr. [**Last Name (STitle) 519**] who asked him to report to the ED.

Here he is in no apparent distress, afebrile, but has diffuse
swelling of the entire right leg, markedly larger than the left
leg, and erythema which is blanching throughout the anterior
thigh.  He is not tender, but there is diffuse edema.  His drain
is putting out minimal fluid which is serosanguinous, and
flushes with minimal difficulty.  His incision sites are intact.
 He
underwent RLE ultrasound to evaluate for DVT which was negative
but could not evaluate the veins well in the calf.  There was,
of note, a 4.8 x 1.5 x 4.2 cm and located in the anterior thigh.


Past Medical History:
PMH:
 - metastatic squamous cell carcinoma (unknown primary lesion)
 - CAD s/p MI (remote), EF 50%
 - Aortic stenosis
 - Afib on coumadin
 - HTN
 - BPH
 - L retinal artery occlusion in [**2134**] (secondary to emoblic
disease)

PSH:
 - R inguinal lymph node dissection ([**2146-2-10**])
 - L inguinal hernia repair ([**2135**])


Social History:
nonsmoker, lives with wife, no EtOH


Family History:
CAD in multiple family members


Physical Exam:
EXAM:
Vitals: 97.6  56  99/54  22  97RA
AAO x 3, NAD
RRR, [**4-3**] holosystolic murmur noted on auscultation
CTA B/L no RRW appreciated
soft, NT, ND.  Erythema form RLE extends minimally in to RLQ.
RLE: 4.8 x 1.5 x 4.2 cm and located in the anterior thigh.
Dopplerable signals x 2
LLE: no CCE, palpable pulses throughout.

Pertinent Results:
[**2146-3-26**] 06:20PM BLOOD WBC-14.7*# RBC-3.33* Hgb-10.5* Hct-31.7*
MCV-95 MCH-31.5 MCHC-33.1 RDW-13.3 Plt Ct-206
[**2146-3-27**] 07:10AM BLOOD WBC-19.2* RBC-3.01* Hgb-9.2* Hct-28.5*
MCV-95 MCH-30.5 MCHC-32.2 RDW-13.0 Plt Ct-169
[**2146-3-28**] 06:15AM BLOOD WBC-18.3* RBC-2.72* Hgb-8.5* Hct-25.5*
MCV-94 MCH-31.4 MCHC-33.5 RDW-13.2 Plt Ct-159
[**2146-3-29**] 05:22AM BLOOD WBC-13.7* RBC-3.19* Hgb-9.9* Hct-28.6*
MCV-90 MCH-31.1 MCHC-34.6 RDW-13.7 Plt Ct-176
[**2146-4-2**] 04:51PM BLOOD WBC-10.4 RBC-2.50* Hgb-7.7* Hct-23.3*
MCV-93 MCH-31.0 MCHC-33.3 RDW-13.3 Plt Ct-230
[**2146-4-6**] 05:35AM BLOOD WBC-10.4 RBC-3.74* Hgb-11.4* Hct-33.8*
MCV-90 MCH-30.4 MCHC-33.6 RDW-14.2 Plt Ct-263
[**2146-3-26**] 06:20PM BLOOD PT-22.8* PTT-31.6 INR(PT)-2.1*
[**2146-3-27**] 07:10AM BLOOD PT-25.2* PTT-40.6* INR(PT)-2.4*
[**2146-3-31**] 05:58AM BLOOD PT-25.4* PTT-39.1* INR(PT)-2.4*
[**2146-4-3**] 05:34AM BLOOD PT-34.8* INR(PT)-3.5*
[**2146-4-5**] 04:56AM BLOOD PT-21.5* PTT-38.1* INR(PT)-2.0*
[**2146-3-26**] 06:20PM BLOOD UreaN-39* Creat-1.4* Na-136 K-4.8 Cl-103
HCO3-25 AnGap-13
[**2146-4-5**] 05:30PM BLOOD Glucose-119* UreaN-28* Creat-1.7* Na-136
K-4.2 Cl-104 HCO3-26 AnGap-10
[**2146-4-6**] 05:35AM BLOOD Glucose-102* UreaN-27* Creat-1.5* Na-136
K-3.9 Cl-105 HCO3-27 AnGap-8
[**2146-3-27**] 12:04AM BLOOD CK-MB-10 MB Indx-7.9* cTropnT-0.05*
[**2146-3-28**] 03:55AM BLOOD CK-MB-12* MB Indx-3.1 cTropnT-1.25*
[**2146-4-2**] 09:58AM BLOOD CK-MB-3 cTropnT-2.23*
[**2146-4-2**] 04:51PM BLOOD cTropnT-1.81*
[**2146-4-3**] 02:02AM BLOOD cTropnT-1.44*
[**2146-4-5**] 01:10PM BLOOD CK-MB-3 cTropnT-0.85*

CT lower ext [**3-27**]- There is anasarca, particularly on the right
flank and right lower extremity. There are degenerative changes,
but no
suspicious bone lesions are present. A 2.6 x 2.2 cm collection
in the right groin containing a drainage catheter is present,
smaller than on the previous examination. Inferior to the
collection containing a drain is an ovoid collection measuring
3.2 x 1.5 cm (3:164). At the level of the acetabula on the right
is a 3.2 x 1.4 cm collection (3:100).

CTV: Normal venous opacification is seen in the inferior vena
cava and
extending into the common iliac and leg veins without signs for
vascular
distention, or occlusion. There is atherosclerotic disease of
the popliteal, and common femoral artery, but no aneurysm or
occlusion. Increased density of contrast in the right leg veins
compared to the left may indicate increased venous return due to
hyperemia on the right.

CT [**3-29**] - Hypodense fluid collection with areas of hyperdensity
is visualized in the right thigh measuring 13 cm in the
craniocaudal dimension x 3.8 cm in the transverse dimension.
There is also a 4.7 CC x 3.8 TV cm hypodense fluid collection
inferior to the first collection which may be contiguous with
the superior collection.

Upper ext US - Non-occlusive thrombus surrounding the PICC at
site of insertion in the left basilic vein. No proximal thrombus
identified.


Brief Hospital Course:
Patient was admitted to Dr.[**Name (NI) 1745**] surgical service on [**2146-3-26**].
He was started on empiric antibiotics of Vancomycin 1000 mg IV Q
24H  and Piperacillin-Tazobactam 4.5 g IV Q8H. Due to concerns
of wound infection and given the location of this complicated
fluid collection, IR aspiration was initially attempted. This
was difficult due to the complexity of the collections. During
his hospital course, he did require a brief ICU admission for
hypotension [**2146-3-28**]. He was transferred to general floor after
stabilization on [**2146-3-29**].  A second IR aspiration was attempted
on [**2146-3-29**]. Due to lack of improvement and continued concerns,
he was taken to the operating room on [**2146-4-1**] for an incision,
debridement and washout. There were no complication to the
procedure. He will be discharged to rehab. Please refer to the
following review of systems to summarize his hospital course.

Neuro: The patient received Tylenol and morphine with good
effect and adequate pain control. Patient remained AAox3
throughout his stay.

CV: The patient an episode of hypotenstion for which he was
transferred to the Intensive care unit. The patient's pressures
remained low at SBP 90-100. Vital signs were routinely
monitored. On admission, on telemetry monitoring, noticed to
have frequent tachyarrhythmias. He did have evidence of demand
cardiac ischemia. He was plavix loaded. Cardiology consulted
with recommendations to start amiodarone. Patient did not have
any more HD instability. He remained stable for the rest of his
hospital stay. Plans for outpatient cardiology appointment and
the following recommendations - ASA, Amio x 1 week, d/c on
dig/metop, no cardiac catherization. F/u c/Dr. [**Last Name (STitle) **] as outpt
for repeat echo.

Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout his hospitalization.

GI/GU/FEN: Diet was advanced when appropriate, which was well
tolerated. Patient's intake and output were closely monitored,
and IV fluid was adjusted when necessary. Electrolytes were
routinely followed, and repleted when necessary. The patient
found having a foley catheter to be comfortable and reported
difficulty urinating due to difficulty relaxing. Patient says
having condom catheter helped him relax. Due to overall poor
nutritional status, he was started on nutritional shakes.

ID: The patient's white blood count and fever curves were
closely watched for signs of infection. After the washout the
patient was receiving TID dressing changes,wet-to-dry on the R
groin wound. Infectious disease consulted. Final plan was to
discharge patient home with 4 weeks of zosyn for completion
therapy. His wound cultures did return with Pseudomonas and
pan-sensitive enterococcus.

Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly while on a
sliding scale regimen.

Hematology: The patient's complete blood count was examined
routinely. The patient was transfused with PRBC's when needed
for a total of 7 units of PRBC's during the patient's entire
hospital stay. This likely due to bleeding from his incision
which ceased.

Prophylaxis: The patient received warfarin and ASA. Pt is on
bsased on INR checks. Venodyne boots were used during this stay.
Pt was encouraged to get up and ambulate, though he felt
slightly deconditioned toward end of stay. Rehabilitation was
recommended.

At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, and pain was well controlled. The patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan.
The patient will go to an extended care facility for more
intensive rehabilitation.


Medications on Admission:
digoxin 250 q OTHER day, ditropan 5'', lasix 20', vicodin 5/500
q6h prn, lisinopril 10', metoprolol 25'', nitroglycerin prn
chest pain, simvastatin 40', flomax 0.4', travatan 0.004% 1 drop
in LEFT eye daily, coumadin (5' except 7.5' Wed), vit B12, ASA
81', colace 100'', vit D, augmentin, coumadin


Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for costipation.
7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
8. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

9. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO DAILY (Daily).
10. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
12. insulin lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
13. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
14. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for mouth sores.
16. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
17. Piperacillin-Tazobactam 4.5 g IV Q8H
Please infuse over 4 hours per ID, thanks
18. Morphine Sulfate 2 mg IV Q4H:PRN pain
19. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
20. warfarin 2 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for
1 doses.


Discharge Disposition:
Extended Care

Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Doctor Last Name 5749**] [**Doctor Last Name **] Village - [**Location (un) **]

Discharge Diagnosis:
right groin collection/infection


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:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:

*You experience new chest pain, pressure, squeezing or
tightness.

*New or worsening cough, shortness of breath, or wheeze.

*If you are vomiting and cannot keep down fluids or your
medications.

*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.

*You see blood or dark/black material when you vomit or have a
bowel movement.

*You experience burning when you urinate, have blood in your
urine, or experience a discharge.

*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.

*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.

*Any change in your symptoms, or any new symptoms that concern
you.

Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.

Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**6-7**] lbs until you follow-up with your
surgeon.

Avoid driving or operating heavy machinery while taking pain
medications.

Incision Care:

*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.

*Avoid swimming and baths until your follow-up appointment.

*Please have the groin moist-to-dry dressing changed with a
lightly soaked wet packing into the wound area avergaging [**4-1**]
gauze sponges initially, with subsequent adjustment per provider
charged with dressing changes. For moisture the gauze should be
soaked in Dakin's solution one quarter strength. Every crevice
and space in the wound should be packed tightly. Laying gauze on
wound is insufficient. On top of wet packed dressing, a dry
gauze covering should be placed. An ABD or more gauze may be
placed on top of this and taped to the skin. Paper tape is
recommended due to its minimally abrasive texture and safety for
the skin. Duoderm may be used to further diminish possibllity of
injury to skin.

*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.

PICC Line:

*Please monitor the site regularly, and [**Name6 (MD) 138**] your MD, nurse
practitioner, or [**Name6 (MD) 269**] Nurse if you notice redness, swelling,
tenderness or pain, drainage or bleeding at the insertion site.

* [**Name6 (MD) **] your MD [**First Name (Titles) **] [**Last Name (Titles) 10836**] to the Emergency Room immediately if
the PICC Line tubing becomes damaged or punctured, or if the
line is pulled out partially or completely. DO NOT USE THE PICC
LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and
dry. Contact your [**Name2 (NI) 269**] Nurse if the dressing comes undone or is
significantly soiled for further instructions.

Followup Instructions:
Please call Dr.[**Name (NI) 1745**] office in [**1-30**] weeks for anappointment:
([**Telephone/Fax (1) 5323**]
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name12 (NameIs) **] ID WEST (SB) Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2146-4-18**] 10:00
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2146-4-22**] 10:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name12 (NameIs) **] ID WEST (SB) Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2146-4-25**] 10:20


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]

Completed by:[**2146-4-8**]
{'Infected postoperative seroma,Subendocardial infarction, initial episode of care,Cellulitis and abscess of leg, except foot,Secondary and unspecified malignant neoplasm of lymph nodes of inguinal region and lower limb,Acute kidney failure, unspecified,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Unspecified essential hypertension,Atrial fibrillation,Aortic valve disorders,Hypotension, unspecified,Coronary atherosclerosis of native coronary artery,Diarrhea,Long-term (current) use of anticoagulants,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Personal history of other malignant neoplasm of skin'}


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: Cellulitis with RLE swelling and erythema

PRESENT ILLNESS: 88 yoM with recent history of Right sided groin lymphadenectomy
for metatatic melanoma.  Patient has had difficulty with seroma
and was recently discharged on [**3-22**] home on augmentin after IR
drainage of seroma located just right of
the pudendum.  He was at home, doing relatively well until this
morning when he noted progressive swelling of his right upper
leg / thigh area.  It also was more erythematous and he called
Dr. [**Last Name (STitle) 519**] who asked him to report to the ED.

MEDICAL HISTORY: PMH:
 - metastatic squamous cell carcinoma (unknown primary lesion)
 - CAD s/p MI (remote), EF 50%
 - Aortic stenosis
 - Afib on coumadin
 - HTN
 - BPH
 - L retinal artery occlusion in [**2134**] (secondary to emoblic
disease)

MEDICATION ON ADMISSION: digoxin 250 q OTHER day, ditropan 5'', lasix 20', vicodin 5/500
q6h prn, lisinopril 10', metoprolol 25'', nitroglycerin prn
chest pain, simvastatin 40', flomax 0.4', travatan 0.004% 1 drop
in LEFT eye daily, coumadin (5' except 7.5' Wed), vit B12, ASA
81', colace 100'', vit D, augmentin, coumadin

ALLERGIES: Levsin / Shellfish

PHYSICAL EXAM: EXAM:
Vitals: 97.6  56  99/54  22  97RA
AAO x 3, NAD
RRR, [**4-3**] holosystolic murmur noted on auscultation
CTA B/L no RRW appreciated
soft, NT, ND.  Erythema form RLE extends minimally in to RLQ.
RLE: 4.8 x 1.5 x 4.2 cm and located in the anterior thigh.
Dopplerable signals x 2
LLE: no CCE, palpable pulses throughout.

FAMILY HISTORY: CAD in multiple family members

SOCIAL HISTORY: nonsmoker, lives with wife, no EtOH 

### Response:
{'Infected postoperative seroma,Subendocardial infarction, initial episode of care,Cellulitis and abscess of leg, except foot,Secondary and unspecified malignant neoplasm of lymph nodes of inguinal region and lower limb,Acute kidney failure, unspecified,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Unspecified essential hypertension,Atrial fibrillation,Aortic valve disorders,Hypotension, unspecified,Coronary atherosclerosis of native coronary artery,Diarrhea,Long-term (current) use of anticoagulants,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Personal history of other malignant neoplasm of skin'}
