CHIEF COMPLAINT: Fever

PRESENT ILLNESS: This is a 57 year old female with history of bipolar disorder
and psychosis who had a TKR on [**2134-6-15**] and had been in rehab
until she developed fevers to 104 and swelling in the left lower
extremity yesterday.  She was started on cephalexin and
ciprofloxacin but continued to be febrile up to 104 today so she
was brought to the ED.

MEDICAL HISTORY: Bipolar disease with psychosis and an episode of NMS in [**2116**]
Non-healing cellulitis in [**2129**]
R TKR [**2132-8-18**]
Spinal stenosis
cholecysectomy
OA
Delirium
Left Knee TKR [**5-/2134**]

MEDICATION ON ADMISSION: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every

ALLERGIES: Haldol

PHYSICAL EXAM: Physical Exam on Presentation:
General: Tired and somnolent, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Left lower Ext: warm, swollen over right, no erythema, incision
intact, adeqaute ROM

FAMILY HISTORY: NC

SOCIAL HISTORY: The patient denies tobacco or alcohol use. The patient has been
at [**Hospital3 **] post-surgery but normally she lives alone and
has two children. The patient's sister assists her during
exacerbations of her bipolar disorder. Sister is HCP.
Infection and inflammatory reaction due to internal joint prosthesis,Unspecified septicemia,Sepsis,Intestinal infection due to Clostridium difficile,Pyogenic arthritis, lower leg,Paralytic ileus,Cellulitis and abscess of leg, except foot,Hyperosmolality and/or hypernatremia,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Bipolar disorder, unspecified,Anemia, unspecified,Hypocalcemia,Esophageal reflux,Morbid obesity,Body Mass Index 33.0-33.9, adult,Malnutrition of moderate degree
React-inter joint prost,Septicemia NOS,Sepsis,Int inf clstrdium dfcile,Pyogen arthritis-l/leg,Paralytic ileus,Cellulitis of leg,Hyperosmolality,Abn react-artif implant,Bipolar disorder NOS,Anemia NOS,Hypocalcemia,Esophageal reflux,Morbid obesity,BMI 33.0-33.9,adult,Malnutrition mod degree
Admission Date:  [**2134-7-3**]              Discharge Date:   [**2134-7-17**]

Date of Birth:  [**2076-11-14**]             Sex:   F

Service: MEDICINE

Allergies:
Haldol

Attending:[**First Name3 (LF) 2279**]
Chief Complaint:
Fever

Major Surgical or Invasive Procedure:
Joint aspiration (Left Knee)
Right Subclavian CVL placement
Flexible Sigmoidoscopy with biopsy
Left knee irrigation and debridment with polyliner exchange
(left knee)


History of Present Illness:
This is a 57 year old female with history of bipolar disorder
and psychosis who had a TKR on [**2134-6-15**] and had been in rehab
until she developed fevers to 104 and swelling in the left lower
extremity yesterday.  She was started on cephalexin and
ciprofloxacin but continued to be febrile up to 104 today so she
was brought to the ED.

In the ED intial VS T 99.9, P 108, BP 106/57, RR 22, O2 96% on
4L.  Exam notable for a very swollen left lower extremity that
was quite warm with some erythema. Maximum heart rate was in the
130s.  She received 3 liters IV fluid with improvement of her
tachycardia to the 90's.  She also received vancomycin and
piperacillin-tazobactam for empiric coverage of infection.
Ortho was initially concerned about septic arthritis and tapped
the joint, but thought fluid was very clear and unlikely to be
infected and therefore triaged patient to MICU.  VS prior to tx
BP 93/41,P 100, RR 25, O2 99% on 2L, CT w/o air.  LENI negative.

.
Review of systems:
(+) Per HPI
(-) Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough, shortness of breath, or wheezing. Denies chest
pain, chest pressure, palpitations, or weakness. Denies nausea,
vomiting, diarrhea, constipation, abdominal pain, or changes in
bowel habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.


Past Medical History:
Bipolar disease with psychosis and an episode of NMS in [**2116**]
Non-healing cellulitis in [**2129**]
R TKR [**2132-8-18**]
Spinal stenosis
cholecysectomy
OA
Delirium
Left Knee TKR [**5-/2134**]

Social History:
The patient denies tobacco or alcohol use. The patient has been
at [**Hospital3 **] post-surgery but normally she lives alone and
has two children. The patient's sister assists her during
exacerbations of her bipolar disorder. Sister is HCP.


Family History:
NC

Physical Exam:
Physical Exam on Presentation:
General: Tired and somnolent, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Left lower Ext: warm, swollen over right, no erythema, incision
intact, adeqaute ROM

Physical Exam at Discharge:
Vitals:Tmax: 99.6, Tcurrent: 98.4, BP:112/65, HR:78, RR:18
General: A+Ox3, energetic and NAD
Abdomen: soft, nontender, stable gaseous distension, bowel
sounds present, no rigidity or guarding
Extremities: 1+ pitting edema in LLE, incision clean, dry, and
intact, mild erythema around incision

Pertinent Results:
Admission Labs:
=================
[**2134-7-3**] 06:43PM   TYPE-[**Last Name (un) **] TEMP-38.9 PO2-86 PCO2-50* PH-7.29*
TOTAL CO2-25 BASE XS--2 INTUBATED-INTUBATED COMMENTS-GREEN TOP
[**2134-7-3**] 06:43PM   LACTATE-1.5 NA+-139
[**2134-7-3**] 06:43PM   freeCa-0.96*
[**2134-7-3**] 06:30PM   GLUCOSE-100 UREA N-13 CREAT-1.2* SODIUM-137
POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-25 ANION GAP-11
[**2134-7-3**] 06:30PM   CK(CPK)-60
[**2134-7-3**] 06:30PM   CK-MB-2 cTropnT-0.02*
[**2134-7-3**] 06:30PM   ALBUMIN-2.8* CALCIUM-7.2* PHOSPHATE-3.5
MAGNESIUM-1.6
[**2134-7-3**] 06:30PM   WBC-10.4 RBC-2.64* HGB-7.2* HCT-23.2* MCV-88
MCH-27.4 MCHC-31.2 RDW-14.1
[**2134-7-3**] 06:30PM   NEUTS-41* BANDS-43* LYMPHS-4* MONOS-9 EOS-1
BASOS-0 ATYPS-2* METAS-0 MYELOS-0
[**2134-7-3**] 06:30PM   HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-OCCASIONAL
MACROCYT-1+ MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
SCHISTOCY-OCCASIONAL
[**2134-7-3**] 06:30PM   PLT COUNT-590*
[**2134-7-3**] 06:30PM   PT-15.2* PTT-29.0 INR(PT)-1.3*
[**2134-7-3**] 06:30PM   FIBRINOGE-530*
[**2134-7-3**] 03:45PM JOINT FLUID  WBC-425* HCT-3.5* POLYS-67*
LYMPHS-15 MONOS-0 MACROPHAG-18
[**2134-7-3**] 03:45PM JOINT FLUID  NUMBER-NONE
[**2134-7-3**] 10:50AM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2134-7-3**] 10:50AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.5
LEUK-NEG
[**2134-7-3**] 10:50AM URINE  RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1
[**2134-7-3**] 10:50AM URINE  MUCOUS-RARE
[**2134-7-3**] 10:32AM   COMMENTS-GREEN TOP
[**2134-7-3**] 10:32AM   GLUCOSE-95 LACTATE-1.9 K+-3.7
[**2134-7-3**] 10:10AM   GLUCOSE-94 UREA N-11 CREAT-1.3* SODIUM-141
POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-27 ANION GAP-17
[**2134-7-3**] 10:10AM   CRP-176.3*
[**2134-7-3**] 10:10AM   WBC-14.0*# RBC-3.03* HGB-8.3* HCT-26.6*
MCV-88 MCH-27.3 MCHC-31.1 RDW-13.9
[**2134-7-3**] 10:10AM   NEUTS-89.1* LYMPHS-4.3* MONOS-5.4 EOS-0.9
BASOS-0.4
[**2134-7-3**] 10:10AM   PLT COUNT-757*
[**2134-7-3**] 10:10AM   PT-13.8* PTT-26.8 INR(PT)-1.2*
[**2134-7-3**] 10:10AM   SED RATE-86*

DISCHARGE LABS
================
[**2134-7-17**] 05:27AM BLOOD WBC-10.5 RBC-1.89*# Hgb-5.1*# Hct-16.2*#
MCV-86 MCH-27.0 MCHC-31.5 RDW-16.4* Plt Ct-794*
[**2134-7-17**] 07:36AM BLOOD Hct-22.3*#
[**2134-7-17**] 05:27AM BLOOD PT-14.9* PTT-37.6* INR(PT)-1.3*
[**2134-7-7**] 06:10AM BLOOD Ret Aut-0.8*
[**2134-7-17**] 05:27AM BLOOD Glucose-103* UreaN-6 Creat-0.9 Na-144
K-3.8 Cl-109* HCO3-28 AnGap-11
[**2134-7-6**] 05:22AM BLOOD LD(LDH)-107 TotBili-0.1 DirBili-0.1
IndBili-0.0
[**2134-7-17**] 05:27AM BLOOD Calcium-7.9* Phos-3.4 Mg-2.0
[**2134-7-6**] 05:22AM BLOOD calTIBC-144 Hapto-323* Ferritn-1224*
TRF-111*
[**2134-7-3**] 10:10AM BLOOD CRP-176.3*
[**2134-7-17**] 05:27AM BLOOD Vanco-19.5
[**2134-7-14**] 04:07PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.007
[**2134-7-14**] 04:07PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD
[**2134-7-8**] 06:24AM URINE RBC-<1 WBC-2 Bacteri-FEW Yeast-NONE Epi-1
TransE-<1
[**2134-7-8**] 05:21PM JOINT FLUID WBC-[**Numeric Identifier **]* RBC-[**Numeric Identifier **]* Polys-94*
Lymphs-0 Monos-0 Macro-6
[**2134-7-3**] 03:45PM JOINT FLUID WBC-425* HCT,Fl-3.5* Polys-67*
Lymphs-15 Monos-0 Macro-18
[**2134-7-9**] 12:10PM OTHER BODY FLUID WBC-3250* RBC-[**Numeric Identifier 14123**]* Polys-90*
Lymphs-6* Monos-0 Macro-4*
[**2134-7-9**] 12:15PM OTHER BODY FLUID UNIVERSAL PCR FOR BACTERIA-PND
[**2134-7-9**] 12:15PM OTHER BODY FLUID UNIVERSAL PCR FOR AFB-PND
[**2134-7-9**] 12:15PM OTHER BODY FLUID UNIVERSAL PCR FOR BACTERIA-PND
[**2134-7-9**] 12:15PM OTHER BODY FLUID UNIVERSAL PCR FOR AFB-PND
[**2134-7-9**] 12:15PM OTHER BODY FLUID UNIVERSAL PCR FOR BACTERIA-PND
[**2134-7-9**] 12:15PM OTHER BODY FLUID UNIVERSAL PCR FOR AFB-PND
[**2134-7-9**] 12:10PM OTHER BODY FLUID UNIVERSAL PCR FOR BACTERIA-PND
[**2134-7-9**] 12:10PM OTHER BODY FLUID UNIVERSAL PCR FOR AFB-PND

MICROBIOLOGY DATA:
===================
Blood cultures 6/18, [**7-4**], [**7-5**], [**7-8**], [**7-14**] FINAL NEGATIVE
Blood culture [**7-15**] PENDING

Urine culture [**7-3**], [**7-4**] NO GROWTH
Urine cultures 6/23 Culture workup discontinued. Further
incubation showed contamination with mixed skin/genital flora.
Clinical significance of isolate(s)uncertain. Interpret with
caution. ENTEROCOCCUS SP..    10,000-100,000 ORGANISMS/ML.

Stool culture [**7-4**] FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
[**2134-7-4**] 6:31 pm STOOL     CONSISTENCY: WATERY
   OVA + PARASITES (Final [**2134-7-5**]):
      NO OVA AND PARASITES SEEN.
      This test does not reliably detect Cryptosporidium,
Cyclospora or
      Microsporidium. While most cases of Giardia are detected
by routine
      O+P, the Giardia antigen test may enhance detection when
organisms
      are rare.
   FECAL CULTURE (Final [**2134-7-6**]):    NO SALMONELLA OR SHIGELLA
FOUND.
   CAMPYLOBACTER CULTURE (Final [**2134-7-6**]):    NO CAMPYLOBACTER
FOUND.
[**7-14**] Stool culture C. Diff NEGATIVE
[**7-15**] Stool culture C. Diff NEGATIVE

[**2134-7-9**] 12:10 pm TISSUE     Site: KNEE
SYNOVIAL TISSUE LEFT KNEE #1.
MEMBRANE FROM FEMORAL NOTCH, LEFT KNEE.
SYNOVIAL TISSUE #2 LEFT KNEE
MEDIAL POCKET HEMATOMA--LFT--KNEE. = All of these had PMNs,
[**1-18**]+, but NO MICROORGANISMS SEEN. TISSUE (Final [**2134-7-12**]):    NO
GROWTH. ANAEROBIC CULTURE (Final [**2134-7-15**]):    NO GROWTH.

[**7-3**] MRSA Screen NEGATIVe

[**2134-7-3**] 3:45 pm JOINT FLUID
  GRAM STAIN (Final [**2134-7-3**]):
      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
      NO MICROORGANISMS SEEN.
   FLUID CULTURE (Final [**2134-7-6**]):    NO GROWTH.
[**2134-7-8**] 5:21 pm JOINT FLUID      Source: Knee.
   GRAM STAIN (Final [**2134-7-8**]):
      2+   (1-5 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.
   FLUID CULTURE (Final [**2134-7-11**]):    NO GROWTH.
   FUNGAL CULTURE (Preliminary):    NO FUNGUS ISOLATED.
   ACID FAST SMEAR (Final [**2134-7-9**]):
      NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
   ACID FAST CULTURE (Preliminary):    NO MYCOBACTERIA ISOLATED.


[**2134-7-9**] 12:10 pm FLUID,OTHER     Site: KNEE
      LEFT KNEE SYNOVIAL FLUID.
   GRAM STAIN (Final [**2134-7-9**]):
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.
   FLUID CULTURE (Final [**2134-7-12**]):    NO GROWTH.
   ANAEROBIC CULTURE (Final [**2134-7-15**]):    NO GROWTH.

[**2134-7-9**] 12:10 pm FLUID WOUND     Site: KNEE
      SYNOVIAL FLUID DRAINED FROM LFT. KNEE.
   GRAM STAIN (Final [**2134-7-9**]):
      2+   (1-5 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.
   FLUID CULTURE (Final [**2134-7-12**]):    NO GROWTH.

IMAGING:
==========
[**2134-7-3**]
PORTABLE AP CHEST RADIOGRAPH: Mild left base
atelectasis/scarring again seen.
There is no focal consolidation or pneumothorax. There is no
vascular
congestion or pleural effusions. Cardiomediastinal and hilar
contours are
within normal limits.

IMPRESSION: No acute cardiopulmonary process.

[**2134-7-4**]
PORTABLE CHEST XRAY
Right subclavian central line tip at SVC/RA junction. No
pneumothorax
detected.

There are low inspiratory volumes. Allowing for this, I doubt
the presence of
significant CHF. Bibasilar atelectasis noted. No effusion.

Compared with [**2134-7-3**], at 22:37 p.m., the right central line
appears to have
been retracted. On the current examination, comparative density
between the
right and left chest is similar, suggesting that the appearance
on the most
recent previous film was an artifact related to overlying soft
tissues.

[**2134-7-3**]
LENIS
IMPRESSION:
1. No DVT in the left leg. Marked left lower extremity edema
without fluid
collections.

[**2134-7-4**]
LOWER EXTREMITY CT
CT LEFT LOWER EXTREMITY. MDCT imaging was performed from the mid
femur to the
ankle without IV contrast. Sagittal and coronal reformats were
performed.

COMPARISON: Left leg venous ultrasound [**2134-7-3**].

FINDINGS: The patient has undergone total left knee
arthroplasty, and the
hardware appears intact. There are no fractures. Degenerative
changes are
present at the ankle, and mid foot.

[**2134-7-4**]
ABDOMINAL XRAY
No SBO, inadequate evaluation of free air due to portable
technique. Sigmoid
dilated to 10.5cm is air filled, recommend continued evaluation
and followup
abdominal film if indicated.

- PORTABLE ABDOMEN Study Date of [**2134-7-6**] 9:01 AM
IMPRESSION: Similar moderate colonic distention. No definite
evidence of  pneumoperitoneum, within the limits of supine
radiograph.

- KNEE (2 VIEWS) LEFT Study Date of [**2134-7-9**] 2:26 PM
IMPRESSION: Post-surgical changes of the left knee. Status post
I and D.  Intact hardware.

- PORTABLE ABDOMEN Study Date of [**2134-7-12**] 9:38 AM
FINDINGS: Again seen is gaseous distention of the colon,
measuring up to 9.5
cm in diameter. There are no definite loops of air filled
distended small
bowel. No large quantity of free air is identified on the supine
radiographs.

IMPRESSION: Persistent gaseous distention of the colon,
consistent with
ileus.

- PORTABLE ABDOMEN Study Date of [**2134-7-15**] 3:19 PM
IMPRESSION: No significant change in the degree of colonic
distention, most
consistent with ileus.

- PORTABLE ABDOMEN Study Date of [**2134-7-17**]
Read PENDING

PATHOLOGY
=========
Pathology Report Tissue: GI BX'S (2 JARS) Study Date of [**2134-7-16**]

Report not finalized.
Assigned Pathologist [**Last Name (LF) **],[**First Name3 (LF) **] M.
Logged in only.
PATHOLOGY # [**-1/2754**]
GI BX'S (2 JARS)


Brief Hospital Course:
57 year-old female with a past medical history of bipolar,
dementia, recent left TNK on [**6-15**] presenting with sepsis with
probable source from C.Difficile infection.

# Sepsis with probable source of C.Diff infection:  Originally
thought to be from possible septic joint/cellulitis, and
empirically started on vancomycin/cefepime. Patient was initally
septic, and was transferred to the ICU from the ED. No evidence
of septic joint on aspiration.  Incision site appeared CDI on
exam.  Joint fluid not consistent with septic joint while on
antibiotics.  C.Diff positive on assay.  Discontinued IV
vancomycin/cefepime and placed on PO vancomycin with IV Flagyl.
  Clinical picture is much improved with hemodynamic stability
by HD#2. Patient was transferred to the floor where treatment
for C. diff continued. While on the floor, patient's knee became
more painful with surrounding erythema and swelling. A repeat
tap was done which showed elevated WBC copunt and >90% PMN. She
was taken back to the OR for debridement of the knee with
replacement of lining on [**2134-7-9**]. Patient tolerated the
procedure well, but upon returning to the floor had an increase
in the volume of her diarrhea. She was continued on PO
Vancomycin and IV Flagyl for treatment of C. diff and multiple
KUB's demonstrated colonic gaseous distension. She never vomited
and continued to have copious diarrhea at this time. Patient
tolerated a full diet, and stool volume decreased and became
less loose over time, though gaseous distension remained. She
was without abdominal pain. The distension was deemed to be
chronic ileus and she was discharged with instructions to follow
up in two months for repeat KUB.

# Sigmoid dilation on KUB:  No evidence of obstruction, however
11 cm dilated sigmoid on KUB.  Concern for possible toxic
megacolon.  Continued NPO status and got surgical evaluation for
aid in management.  With improving clinical picture, toxic
megacolon was deemed unlikely. Rectal tube placed with improved
symptomatology.  Repeat KUB post rectal tube showed stable
dilation and absence of abdominal complaints in patient. She
tolerated food, and had stool output that progressed from
copious and watery to smaller quantities and semi-formed. She
remained afebrile and asymptomatic and the distension was felt
to be a chronic ileus. GI performed a flexible sigmoidoscopy
which per report did not show any pseudomembranes; biopsies were
taken and are pending at the time of discharge.

#Fluid Balance: LOS fluid balance +11 Liters during treatment
for sepsis and electrolyte abnormalities. However, patient had
large volume watery stool output and was NPO for procedures on
several days, decreasing her fluid balance. Clinically, patient
was euvolemic on discharge.

#Status Post TKR and subsequent washout with lining replacement:
Patient's original septic picture was felt to be from C.diff but
she subsequently developed septic arthritis in the left knee
given marked pain, erythema, and swelling in the affected knee.
She went back to the OR for debridement and replacement of the
prosthetic lining. Cultures of the joint fluid and blood were
negative, and samples of the joint tissue were sent for PCR.
Without organism identified, patient was started on IV
Vancomycin to cover the most likely offending organisms, and has
been stable and improving on that therapy to discharge.

Chronic Diagnoses:

# Bipolar affective disorder: Continued depakote, risperidone,
and lorazepam

# Anemia: Patient's Hct dropped in hospital in the setting of
multiple procedures, blood draws, and acute illness, but was
stable on discharge. Iron studies showed pattern consistent with
anemia of chronic disease. She was discharged with iron
supplementation.

Transitional Issues:
Patient will be discharged to rehab for extended recovery with
PT. From there she will be evaluated for home services.

Orthopedic followup: Patient will be seen for a wound check with
her orthopedist on [**2134-7-23**]. Stitched should remain in until
this time.
Patient should stay on Lovenox 40units SC daily for 3 weeks, and
then discuss with her orthopedist taking aspirin for an
additional 3 weeks.

Infectious disease followup:
Patient will continue IV Vancomycin therapy for a total of 6
weeks post-surgery and send weekly BUN, CR, CBC with Diff
vancomycin trough level and LFT's to the [**Hospital **] clinic.
Patient will continue IV Flagyl for C.diff for 2 weeks
post-discharge, and continue oral vancomycin until tapered down
by her infectious disease doctor.
The results of the PCR test of joint tissue will be available in
a few weeks and should be followed up by the infectious disease
doctors.

PCP [**Name Initial (PRE) 4939**]:
Patient will see her PCP within one week of discharge and
arrange for a repeat KUB in two months to evaluate her chronic
ileus. The results of patient's flexible sigmoidoscopy with
biopsies should be available for PCP's review as well.

Medications on Admission:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every

6 hours).
2. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)

as needed for Pain.
Disp:*100 Tablet(s)* Refills:*0*
3. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12

hours).
4. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
5. divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One (1)

Tablet, Delayed Release (E.C.) PO BID (2 times a day).
6. risperidone 2 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
7. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous DAILY (Daily).
Disp:*28 syringe* Refills:*0*
8. Keflex 500 mg Capsule Sig: One (1) Capsule PO three times a
day for 10 days.
Disp:*30 Capsule(s)* Refills:*0*


Discharge Medications:
1. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) 40mg/0.4mL
Subcutaneous once a day: One injection to abdomen daily.
Disp:*21 40mg/0.4mL* Refills:*0*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
4. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO Q6H (every 6 hours) as needed for Dyspepsia.
5. multivitamin     Tablet Sig: One (1) Cap PO DAILY (Daily).
6. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
10. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram
Intravenous Q 12H (Every 12 Hours) for 35 days.
11. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. metronidazole in NaCl (iso-os) 500 mg/100 mL Piggyback Sig:
Five Hundred (500) mg Intravenous Q8H (every 8 hours) for 2
weeks.
13. divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO BID (2 times a day).
14. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
15. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO at bedtime.
16. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for anxiety.
17. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
18. risperidone 2 mg Tablet Sig: One (1) Tablet PO at bedtime.
19. vancomycin 250 mg Capsule Sig: One (1) Capsule PO every six
(6) hours.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 105**] - [**Location (un) 86**]

Discharge Diagnosis:
Primary: septic arthritis of left knee, C. diff colitis, Chronic
Ileus

Secondary: Anemia, Bipolar Disorder, osteoarthritis


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

You were admitted to the hospital because you had fever and low
blood pressure at your rehab. You were found to have an
infection called C. diff colitis in your colon. You were
stabilized in the ICU with antibiotics were and transferred to
the medical floor. On the medical floor, your knee became red
and inflamed with a new infection and the orthopedic surgeons
performed a surgery to clean out the infection from your knee on
[**2134-7-9**]. When you returned from surgery, you continued to have
diarrhea as you were still recovering from C. diff colitis.
Because you had so much abdominal distension at this time, and
because your diarrhea lasted so long, the gastroenterologists
performed a flexible sigmoidoscopy procedure to look inside your
colon and take samples to be sure there wasn't a persistant
infection or other visible cause for your diarrhea in addition
to the infection. Shortly afterwards, your diarrhea greatly
improved, your knee appeared to be healing well, and it was felt
that your were ready to transfer to a rehabilitation facility
for the remainder of your recovery. Your belly remains distended
with gas, but because you are eating and stooling without issue,
this can be followed up as an outpatient.

Please make the following changes to your home medications:

1. START taking Lovenox 40 units by subcutaneous injection daily
for three weeks following discharge. When that is complete after
three weeks, DISCUSS taking aspirin for an additional 3 weeks
with your PCP and orthopedic surgeon, as this may interact with
your Divalproex.
2. START wearing TEDS stockings for a total of six weeks
3. START taking Vancomycin 1,000mg twice daily intravenously
until [**9-20**].
4. START taking metronidazole 500mg every eight hours
intravenously for two weeks
5. START taking Vancomycin 250mg by mouth every six hours until
you are instructed to stop by your infectious disease doctor.

Please send the following lab results weekly starting [**2134-7-20**] to
the Infectious Disease Clinic at [**Telephone/Fax (1) 1419**]:

CBC with diff, BUN, creatinine, liver function tests, and
vancomycin trough levels (one hour before you receive your dose)

The Orthopedic Surgeons have the following discharge
instructions for you as well, some of which overlap with your
medical team's instructions:

1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.

2. Please follow up with your primary physician regarding this
admission and any new medications and refills.

3. Resume your home medications unless otherwise instructed.

4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as colace) as needed to prevent
this side effect.  Call your surgeons office 3 days before you
are out of medication so that it can be refilled.  These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house.  Please allow
an extra 2 days if you would like your medication mailed to your
home.

5. You may not drive a car until cleared to do so by your
surgeon.

6. Please keep your wounds clean. You may shower starting five
(5) days after surgery, but no tub baths or swimming for at
least four (4) weeks. No dressing is needed if wound continues
to be non-draining.

7. Please call your surgeon's office to schedule or confirm your
follow-up appointment in two (2) weeks.

8. Please DO NOT take any non-steroidal anti-inflammatory
medications (NSAIDs such as celebrex, ibuprofen, advil, aleve,
motrin, etc).

9. ANTICOAGULATION: Please continue your lovenox for three (3)
weeks to help prevent deep vein thrombosis (blood clots).  After
completing the lovenox, please take Aspirin 325mg  TWICE  daily
for three weeks.  [**Male First Name (un) **] STOCKINGS x 6 WEEKS.

10. WOUND CARE: Please keep your incision clean and dry. It is
okay to shower five days after surgery but no tub baths,
swimming, or submerging your incision until after your two (2)
week checkup. Please place a dry sterile dressing on the wound
each day if there is drainage, otherwise leave it open to air.
Check wound regularly for signs of infection such as redness or
thick yellow drainage. Staples will be removed by the visiting
nurse or rehab facility in two (2) weeks.

11. VNA (once at home): Home PT/OT, dressing changes as
instructed, wound checks.

12. ACTIVITY: Weight bearing as tolerated on the operative
extremity. Mobilize. CPM/ROM as tolerated. No strenuous exercise
or heavy lifting until follow up appointment.

Followup Instructions:
Call Dr[**Name (NI) **] office at [**Telephone/Fax (1) 1228**] to be seen on [**7-23**]
for a wound check for your leg.

Please call to confirm your appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 438**]
in the Infectious Disease Clinic at [**Hospital1 827**]. It is scheduled for:
DATE: [**2134-7-29**]
TIME: 9AM

Please contact your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 807**] at [**Telephone/Fax (1) 823**], to
schedule a follow-up appointment within a week of discharge. You
will need a follow-up abdominal x-ray in two months to verify
that your belly distension is chronic when you are eating and
stooling normally.


                             [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]
{'Infection and inflammatory reaction due to internal joint prosthesis,Unspecified septicemia,Sepsis,Intestinal infection due to Clostridium difficile,Pyogenic arthritis, lower leg,Paralytic ileus,Cellulitis and abscess of leg, except foot,Hyperosmolality and/or hypernatremia,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Bipolar disorder, unspecified,Anemia, unspecified,Hypocalcemia,Esophageal reflux,Morbid obesity,Body Mass Index 33.0-33.9, adult,Malnutrition of moderate degree'}


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: Fever

PRESENT ILLNESS: This is a 57 year old female with history of bipolar disorder
and psychosis who had a TKR on [**2134-6-15**] and had been in rehab
until she developed fevers to 104 and swelling in the left lower
extremity yesterday.  She was started on cephalexin and
ciprofloxacin but continued to be febrile up to 104 today so she
was brought to the ED.

MEDICAL HISTORY: Bipolar disease with psychosis and an episode of NMS in [**2116**]
Non-healing cellulitis in [**2129**]
R TKR [**2132-8-18**]
Spinal stenosis
cholecysectomy
OA
Delirium
Left Knee TKR [**5-/2134**]

MEDICATION ON ADMISSION: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every

ALLERGIES: Haldol

PHYSICAL EXAM: Physical Exam on Presentation:
General: Tired and somnolent, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Left lower Ext: warm, swollen over right, no erythema, incision
intact, adeqaute ROM

FAMILY HISTORY: NC

SOCIAL HISTORY: The patient denies tobacco or alcohol use. The patient has been
at [**Hospital3 **] post-surgery but normally she lives alone and
has two children. The patient's sister assists her during
exacerbations of her bipolar disorder. Sister is HCP. 

### Response:
{'Infection and inflammatory reaction due to internal joint prosthesis,Unspecified septicemia,Sepsis,Intestinal infection due to Clostridium difficile,Pyogenic arthritis, lower leg,Paralytic ileus,Cellulitis and abscess of leg, except foot,Hyperosmolality and/or hypernatremia,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Bipolar disorder, unspecified,Anemia, unspecified,Hypocalcemia,Esophageal reflux,Morbid obesity,Body Mass Index 33.0-33.9, adult,Malnutrition of moderate degree'}
