CHIEF COMPLAINT: Sternal wound infection with drainage of
pus

PRESENT ILLNESS: Ms. [**Known lastname **] is a 68-year-old
female who had coronary artery bypass surgery in [**2187-5-16**] by Dr. [**Last Name (STitle) **].  Postoperatively, she had multiple
problems with her sternal wound, and was most recently
admitted in [**2187-4-16**].  She now returns from an outside
hospital after a positive culture for methicillin resistant
staphylococcus aureus from the wound.  She reports being
otherwise stable, and is getting ready for discharge home
from the rehabilitation where she has been postoperatively.
She denies any fevers or chills.  She does state that she has
a small hole at the inferior aspect of her sternum that oozes
copious amounts of pus.

MEDICAL HISTORY: 1.  Status post coronary artery bypass graft in [**2187-3-16**]
2.  Asthma and chronic obstructive pulmonary disease, steroid
dependent
3.  Gastroesophageal reflux disease
4.  Transient ischemic attack and cerebrovascular accident
5.  Insulin-dependent diabetes mellitus
6.  Hypertension
7.  Status post total knee replacement
8.  Seizure disorder
9.  Renal mass, not otherwise specified
10. Anxiety disorder
11. Right subclavian steal syndrome

MEDICATION ON ADMISSION: 1.  Prevacid 30 mg by mouth once daily
2.  Amiodarone 200 mg by mouth once daily
3.  Lasix 20 mg by mouth once daily
4.  Imdur 90 mg by mouth once daily
5.  Multivitamin
6.  Albuterol and Atrovent nebulizers as needed
7.  Lovenox 40 mg subcutaneously once daily
8.  Dilantin 300 mg by mouth twice a day
9.  Humalog 75/25, 20 units every morning
10. Sliding scale insulin
11. Tylenol 650 mg by mouth every four to six hours as needed
12. Vicodin 5/500
13. Ambien 5 mg by mouth daily at bedtime
14. Aldactone 75 mg by mouth once daily
15. Plavix 75 mg by mouth once daily
16. Prednisone 5 mg by mouth once daily
17. Colace 100 mg by mouth twice a day
18. Accolate 20 mg by mouth once daily
19. Combivent metered dose inhaler

ALLERGIES: Aspirin and ACE inhibitors give her anaphylaxis.
She is also allergic to beta blockers, which give her
bronchospasm.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Other postoperative infection,Chronic obstructive asthma, unspecified,Other convulsions,Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled,Urinary tract infection, site not specified,Subclavian steal syndrome,Unspecified essential hypertension,Esophageal reflux,Aortocoronary bypass status
Other postop infection,Chronic obst asthma NOS,Convulsions NEC,DMI wo cmp nt st uncntrl,Urin tract infection NOS,Subclavian steal syndrom,Hypertension NOS,Esophageal reflux,Aortocoronary bypass
Admission Date:  [**2187-6-29**]       Discharge Date:  [**2187-7-9**]

Date of Birth:   [**2118-10-20**]       Sex:  F

Service:  CARDIAC SURGERY

CHIEF COMPLAINT:  Sternal wound infection with drainage of
pus

HISTORY OF PRESENT ILLNESS:  Ms. [**Known lastname **] is a 68-year-old
female who had coronary artery bypass surgery in [**2187-5-16**] by Dr. [**Last Name (STitle) **].  Postoperatively, she had multiple
problems with her sternal wound, and was most recently
admitted in [**2187-4-16**].  She now returns from an outside
hospital after a positive culture for methicillin resistant
staphylococcus aureus from the wound.  She reports being
otherwise stable, and is getting ready for discharge home
from the rehabilitation where she has been postoperatively.
She denies any fevers or chills.  She does state that she has
a small hole at the inferior aspect of her sternum that oozes
copious amounts of pus.

PAST MEDICAL HISTORY:
1.  Status post coronary artery bypass graft in [**2187-3-16**]
2.  Asthma and chronic obstructive pulmonary disease, steroid
dependent
3.  Gastroesophageal reflux disease
4.  Transient ischemic attack and cerebrovascular accident
5.  Insulin-dependent diabetes mellitus
6.  Hypertension
7.  Status post total knee replacement
8.  Seizure disorder
9.  Renal mass, not otherwise specified
10. Anxiety disorder
11. Right subclavian steal syndrome

ALLERGIES:   Aspirin and ACE inhibitors give her anaphylaxis.
She is also allergic to beta blockers, which give her
bronchospasm.

MEDICATIONS ON ADMISSION:
1.  Prevacid 30 mg by mouth once daily
2.  Amiodarone 200 mg by mouth once daily
3.  Lasix 20 mg by mouth once daily
4.  Imdur 90 mg by mouth once daily
5.  Multivitamin
6.  Albuterol and Atrovent nebulizers as needed
7.  Lovenox 40 mg subcutaneously once daily
8.  Dilantin 300 mg by mouth twice a day
9.  Humalog 75/25, 20 units every morning
10. Sliding scale insulin
11. Tylenol 650 mg by mouth every four to six hours as needed
12. Vicodin 5/500
13. Ambien 5 mg by mouth daily at bedtime
14. Aldactone 75 mg by mouth once daily
15. Plavix 75 mg by mouth once daily
16. Prednisone 5 mg by mouth once daily
17. Colace 100 mg by mouth twice a day
18. Accolate 20 mg by mouth once daily
19. Combivent metered dose inhaler

PHYSICAL EXAMINATION:   She is a well-appearing, pleasant
female, in no acute distress.  Her temperature is 97.5, pulse
87, blood pressure 120/60, respiratory rate 16, oxygen
saturation 97% on room air.  Neurologically, she is grossly
intact.  Cardiovascular:  She has a regular rate and rhythm
without murmur.  Breath sounds are coarse, with scattered
rhonchi but no wheezes.  Her abdomen is obese, soft,
nontender, nondistended, with bowel sounds present.  Her
sternal incision has skin that is well healed with the
exception of a .5 cm open area along the inferior portion,
draining large amounts of yellow pus.  There is no erythema,
and the sternum is stable to palpation.  Her left lower
extremity vein harvest site distal to the knee also has a
small open area with minimal drainage and a small amount of
erythema.

LABORATORY DATA:  White blood cell count 13.5, hematocrit
34.8, platelets 424.  Sodium 142, potassium 4.1, chloride
106, bicarbonate 26, BUN 11, creatinine 0.8, glucose 101.
Her coagulation studies are normal.

HOSPITAL COURSE:   The patient was admitted to the Cardiac
Surgery service with a diagnosis of sternal wound infection.
A culture was immediately taken of the wound.  A PICC line
was placed, and she was started on intravenous vancomycin
and, in addition, she was started on oral Levaquin.  A
urinalysis was sent that revealed that she had a urinary
tract infection. In addition, the wound culture was positive
for 4+ PMNs in addition rule out 4+ gram-positive cocci and
4+ gram-negative rods.  This culture ultimately grew
methicillin resistant staphylococcus aureus, group B strep,
another unidentified gram-positive rod that we are presuming
was diphtheroids or Carinii bacterium.  In addition, from her
anaerobic culture, she grew Prevotella that was beta
lactamase positive and Peptostreptococcus.

A CT scan was obtained that demonstrated inflammatory changes
within the anterior mediastinum and a 7 x 13 mm fluid
collection.  In addition, there were some small lymph nodes
within the mediastinum.  In addition, they found a tiny
calcified nodule in the right middle lobe that was felt to
likely represent a granuloma, and another tiny noncalcified
nodule in the lingula that was also likely benign in origin.
Finally, her adrenal mass was imaged and demonstrated no
change in size.  The Radiology staff believes that this is
likely an adenoma.

A Plastic Surgery consult was obtained regarding this
patient's sternal wound infection.  They ultimately
recommended a two-stage operation in which the patient was
debrided and later received a closure flap.  Therefore, on
[**2187-7-2**], the patient was taken to the operating room,
where she had a sternal debridement.  The procedure itself
was unremarkable.  Postoperatively, she was taken to the
Cardiac Surgery Intensive Care Unit.  During this time, her
white blood cell count climbed to as high as 19.9.  She did
have wet-to-dry dressings to her sternum and, within about
two days, it was felt that her wound looked improved enough
for the second stage of her operation.  On [**2187-7-4**], she
was taken to the operating room by Dr. [**Last Name (STitle) 13797**] and his team.
There she received bilateral pectoralis major muscle
advancement flap closure of her wound.  The patient's
procedure itself was unremarkable.  Postoperatively, she was
kept in the Post-Anesthesia Care Unit for some time for
observation, but ultimately arrived on the floor.

She did have some postoperative issues with pain management,
and it was difficult to find an appropriate regimen for her.
Initially she was kept on Vicodin with morphine for
breakthrough pain.  This did not adequately control her.  We
tried her on a patient-controlled analgesia, which she was
not able to use effectively.  Finally, she was started on
oral percocet, and that appeared to manage her pain
adequately well.

The patient's hematocrit did drop as low as 20,000.  She
received a total of four units of packed red blood cells.
Throughout the ensuing days of her hospitalization, she
demonstrated continued improvement.  Her wound remained
clean, dry and intact, without erythema.  On the day prior to
her transfer back to rehabilitation, the Plastic Surgery team
asked us to start applying bacitracin to the wound twice a
day.  She did have two [**Doctor Last Name 406**] drains that were left in place
with bulb suction.  In addition, she has wound anchors going
through some of her breast tissue that need to remain in
place until her postoperative visit.  Finally, she is to wear
a surgical bra at all times, and is to only have it open and
removed for wound inspection and dressing changes.

While the patient was here, we had a consult from the [**Last Name (un) **]
diabetes team.  They recommended changing her insulin from
75/25 once daily to a twice a day regimen.  She appeared to
be stable on 9 units of NPH in the morning and 5 units of NPH
in the evening with a sliding scale to cover.

A Medicine consult was obtained to help manage the patient's
multiple medical problems.  They ultimately recommended that
she be continued on her antibiotics and that her Aldactone be
restarted, which was held postoperatively.  In addition, they
recommended that a Dilantin level be checked.  It was found
to be therapeutic at 12.3.  All of her other medical problems
during this hospitalization appeared to be stable.

As the patient progressed to postoperative day number three
and four from her advancement flap, her white blood cell
count improved.  On the day prior to discharge, her white
count was down to 14,000.

On [**2187-7-9**], the patient was transferred back to
rehabilitation for further care and management.  She needs to
return in eight days to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13797**]
in his [**Hospital 3816**] clinic.

The patient is transferred on the following medications:
1.  Vancomycin 1 gram intravenously every 12 hours for six
weeks
2.  Levaquin 500 mg by mouth once daily for six weeks
3.  Protonix 40 mg by mouth once daily
4.  Amiodarone 200 mg by mouth once daily
5.  Lasix 20 mg by mouth twice a day
6.  Imdur 90 mg by mouth once daily
7.  Ambien 5 mg by mouth daily at bedtime
8.  Potassium chloride 20 mEq by mouth twice a day
9.  Multivitamin once daily
10. Lovenox 40 mg subcutaneously twice a day
11. Plavix 75 mg once daily
12. Prednisone 5 mg once daily
13. Ativan 0.5 mg twice a day
14. Colace 100 mg twice a day
15. Dilantin 300 mg twice a day
16. Accolate 20 mg by mouth once daily
17. Spironolactone 25 mg once daily
18. Bacitracin ointment to wound twice a day
19. Combivent metered dose inhaler one to two puffs four
times a day
20. Percocet 5/325 one to two by mouth every four to six
hours as needed
21. Morphine sulfate intravenously/subcutaneously, 1 to 5 mg
every six hours for breakthrough pain
22. NPH 9 units in the morning, 6 units in the evening at
bedtime
23. Sliding scale regular insulin
24. Albuterol and Atrovent nebulizers as needed

Note to rehabilitation staff:  The patient has subclavian
steal syndrome and has a significantly lower blood pressure
in the right arm.  We ask that all blood pressures be
measured in the left forearm below her PICC line.

DISCHARGE DIAGNOSIS:
1.  Sternal wound infection, now status post surgical
debridement and bilateral pectoralis major muscle advancement
flap closure
2.  Methicillin resistant staphylococcus aureus infection
3.  Insulin-dependent diabetes mellitus, partially controlled
4.  Hypertension
5.  Right subclavian steal
6.  Status post coronary artery bypass graft




                            [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D.  [**MD Number(1) 3113**]

Dictated By:[**Last Name (NamePattern1) 9638**]
MEDQUIST36

D:  [**2187-7-8**]  20:20
T:  [**2187-7-9**]  00:26
JOB#:  [**Job Number 38925**]
{'Other postoperative infection,Chronic obstructive asthma, unspecified,Other convulsions,Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled,Urinary tract infection, site not specified,Subclavian steal syndrome,Unspecified essential hypertension,Esophageal reflux,Aortocoronary bypass status'}


You are an AI assistant analyzing clinical admission notes from the MIMIC III dataset. Your task is to map symptoms mentioned in the notes to a list of provided ICD-9 LONG_TEXT.



### Clinical text :
CHIEF COMPLAINT: Sternal wound infection with drainage of
pus

PRESENT ILLNESS: Ms. [**Known lastname **] is a 68-year-old
female who had coronary artery bypass surgery in [**2187-5-16**] by Dr. [**Last Name (STitle) **].  Postoperatively, she had multiple
problems with her sternal wound, and was most recently
admitted in [**2187-4-16**].  She now returns from an outside
hospital after a positive culture for methicillin resistant
staphylococcus aureus from the wound.  She reports being
otherwise stable, and is getting ready for discharge home
from the rehabilitation where she has been postoperatively.
She denies any fevers or chills.  She does state that she has
a small hole at the inferior aspect of her sternum that oozes
copious amounts of pus.

MEDICAL HISTORY: 1.  Status post coronary artery bypass graft in [**2187-3-16**]
2.  Asthma and chronic obstructive pulmonary disease, steroid
dependent
3.  Gastroesophageal reflux disease
4.  Transient ischemic attack and cerebrovascular accident
5.  Insulin-dependent diabetes mellitus
6.  Hypertension
7.  Status post total knee replacement
8.  Seizure disorder
9.  Renal mass, not otherwise specified
10. Anxiety disorder
11. Right subclavian steal syndrome

MEDICATION ON ADMISSION: 1.  Prevacid 30 mg by mouth once daily
2.  Amiodarone 200 mg by mouth once daily
3.  Lasix 20 mg by mouth once daily
4.  Imdur 90 mg by mouth once daily
5.  Multivitamin
6.  Albuterol and Atrovent nebulizers as needed
7.  Lovenox 40 mg subcutaneously once daily
8.  Dilantin 300 mg by mouth twice a day
9.  Humalog 75/25, 20 units every morning
10. Sliding scale insulin
11. Tylenol 650 mg by mouth every four to six hours as needed
12. Vicodin 5/500
13. Ambien 5 mg by mouth daily at bedtime
14. Aldactone 75 mg by mouth once daily
15. Plavix 75 mg by mouth once daily
16. Prednisone 5 mg by mouth once daily
17. Colace 100 mg by mouth twice a day
18. Accolate 20 mg by mouth once daily
19. Combivent metered dose inhaler

ALLERGIES: Aspirin and ACE inhibitors give her anaphylaxis.
She is also allergic to beta blockers, which give her
bronchospasm.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Other postoperative infection,Chronic obstructive asthma, unspecified,Other convulsions,Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled,Urinary tract infection, site not specified,Subclavian steal syndrome,Unspecified essential hypertension,Esophageal reflux,Aortocoronary bypass status'}
