CHIEF COMPLAINT: Back pain

PRESENT ILLNESS: 68F with history of DM, HTN, and PVD two weeks s/p L4-5
laminectomy who originally presented to ED [**2122-11-12**] from rehab
with fever, new backpain, SOB, and one episode of bowel
incontinence.
.
The patient was discharged to Rehab on [**11-3**] after her lumbar
laminectomy of L4 with insitu fusion L4-L5 on [**10-29**] at [**Hospital1 15204**]. She was noted to have fever to 101F last
Wednesday and had no further work-up to her family's knowledge.
Over the next week, she had increasing use of nebulizers and
reports the onset of a cough, productive of yellow sputum. She
also endorses SOB with ambulation, but not significantly
different from her chronic DOE. On Tuesday [**2122-11-10**], she bent
over to pick up an object and noted acutely increased pain in
her back. The pain resolved over the next day. She had one
episode of bowel incontinence. Per Rehab she has had bladder
incontinence since her surgery. At Rehab on the morning of
admission she was noted to be febrile to 102.8, 81% on RA and
was sent to [**Hospital6 10353**] for further evaluation, where
she was noted to have T102.3 and decreased sO2 (in the mid 80's,
improved to 96% on 3L). BP was 160s/80s on arrival. She vomited
a small amt of "[**Location (un) 2452**] popsicle". Due to ongoing back pain and
fever she reportedly received levaquin and 2U PRBC (no
documentation of this). She was then transfered to [**Hospital1 18**] for
further workup including an MRI.

MEDICAL HISTORY: 1. DM2
2. PVD, s/p angioplasty and stents
3. CAD
4. hypercholesterolemia
5. s/p hallux arthrodesis
6. asthma
7. HTN
8. s/p L4-5 laminectomy [**10-29**]

MEDICATION ON ADMISSION: Lasix 20 mg daily
Klonopin 1 mg three times a day
Zoloft 100 mg daily
Avandia 8 mg daily
Zestril 20 mg daily
Lipitor 40 mg daily
ASA 81 daily
Advair as needed
Rhinocort as needed
Senokot as needed
Tylenol as needed

ALLERGIES: Mevacor / Latex

PHYSICAL EXAM: Vitals: T 99.8 BP: 117/33-133/64 P: 71-82 R: 22 O2: 94-99% on 4L

FAMILY HISTORY: Significant for CAD, HTN, DM, colon ca. History of stroke in mom
and sister.

SOCIAL HISTORY: The patient is widowed and lives alone. She has two daughters.
She is retired, formerly worked as an insurance underwriter. She
denies alcohol, tobacco and IVDA. She ambulates at baseline.
Infected postoperative seroma,Pneumonia, organism unspecified,Congestive heart failure, unspecified,Dehydration,Other pulmonary insufficiency, not elsewhere classified,Thrombocytopenia, unspecified,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Infection with microorganisms resistant to penicillins,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Unspecified essential hypertension,Peripheral vascular disease, unspecified,Iron deficiency anemia, unspecified,Swelling, mass, or lump in head and neck,Hypotension, unspecified,Asthma, unspecified type, unspecified
Infected postop seroma,Pneumonia, organism NOS,CHF NOS,Dehydration,Other pulmonary insuff,Thrombocytopenia NOS,Abn react-surg proc NEC,Mth sus Stph aur els/NOS,Inf mcrg rstn pncllins,DMII neuro nt st uncntrl,Neuropathy in diabetes,Hypertension NOS,Periph vascular dis NOS,Iron defic anemia NOS,Swelling in head & neck,Hypotension NOS,Asthma NOS
Admission Date:  [**2122-11-12**]              Discharge Date:   [**2122-11-23**]

Date of Birth:  [**2054-3-7**]             Sex:   F

Service: MEDICINE

Allergies:
Mevacor / Latex

Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
Back pain

Major Surgical or Invasive Procedure:
Surgical wound debridement
Central Line placement
Intubation
PICC line placement


History of Present Illness:
68F with history of DM, HTN, and PVD two weeks s/p L4-5
laminectomy who originally presented to ED [**2122-11-12**] from rehab
with fever, new backpain, SOB, and one episode of bowel
incontinence.
.
The patient was discharged to Rehab on [**11-3**] after her lumbar
laminectomy of L4 with insitu fusion L4-L5 on [**10-29**] at [**Hospital1 15204**]. She was noted to have fever to 101F last
Wednesday and had no further work-up to her family's knowledge.
Over the next week, she had increasing use of nebulizers and
reports the onset of a cough, productive of yellow sputum. She
also endorses SOB with ambulation, but not significantly
different from her chronic DOE. On Tuesday [**2122-11-10**], she bent
over to pick up an object and noted acutely increased pain in
her back. The pain resolved over the next day. She had one
episode of bowel incontinence. Per Rehab she has had bladder
incontinence since her surgery. At Rehab on the morning of
admission she was noted to be febrile to 102.8, 81% on RA and
was sent to [**Hospital6 10353**] for further evaluation, where
she was noted to have T102.3 and decreased sO2 (in the mid 80's,
improved to 96% on 3L). BP was 160s/80s on arrival. She vomited
a small amt of "[**Location (un) 2452**] popsicle". Due to ongoing back pain and
fever she reportedly received levaquin and 2U PRBC (no
documentation of this). She was then transfered to [**Hospital1 18**] for
further workup including an MRI.


Past Medical History:
1. DM2
2. PVD, s/p angioplasty and stents
3. CAD
4. hypercholesterolemia
5. s/p hallux arthrodesis
6. asthma
7. HTN
8. s/p L4-5 laminectomy [**10-29**]


Social History:
The patient is widowed and lives alone. She has two daughters.
She is retired, formerly worked as an insurance underwriter. She
denies alcohol, tobacco and IVDA. She ambulates at baseline.

Family History:
Significant for CAD, HTN, DM, colon ca. History of stroke in mom
and sister.

Physical Exam:
Vitals: T 99.8 BP: 117/33-133/64 P: 71-82 R: 22 O2: 94-99% on 4L

Gen: pleasant obese female, somewhat delirious, inable to
concentrate on questions, NAD
HEENT: Flushed face, anicteric sclerae, mmm, no teeth
Neck: R IJ in place, JVD hard to assess secondary to obesity and
positioning (lying flat)
Lung: poor lung exam [**1-21**] positioning, but decreased sounds on
L>R
CV: III/VI SEM @ LSB, faint femoral and DP pulses distally
Abd: obese. +bs. soft. nt. nd.
Ext: 1+ pitting edema B. skin warm/dry. L hand dressed w/ no
drainage through dressing. Multiple ecchymoses on UE B.
pneumoboots in place
Neuro: no focal deficits. PERLA, EOMI.


Pertinent Results:
On Admission:
[**2122-11-12**] 09:06AM   LACTATE-1.0
[**2122-11-12**] 08:55AM   GLUCOSE-116* UREA N-21* CREAT-1.2* SODIUM-144
POTASSIUM-3.6 CHLORIDE-109* TOTAL CO2-25 ANION GAP-14
[**2122-11-12**] 08:55AM   CK(CPK)-59
[**2122-11-12**] 08:55AM   CK-MB-NotDone cTropnT-0.02*
[**2122-11-12**] 08:55AM   WBC-13.6* RBC-3.63* HGB-10.4* HCT-31.1*
MCV-86 MCH-28.7 MCHC-33.5 RDW-14.5
[**2122-11-12**] 08:55AM   HYPOCHROM-NORMAL ANISOCYT-1+
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-2+
POLYCHROM-OCCASIONAL STIPPLED-OCCASIONAL TEARDROP-OCCASIONAL
[**2122-11-12**] 08:55AM   PLT SMR-NORMAL PLT COUNT-166
[**2122-11-12**] 12:23AM   LACTATE-1.4
[**2122-11-12**] 12:10AM   UREA N-19 CREAT-1.2* SODIUM-144 POTASSIUM-3.8
CHLORIDE-109* TOTAL CO2-23 ANION GAP-16
[**2122-11-12**] 12:10AM   CK(CPK)-45
[**2122-11-12**] 12:10AM   cTropnT-<0.01
[**2122-11-12**] 12:10AM   CK-MB-NotDone cTropnT-<0.01
[**2122-11-12**] 12:10AM   WBC-16.0*# RBC-4.02* HGB-11.7* HCT-34.9*
MCV-87# MCH-29.1 MCHC-33.6 RDW-14.7
[**2122-11-12**] 12:10AM   NEUTS-84* BANDS-4 LYMPHS-9* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2122-11-12**] 12:10AM   HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-OCCASIONAL
[**2122-11-12**] 12:10AM   PLT SMR-NORMAL PLT COUNT-205
[**2122-11-12**] 12:10AM   PT-13.0 PTT-23.2 INR(PT)-1.1
[**2122-11-12**] 12:10AM URINE  COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2122-11-12**] 12:10AM URINE  RBC-0-2 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
.
On Discharge:
Na 148 K 3.7 Cl 110 CO2 28 Bun 11 Cr 1.0 Glucose 99
Ca: 9.0 Mg: 1.8 P: 3.2
Wbc 8.0 Hct 25.8 Plts 247
.
Microbiology:
Sputum [**11-17**] - no growth
Stool [**11-18**], [**11-19**], [**11-22**] - negative for C.diff
Blood cx [**11-12**], [**11-15**], [**11-14**] - no growth
Swab back [**11-15**] - coag + staph aureus moderate growth (MRSA) see
below
Urine cx [**11-14**], [**11-12**] - no growth
Fluid [**11-12**] (epidural collection) - GRAM STAIN (Final [**2122-11-12**]):

      2+   (1-5 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      1+    (<1 per 1000X FIELD):   GRAM POSITIVE COCCI IN
PAIRS.

   FLUID CULTURE (Final [**2122-11-14**]):
      STAPH AUREUS COAG +.    MODERATE GROWTH.
         Oxacillin RESISTANT Staphylococci MUST be reported as
also
         RESISTANT to other penicillins, cephalosporins,
carbacephems,
         carbapenems, and beta-lactamase inhibitor combinations.

         Rifampin should not be used alone for therapy.
         Please contact the Microbiology Laboratory ([**6-/2423**])
immediately if
         sensitivity to clindamycin is required on this
patient's isolate.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------   =>8 R
OXACILLIN-------------   =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------   <=1 S
VANCOMYCIN------------   <=1 S

   ANAEROBIC CULTURE (Final [**2122-11-16**]):    NO ANAEROBES ISOLATED.



.
CXR [**2122-11-16**]:
The pulmonary edema is unchanged. Bilateral pleural effusions
are increasing in size, especially the left. The mediastinal is
unchanged. New ET tube is present, located 3.7 cm above the
carina. Right IJ catheter tip unchanged in position over the
SVC. There is no pneumothorax.  IMPRESSION: Persistent mild
pulmonary edema. ET tube in standard position
.
TTE [**2122-11-16**]:  Preserved global and regional biventricular
systolic function. Mild pulmonary artery systolic hypertension.
Prominent epicardial fat pad.
.
MRI [**2122-11-13**]:
IMPRESSION: Postoperative changes. Infection should be
considered but cannot be confirmed. There is a possibility of a
CSF leak, as there is a subcutaneous collection at the
laminectomy site, but this would be difficult to confirm without
myelography.
.
EKG [**2122-11-14**]: Sinus tachycardia
Borderline low QRS voltage - is nonspecific
Modest nonspecific ST-T wave changes
Since previous tracing of [**2122-11-13**], sinus tachycardia present
.
CHEST CT [**11-14**]:
1. No pulmonary embolism. 2. Moderate cardiomegaly with
bilateral moderate layering pleural effusion. 3. Pulmonary
interstitial and alveolar edema. A followup CT could be
performed after treating the CHF to evaluate for pulmonary
pathology. 4. Bilateral lower lobe atelectasis.


Brief Hospital Course:
Ms. [**Known lastname 26075**] is a 68 lady with a history of DM2, HTN, and PVD s/p
recent L4-5 laminectomy, admitted with back pain from rehab
found to have a left lower lobe pneumonia and MRSA surgical
wound infection.
.
In the [**Hospital1 **] ED, she was initially hypertensive at 147/47 but then
became hypotensive 90s/40s. She was started on the sepsis
protocol with placement of RIJ. She received vancomycin,
levofloxacin, morphine 2mg x2. Neurology was consulted and felt
that given her recent surgery, new back pain, question of
incontinence, the week-long fever and her DM, an infection in
the surgical region was likely. Neurospine was consulted. The
patient had an MRI L-spine with contrast to r/o epidural
abscess. The MRI revealed fluid collection which is likely a
post-surgical seroma and not an abscess. No evidence of cauda
equina. She was initially admitted to MICU, but transferred to
floor on admission given her hemodynamic/respiratory stability.
However, patient then returned to the MICU after becoming
acutely hypoxic on the floor with oxygen saturation of 84% on
4L. She was noted to be tachypneic, in severe respiratory
distress, using accessory muscles. ABG 7.25/53/105 on NRB
(lactate 0.7). CXR c/w CHF, she was readmitted to MICU.
.
MICU Course:
The patient was diuresed and continued on nebs PRN for
bronchospasm. The patient was taken back to the OR for wound
debridement, and was intubated for this procedure, not for
respiratory failure. She was extubated in the morning following
the procedure, and weaned down to 4L NC with O2 sats 99%. The
patient was continued on Zosyn for nosocomial pneumonia and
Vancomycin for MRSA wound infection, per ID recs, will need to
have a 6 week course. The patient underwent a speech/swallow
eval following extubation, which advanced her to pureed liquids.

.
Upon transfer back to the medical floor, the patient was
breathing comfortably on 4L O2, speaking in full sentences, no
accessory muscle use. The patient denied any chest pain or
dyspnea, + productive cough, denies N/V. No abdominal cramping,
but having some diarrhea. Does not complain of mild back pain,
but was unable to quantify with a number on a scale of 10.
Patient had recently received ativan and clonazepam, with a
subsequent clouded mental status. Per patient's daughters who
had been at the bedside, this change in mental status only
occurred after sedating medications.
.
In terms of pneumonia the patient continued to be weaned off O2,
currently sating well on room air. She was treated with a 10 day
course of Zosyn ([**Date range (1) 26158**]). She had a slightly positive fluid
balance with b/l pleural effusions and vascular congestion on
CXR and therefore recieved a total of 30 mg IV lasix for
additional diuresis. She was continued on nebulizers for her
asthma. Her sputum cultures returned negative. Patient currently
does not have any cough or sputum production. She remains
afebrile and saturating well on RA.
.
In terms of her wound infection. Patient found to have MRSA
growing from the fluid drained from her surgical site. She
requires a 6 week course of IV Vancomycin (started [**11-15**] as day
zero). A PICC line was placed for prolonged IV antibiotics. She
had a central line placed in the MICU which was removed after
PICC line placement. Her blood cultures have all been negative.
Her wound is clean and dry. She is scheduled to have her staples
removed from her wound site on Friday [**12-4**] at 11:15 AM
at the [**Hospital Ward Name 23**] Building Orthopedic Unit.
.
Patient has complained of very little pain and this is
controlled with Tylenol. The patient was initially treated with
oxycodone which caused her to become delirious. She was also
receiving clonazepam 0.5 mg [**Hospital1 **] for anxiety which was also
likely contributing to her confusion. The narcotic medications
were withdrawn with dramatic improvement in her mental status.
Her benzodiazepines were tapered to 0.25 mg [**Hospital1 **]. This should be
tapered further as tolerated. Her mental status upon discharge
is clear. Both of her daughters were at the bedside who agree
that she is at baseline and much improved now that she is off
narcotics. Apparently the family has a history of adverse
reactions to pain medications.
.
In terms of her cardiovascular disease including HTN, CAD, CHF
(EF >50% 11/28). She was apparently taking lasix at home (?dose)
and is discharged on 20 mg daily. She should follow up with her
PCP regarding this dose. She required IV lasix bolus (10mg, then
20 mg) for excess fluid removal while in hospital. She was
treated with Lisinopril 5 mg daily with good blood pressure
control (120-130/60s). Of note, the patient was taking Zestril
20 mg daily. We are discharging her on 10 mg of Lisinopril since
this provided good control, this can be titrated up in the
future as tolerated. She was also continued on a Statin. Of
note, the patient is not taking aspirin or a beta blocker. This
can be addressed with her primary care physician upon follow up.
.
Patient was also found to be anemic. On admission her Hct was 31
with subsequently dropped to ~30. Likely multifactorial in the
setting of IVF fluid resuscitation in the MICU, wound
debridement in the OR, hx of chronic disease and multiple lab
draws during this admission. A repeat CBC should be performed in
approximately one week to make sure that her anemia is not
worsening.
.
Patient also developed some diarrhea during this admission. She
was tested for C.diff which was negative x 3. She was given
loperamide prn with improvement. She denies any abdominal pain
and she did not develop any fevers. Her bowel regimen was held
after this.
.
Nutrition - patient cleared by speech and swallow. Eating a soft
pureed diet then advanced to regular diet. Note that she has
lost her lower dentures but is eating well. Her daughter have
ordered another set of lower dentures for which she will have to
be fitted.
.
In terms of her anxiety and depression the patient was continued
on Zoloft per outpatient regimen. She was also treated with
Clonazepam 0.5 mg [**Hospital1 **]. This produced substantial delirium. This
medication was tapered to 0.25 mg [**Hospital1 **] for fear of withdrawal.
However, this should be tapered further as tolerated an only
used as needed for anxiety. Sedating medications and narcotics
should be avoided in the future if possible.
.
For her diabetes she was maintained on an insulin sliding scale
with good control. She is now able to resume her outpatient
regimen of Avandia 80 mg daily. She is to continue to be
maintained on a sliding scale. Please report all FS values to
her PCP in the event that her medications must be adjusted.
.
Electrolyte Imbalance: Patient also developed some hypernatremia
while in hospital with a sodium level of 148. Likely in the
setting of dehydration after diuresis with lasix for fluid
overload. Her free water deficit was calculated and found to be
2L. She was repleted with D5W for this deficit. Patient also had
some low potassium levels also likely secondary to lasix. She
was repleted with PO potassium with improvement. Patient should
have a repeat chemistry done in two days to assess for any
electrolyte abnormalities.
.
Prophylaxis: Heparin SC, OOBTC, PO diet, PPI, bowel regimen
(then held due to diarrhea)
.
Patient was a full code throughout this admission.


Medications on Admission:
Lasix 20 mg daily
Klonopin 1 mg three times a day
Zoloft 100 mg daily
Avandia 8 mg daily
Zestril 20 mg daily
Lipitor 40 mg daily
ASA 81 daily
Advair as needed
Rhinocort as needed
Senokot as needed
Tylenol as needed


Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Disk
with Device(s)
2. Heparin Flush CVL  (100 units/ml) 1 ml IV DAILY:PRN
10ml NS followed by 1ml of 100 units/ml heparin (100 units
heparin) each lumen QD and PRN.  Inspect site every shift
3. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed.
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Albuterol Sulfate 0.083 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours) as needed.
6. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours) as needed.
8. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical  [**Hospital1 **]
(2 times a day).
9. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for back pain.
10. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection as directed on flow sheet.
11. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
12. Vancomycin 1,000 mg Recon Soln Sig: One (1)  Intravenous
q24 hrs for 28 days.
13. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
14. Clonazepam 0.25 mg Tablet, Rapid Dissolve Sig: One (1)
Tablet, Rapid Dissolve PO twice a day.
15. ASA 81 mg daily


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]

Discharge Diagnosis:
MRSA Wound Infection
Pneumonia
.
Secondary
Diabetes type 2
Hypertension
Hyperlipidemia
Asthma
Peripheral vascular disease


Discharge Condition:
Good - patient afebrile, sating well on room air, OOBTC with
assist, minimal back pain


Discharge Instructions:
Please take all of your medications as directed

Please follow up as listed below

Please return to the hospital if you have any fevers, chills,
worsening back pain, difficulty breathing or any other
complaints.

Followup Instructions:
Please call your PCP to make [**Name Initial (PRE) **] follow up appointment.
PCP: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 26159**]

Please attend the following appointment to have your staples
removed from your back: Friday, [**12-4**] at 11:15 AM [**Hospital1 18**]
[**Location (un) 8661**] Building 2nd flood Orthopedic Unit with Dr. [**Last Name (STitle) 26160**]



Completed by:[**2122-11-23**]

Name:  [**Known lastname 4525**],[**Known firstname **]                 Unit No:   [**Numeric Identifier 4526**]

Admission Date:  [**2122-11-12**]              Discharge Date:   [**2122-11-23**]

Date of Birth:  [**2054-3-7**]             Sex:   F

Service: MEDICINE

Allergies:
Mevacor / Latex

Attending:[**First Name3 (LF) 1852**]
Addendum:
Note: patient was taking aspirin prior to admission, she is
discharged on 81 mg ASA

Note: patient was taking Avandia prior to admission, this
medication was NOT continued due to a history of heart failure.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 1174**] [**Hospital **] Hospital - [**Location (un) **]

                             [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 692**] MD [**MD Number(2) 693**]

Completed by:[**2122-11-23**]
{'Infected postoperative seroma,Pneumonia, organism unspecified,Congestive heart failure, unspecified,Dehydration,Other pulmonary insufficiency, not elsewhere classified,Thrombocytopenia, unspecified,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Infection with microorganisms resistant to penicillins,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Unspecified essential hypertension,Peripheral vascular disease, unspecified,Iron deficiency anemia, unspecified,Swelling, mass, or lump in head and neck,Hypotension, unspecified,Asthma, unspecified type, unspecified'}


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: Back pain

PRESENT ILLNESS: 68F with history of DM, HTN, and PVD two weeks s/p L4-5
laminectomy who originally presented to ED [**2122-11-12**] from rehab
with fever, new backpain, SOB, and one episode of bowel
incontinence.
.
The patient was discharged to Rehab on [**11-3**] after her lumbar
laminectomy of L4 with insitu fusion L4-L5 on [**10-29**] at [**Hospital1 15204**]. She was noted to have fever to 101F last
Wednesday and had no further work-up to her family's knowledge.
Over the next week, she had increasing use of nebulizers and
reports the onset of a cough, productive of yellow sputum. She
also endorses SOB with ambulation, but not significantly
different from her chronic DOE. On Tuesday [**2122-11-10**], she bent
over to pick up an object and noted acutely increased pain in
her back. The pain resolved over the next day. She had one
episode of bowel incontinence. Per Rehab she has had bladder
incontinence since her surgery. At Rehab on the morning of
admission she was noted to be febrile to 102.8, 81% on RA and
was sent to [**Hospital6 10353**] for further evaluation, where
she was noted to have T102.3 and decreased sO2 (in the mid 80's,
improved to 96% on 3L). BP was 160s/80s on arrival. She vomited
a small amt of "[**Location (un) 2452**] popsicle". Due to ongoing back pain and
fever she reportedly received levaquin and 2U PRBC (no
documentation of this). She was then transfered to [**Hospital1 18**] for
further workup including an MRI.

MEDICAL HISTORY: 1. DM2
2. PVD, s/p angioplasty and stents
3. CAD
4. hypercholesterolemia
5. s/p hallux arthrodesis
6. asthma
7. HTN
8. s/p L4-5 laminectomy [**10-29**]

MEDICATION ON ADMISSION: Lasix 20 mg daily
Klonopin 1 mg three times a day
Zoloft 100 mg daily
Avandia 8 mg daily
Zestril 20 mg daily
Lipitor 40 mg daily
ASA 81 daily
Advair as needed
Rhinocort as needed
Senokot as needed
Tylenol as needed

ALLERGIES: Mevacor / Latex

PHYSICAL EXAM: Vitals: T 99.8 BP: 117/33-133/64 P: 71-82 R: 22 O2: 94-99% on 4L

FAMILY HISTORY: Significant for CAD, HTN, DM, colon ca. History of stroke in mom
and sister.

SOCIAL HISTORY: The patient is widowed and lives alone. She has two daughters.
She is retired, formerly worked as an insurance underwriter. She
denies alcohol, tobacco and IVDA. She ambulates at baseline. 

### Response:
{'Infected postoperative seroma,Pneumonia, organism unspecified,Congestive heart failure, unspecified,Dehydration,Other pulmonary insufficiency, not elsewhere classified,Thrombocytopenia, unspecified,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Infection with microorganisms resistant to penicillins,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Unspecified essential hypertension,Peripheral vascular disease, unspecified,Iron deficiency anemia, unspecified,Swelling, mass, or lump in head and neck,Hypotension, unspecified,Asthma, unspecified type, unspecified'}
