CHIEF COMPLAINT: Shunt discontinuity

PRESENT ILLNESS: Ms. [**Known lastname **] is a 34 year old
right handed woman with a history of congenital hydrocephalus
s/p
VPS placement right after birth s/p revision at age 13. She also
appears to have baseline mild MR [**First Name (Titles) **] [**Last Name (Titles) **].

MEDICAL HISTORY: 1. Diabetes
2. chronic UTI/neurogenic bladder requiring cath
3. asthma
4. [**Hospital3 **]
5. hydrocephalus s/p VPS
6. s/p spinal surgery for scoliosis

MEDICATION ON ADMISSION: 1. Detrol
2. Dilantin 200mg daily
3. Fluoxetine 40mg daily
4. Lasix 20mg daily
5. Metformin 1000mg [**Hospital1 **]
6. Proventil INH PRN
7. Simvastatin 20mg daily
8. Piroxicam 20mg PRN
9. Loratidine 10mg daily

ALLERGIES: Amoxicillin / Codeine / Meperidine / Methadone / morphine /
Penicillins / vancomycin

PHYSICAL EXAM: PHYSICAL EXAM5/28/11 the day of admission:
T HR BP 120/80 Resp 12
General: Awake, cooperative, overweight, almost cushingoid in
appearnace.
Head and Neck: no scleral icterus noted, mmm, no lesions noted
in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTA b/l
Cardiac: No murmurs appreciated.
Abdomen: normoactive bowel sounds
Extremities: well perfused, but shortened legs
Skin: There is a protruberance of the shunt lying over the right
clavicle, which ends in an elevated, erthematous and warm patch
of skin over the right chest wall. There are also multiple
excoriations over both legs, with a wound over the right shin.

FAMILY HISTORY: Non-contribiutory

SOCIAL HISTORY: Lives with disabled father and is wheelchair
bound. No TOB or EtOH.
Infection and inflammatory reaction due to nervous system device, implant, and graft,Methicillin resistant pneumonia due to Staphylococcus aureus,Cellulitis and abscess of trunk,Urinary tract infection, site not specified,Paraplegia,Hyposmolality and/or hyponatremia,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Congenital hydrocephalus,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Neurogenic bladder NOS,Epilepsy, unspecified, without mention of intractable epilepsy,Dermatitis due to drugs and medicines taken internally,Other specified antibiotics causing adverse effects in therapeutic use,Mild intellectual disabilities,Pressure ulcer, lower back,Diarrhea,Arthrodesis status,Need for desensitization to allergens
React-nerv sys dev/graft,Meth res pneu d/t Staph,Cellulitis of trunk,Urin tract infection NOS,Paraplegia NOS,Hyposmolality,Abn react-artif implant,Congenital hydrocephalus,DMII wo cmp nt st uncntr,Neurogenic bladder NOS,Epilep NOS w/o intr epil,Drug dermatitis NOS,Adv eff antibiotics NEC,Mild intellect disabilty,Pressure ulcer, low back,Diarrhea,Arthrodesis status,Desensitiza to allergens
Admission Date:  [**2150-5-9**]              Discharge Date:   [**2150-5-22**]

Date of Birth:  [**2115-12-5**]             Sex:   F

Service: NEUROSURGERY

Allergies:
Amoxicillin / Codeine / Meperidine / Methadone / morphine /
Penicillins / vancomycin

Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Shunt discontinuity


Major Surgical or Invasive Procedure:
[**2150-5-9**]: Attempted VP shunt revision complicated by
intraoperative finding of possible chest wall abcess, VP shunt
externalization in the OR by Dr [**Last Name (STitle) **]
[**2150-5-11**]: VP shunt explanted, Right EVD implanted
[**2150-5-20**]: Left sided VP shunt


History of Present Illness:
Ms. [**Known lastname **] is a 34 year old
right handed woman with a history of congenital hydrocephalus
s/p
VPS placement right after birth s/p revision at age 13. She also
appears to have baseline mild MR [**First Name (Titles) **] [**Last Name (Titles) **].

She states having developed erythema over her R chest wall about
a week ago. Earlier today she noted a drastic increase in the
size of the protrusion over her chest wall as well as redness so
came to the [**Hospital3 **] ED and was subsequently transferred to
the
ED here. CXR done at OSH showed calcified fibrous tissue
surrounding the shunt and two focal areas of shunt discontinuity
at right lower neck.

She denies any headache or blurred vision. No nausea except at
the [**Hospital3 **] ED where she vomited once. No fevers.



Past Medical History:
1. Diabetes
2. chronic UTI/neurogenic bladder requiring cath
3. asthma
4. [**Hospital3 **]
5. hydrocephalus s/p VPS
6. s/p spinal surgery for scoliosis


Social History:
Lives with disabled father and is wheelchair
bound. No TOB or EtOH.


Family History:
Non-contribiutory


Physical Exam:
PHYSICAL EXAM5/28/11 the day of admission:
T HR BP 120/80 Resp 12
General: Awake, cooperative, overweight, almost cushingoid in
appearnace.
Head and Neck: no scleral icterus noted, mmm, no lesions noted
in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTA b/l
Cardiac: No murmurs appreciated.
Abdomen: normoactive bowel sounds
Extremities: well perfused, but shortened legs
Skin: There is a protruberance of the shunt lying over the right
clavicle, which ends in an elevated, erthematous and warm patch
of skin over the right chest wall. There are also multiple
excoriations over both legs, with a wound over the right shin.

Neurologic:
Mental Status: Alert, oriented to [**Hospital3 **], [**Location (un) 86**], [**2150-4-12**].
Speech is stuttering but fluent. Names a few high frequency
objects, repeats simple phrases and follows three step commands.
Affect is child-like.

Cranial Nerves:
I: Olfaction not tested.
II: PERRL 5 to 3mm bilaterally. Funduscopic exam revealed sharp
disc margins.
III, IV, VI: EOMI without nystagmus, no phorias or tropias.
Smooth persuit with occasional saccadic intrusion.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and sternocleidomastoid
bilaterally.
XII: Tongue protrudes in midline.

Motor: paraparesis. No pronator drift bilaterally. No
adventitious movements, such as tremors, noted. No asterixis.

  Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L  5    5   5   5   5  5  5  0   0    0   0   0     0    0
R  5    5   5   5   5  5  5  0   0    0   1   0     0    0

*Of note, on confrontation testing she has a paraplegia, but she
does withdraw both feet to baninski testing

Sensory: Intact in arms to LT, PP

Deep tendon reflexes:  Biceps 2+ bilaterally, 1+ bracialradialis
and triceps. Absent at legs and ankles.

Coordination: No dysdiadochokinesia noted or dysmetria in arms.

On the day of discharge: Stable exam


Pertinent Results:
[**2150-5-8**] 08:00PM URINE  MUCOUS-RARE
[**2150-5-8**] 08:00PM URINE  RBC-<1 WBC-1 BACTERIA-MANY YEAST-NONE
EPI-<1
[**2150-5-8**] 08:00PM URINE  BLOOD-NEG NITRITE-POS PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2150-5-8**] 08:00PM URINE  COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.003
[**2150-5-8**] 08:00PM   PT-13.0 PTT-21.9* INR(PT)-1.1
[**2150-5-8**] 08:00PM   PLT COUNT-361
[**2150-5-8**] 08:00PM   NEUTS-75.8* LYMPHS-19.3 MONOS-3.2 EOS-1.3
BASOS-0.4
[**2150-5-8**] 08:00PM   WBC-13.1* RBC-4.54 HGB-12.4 HCT-36.4 MCV-80*
MCH-27.4 MCHC-34.2 RDW-14.2
[**2150-5-8**] 08:00PM   estGFR-Using this
[**2150-5-8**] 08:00PM   GLUCOSE-105* UREA N-5* CREAT-0.3* SODIUM-137
POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-23 ANION GAP-17
[**2150-5-8**] 08:33PM   LACTATE-1.2
[**2150-5-8**] 08:55PM URINE  UCG-NEGATIVE
[**2150-5-8**] 08:55PM URINE  HOURS-RANDOM
[**2150-5-9**] 06:50AM   PT-13.8* PTT-23.1 INR(PT)-1.2*
[**2150-5-9**] 06:50AM   PLT COUNT-351
[**2150-5-9**] 06:50AM   WBC-14.3* RBC-4.60 HGB-12.8 HCT-37.9 MCV-82
MCH-27.8 MCHC-33.7 RDW-14.6
[**2150-5-9**] 06:50AM   GLUCOSE-122* UREA N-6 CREAT-0.4 SODIUM-136
POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-24 ANION GAP-16
[**2150-5-9**] 02:23PM   PLT COUNT-338
[**2150-5-9**] 02:23PM   WBC-9.8 RBC-4.28 HGB-11.8* HCT-35.3* MCV-82
MCH-27.5 MCHC-33.4 RDW-14.5
[**2150-5-9**] 02:23PM   CALCIUM-8.7 PHOSPHATE-3.3 MAGNESIUM-1.8
[**2150-5-9**] 02:23PM   GLUCOSE-128* UREA N-7 CREAT-0.3* SODIUM-137
POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-24 ANION GAP-14
[**2150-5-9**] 02:24PM URINE  WBCCLUMP-RARE MUCOUS-OCC
[**2150-5-9**] 02:24PM URINE  CA OXAL-OCC
[**2150-5-9**] 02:24PM URINE  GRANULAR-4* HYALINE-4* WBCCAST-2*
[**2150-5-9**] 02:24PM URINE  RBC-6* WBC-81* BACTERIA-MOD YEAST-NONE
EPI-6
[**2150-5-9**] 02:24PM URINE  BLOOD-TR NITRITE-NEG PROTEIN-100
GLUCOSE-TR KETONE-80 BILIRUBIN-SM  UROBILNGN-2* PH-6.0 LEUK-LG
[**2150-5-9**] 02:24PM URINE  COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.020
[**2150-5-9**] 04:48PM URINE  UCG-NEGATIVE
[**2150-5-9**] 04:48PM URINE  HOURS-RANDOM
[**2150-5-9**] 04:58PM CEREBROSPINAL FLUID (CSF)  WBC-6 RBC-1*
POLYS-50 LYMPHS-31 MONOS-19
[**2150-5-9**] 04:58PM CEREBROSPINAL FLUID (CSF)  PROTEIN-6*
[**2150-5-9**] 07:50PM   SED RATE-30*
[**2150-5-9**] 07:50PM   CRP-62.4*

CT HEAD W/O CONTRAST Study Date of [**2150-5-8**] 8:29 PM
IMPRESSION:
1. Hydrocephalus, raising the possibility of shunt malfunction,
however,
prior studies are not available for direct comparison.
2. Absent septum pellucidum with lack of visualization of the
corpus
callosum, which may be attenuated or there may be possible
agenesis. If
further delineation is desired, MR could be performed.

CHEST (PA & LAT) Study Date of [**2150-5-8**] 9:10 PM PA AND LATERAL
VIEWS OF THE CHEST: A VP shunt catheter is noted coursing along
the right neck and right anterior chest, however there are
multiple areas of apparent discontinuity within the catheter as
it courses within the neck. There are low lung volumes. The
heart size is top normal. The mediastinal and hilar contours are
unremarkable. The lungs are clear and the pulmonary vascularity
is normal. No pleural effusion or pneumothorax is seen.Bilateral
[**Location (un) 931**] rods are in place.

IMPRESSION: Discontinuity of the VP shunt catheter within the
right neck.

 SHUNT SERIES AP & LAT SKULL, AP CHEST, AP ABDOMEN Study Date of
[**2150-5-8**] 10:54 PM REPORT not read as of [**5-10**]******************

CHEST (PORTABLE AP) Study Date of [**2150-5-9**] 2:25 PM FRONTAL CHEST
RADIOGRAPH: Retained shunt tubing is noted extending from the
level of the right fifth posterior rib inferiorly. [**Location (un) 931**]
rods are noted. The cardiomediastinal silhouette is stable. The
lungs are grossly clear.  There is no pneumothorax or focal
consolidation.
IMPRESSION:
1. Retained shunt tubing.
2. No acute cardiopulmonary abnormality.

CT ABDOMEN W/CONTRAST Study Date of [**2150-5-9**] 4:04 PM IMPRESSION:

1. Discontinuity of the ventriculoperitoneal shunt, which is not
see above
the level of T3.
2. Area of phlegmonous changes around superior most aspect of
the VP shunt
and extending cephalad. No drainable fluid collection.
3. Cholelithiasis.
4. Multiple subcentimeter simple cysts within the pancreatic
tail, without
suspicious features. Followup with CT in one year is
recommended.
5. Non-obstructive lower pole left renal calculus.

CT head [**5-11**]:
Immediately status post revision of a right frontovertex
approach ventriculostomy catheter, with improved lateral
ventriculomegaly and no evidence of acute intracranial
hemorrhage.

CT Head [**5-20**] postop:  Satisfactory position of left frontal
ventriculostomy catheter, with decreased ventriculomegaly, no
new hemorrhage








Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the Neurosurgery service after a study
revealed a break in her VPS catheter at the level of her neck.

She was taken to the OR on [**5-9**] for revision of her VPS.
Intraoperatively we found frank Puss coming from her chest wall
and the distal portion of the catheter. The VPS was externalized
at the neck and cultures were sent.

An ID consult was obtained for recommendation. A UTI was
detected, she was started on Cipro and Vancomycin for wound
propholaxis which [**Last Name (un) 89381**] her a diffuse rash on [**5-10**].

Initial cultures revealed GNR in her CSF as well as from wound
cultres.

Patient was transferred to the ICU on [**5-10**] for desensitization
for treatment with Cefepime which would provide better CNS
coverage for Gram Negative orginisms, Vancomycin was also
discontinued and she was started on Daptomycin given her drug
reaction.

She was taken to the OR on [**5-11**] for explantation of her right
sided VP shunt. All components of the system were removed
including the intracranial and intra-abdominal portions. She
toelrated the procedure well, was extubated in the OR and taken
to the ICU post-operatively. Her EVD was placed at 10cm and was
functioning well with ICP'[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1131**] [**6-21**] for the first 5 minutes
of transduction.

On [**5-12**], she was stable and was transfered to the stepdown unit.
Transitioning of dilantin to keppra was in place. On [**5-13**],
daptomycin stopped per ID. She had
chest wall edema/erythema which was controlled with benadryl. A
PICC line was placed for [**Known lastname **] term antibiotics. PT and OT were
consulted for assistance with getting out of bed and
mobilization.
On [**5-14**] she was again neurologically stable without acute issues.
On [**5-15**] she was found to be febrile to 102 and was pancultured
including CSF. Her CXR from [**5-14**] showed probable bilateral lower
lobe pneumonias and ID was consulted and recommended switiching
her antibiotics to linezolid and meropenem. She remained stable
on [**5-16**] and [**5-17**]. On [**5-18**] CSF was sent in preparation for ensuring
clean cultures for the OR for replacement of her shunt later in
the week. The gram stain was negative.
On [**5-19**] her PICC line was replaced due to contamination and her
sutures and staples were removed. Labs were sent in preparation
for internalization of her VP Shunt on  [**5-20**].
On [**5-20**] she underwent VP Shunt placement without complication. It
was noted that she had a decubitus on her coccyx so a wound care
consult was called. She was also having diarrhea so stool
cultures were sent that were negative for C. Diff.

On Postoperative Day 1, she did well.  She was tolerating a
regular diet, afebrile with stable vital signs.  ID recommends
treatment with IV Meropenem and Telavancin for 8 postoperative
days and then transition to Oral Cipro 500mg [**Hospital1 **] for 7 days.


Medications on Admission:
1. Detrol
2. Dilantin 200mg daily
3. Fluoxetine 40mg daily
4. Lasix 20mg daily
5. Metformin 1000mg [**Hospital1 **]
6. Proventil INH PRN
7. Simvastatin 20mg daily
8. Piroxicam 20mg PRN
9. Loratidine 10mg daily


Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for headache.
2. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. insulin lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
5. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
6. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
7. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for Rash.
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
11. epinephrine 0.3 mg/0.3 mL Pen Injector Sig: One (1) Pen
Injector Intramuscular ONCE (Once) as needed for anaphylaxis.
12. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
13. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
14. diphenhydramine HCl 12.5 mg/5 mL Elixir Sig: [**12-14**]  PO Q6H
(every 6 hours) as needed for itch/rash.
15. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed for cough.
16. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q6H (every 6 hours) as
needed for wheeze.
17. telavancin 250 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours): x 6 days, stop date [**2150-5-28**].

18. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
19. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
20. DiphenhydrAMINE 50 mg IV ONCE:PRN allergic reaction
21. 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.
22. meropenem 1 gram Recon Soln Sig: One (1) Recon Soln
Intravenous Q8H (every 8 hours): x 6 days, stop date: [**2150-5-28**].
23. Cipro 500 mg Tablet Sig: One (1) Tablet PO every twelve (12)
hours for 7 days: Start after completion of IV antibiotics and
continue for 10 days.


Discharge Disposition:
Extended Care

Facility:
[**Hospital 5503**] [**Hospital **] Hospital - [**Location (un) 5503**]

Discharge Diagnosis:
hydrocephalas
Chronic Urinary Teact infection
Shunt infection


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


Discharge Instructions:
General Instructions

??????	Have a friend/family member check your incision daily for
signs of infection.
??????	Take your pain medicine as prescribed.
??????	Exercise should be limited to walking; no lifting, straining,
or excessive bending.
??????	If your wound closure uses dissolvable sutures, you must keep
that area dry for 10 days.
??????	You may shower before this time using a shower cap to cover
your head.
??????	Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
??????	Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
??????	If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week.  This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
If you have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
??????	Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.

-Please follow up with your primary care physician regarding
findings noted on your Abdominal CT. (Multiple subcentimeter
simple cysts within the pancreatic tail) Followup with Abdomen
CT in one year is recommended.

CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING

??????	New onset of tremors or seizures.
??????	Any confusion or change in mental status.
??????	Any numbness, tingling, weakness in your extremities.
??????	Pain or headache that is continually increasing, or not
relieved by pain medication.
??????	Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
??????	Fever greater than or equal to 101?????? F.


Followup Instructions:
Follow-Up Appointment Instructions

??????Please return to the office in [**6-21**] days(from your date of
surgery) for a wound check. This appointment can be made with
the Nurse Practitioner.  Please make this appointment by calling
[**Telephone/Fax (1) 1669**].
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.

- Please follow up with your primary care physician regarding
findings noted on your Abdominal CT. (Multiple subcentimeter
simple cysts within the pancreatic tail) Followup with Abdomen
CT in one year is recommended.



Completed by:[**2150-5-22**]
{'Infection and inflammatory reaction due to nervous system device, implant, and graft,Methicillin resistant pneumonia due to Staphylococcus aureus,Cellulitis and abscess of trunk,Urinary tract infection, site not specified,Paraplegia,Hyposmolality and/or hyponatremia,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Congenital hydrocephalus,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Neurogenic bladder NOS,Epilepsy, unspecified, without mention of intractable epilepsy,Dermatitis due to drugs and medicines taken internally,Other specified antibiotics causing adverse effects in therapeutic use,Mild intellectual disabilities,Pressure ulcer, lower back,Diarrhea,Arthrodesis status,Need for desensitization to allergens'}


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: Shunt discontinuity

PRESENT ILLNESS: Ms. [**Known lastname **] is a 34 year old
right handed woman with a history of congenital hydrocephalus
s/p
VPS placement right after birth s/p revision at age 13. She also
appears to have baseline mild MR [**First Name (Titles) **] [**Last Name (Titles) **].

MEDICAL HISTORY: 1. Diabetes
2. chronic UTI/neurogenic bladder requiring cath
3. asthma
4. [**Hospital3 **]
5. hydrocephalus s/p VPS
6. s/p spinal surgery for scoliosis

MEDICATION ON ADMISSION: 1. Detrol
2. Dilantin 200mg daily
3. Fluoxetine 40mg daily
4. Lasix 20mg daily
5. Metformin 1000mg [**Hospital1 **]
6. Proventil INH PRN
7. Simvastatin 20mg daily
8. Piroxicam 20mg PRN
9. Loratidine 10mg daily

ALLERGIES: Amoxicillin / Codeine / Meperidine / Methadone / morphine /
Penicillins / vancomycin

PHYSICAL EXAM: PHYSICAL EXAM5/28/11 the day of admission:
T HR BP 120/80 Resp 12
General: Awake, cooperative, overweight, almost cushingoid in
appearnace.
Head and Neck: no scleral icterus noted, mmm, no lesions noted
in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTA b/l
Cardiac: No murmurs appreciated.
Abdomen: normoactive bowel sounds
Extremities: well perfused, but shortened legs
Skin: There is a protruberance of the shunt lying over the right
clavicle, which ends in an elevated, erthematous and warm patch
of skin over the right chest wall. There are also multiple
excoriations over both legs, with a wound over the right shin.

FAMILY HISTORY: Non-contribiutory

SOCIAL HISTORY: Lives with disabled father and is wheelchair
bound. No TOB or EtOH. 

### Response:
{'Infection and inflammatory reaction due to nervous system device, implant, and graft,Methicillin resistant pneumonia due to Staphylococcus aureus,Cellulitis and abscess of trunk,Urinary tract infection, site not specified,Paraplegia,Hyposmolality and/or hyponatremia,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Congenital hydrocephalus,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Neurogenic bladder NOS,Epilepsy, unspecified, without mention of intractable epilepsy,Dermatitis due to drugs and medicines taken internally,Other specified antibiotics causing adverse effects in therapeutic use,Mild intellectual disabilities,Pressure ulcer, lower back,Diarrhea,Arthrodesis status,Need for desensitization to allergens'}
