CHIEF COMPLAINT: Dehisence of right below-knee amputation site with bone exposure

PRESENT ILLNESS: PER ADMITTING VASCULAR TEAM:
Patient is a 59F who initially [**Doctor Last Name 1834**] a R BKA by Dr. [**Last Name (STitle) 83920**]
at [**Hospital2 **] [**Hospital3 6783**] hospital for severe PVD on [**2120-9-29**].  Patient
later developed wound dehiscense with exposed bone.  R BKA wound
culture grew out multi-resistent pseudomonas sensitive only to
vanc and tobramycin.  She was treated with vanc from
[**Date range (1) 80992**], when abx were stopped due to her needing
surgical treatment for osteomyelitis.  A wound vac was placed,
and she was set up for a follow-up appointment with Dr. [**Last Name (STitle) 1391**]
on [**2-12**].  However, at rehab she developed elevated
temperatures to 100.7 and was brought back to [**Hospital2 **] [**Hospital3 6783**]
Hospital on [**2121-2-1**].  An MRA of the R BKA showed 2.58cm of
distal tibia/fibula osteo with
surrounding myositis.

MEDICAL HISTORY: - HTN
- DM2 associated with retinopathy, neuropathy, nephropathy
- Hyperlipidemia
- PVD
- Osteomyelities with MRSA
- OA
- obesity
- seizures
.
PAST SURGICAL HISTORY:
- [**2-25**] R CEA
- [**9-25**] R BKA
- [**10-25**] Tracheostomy in the setting of seizure, PEA, arrest and
vocal cord edema

MEDICATION ON ADMISSION: Albuterol Sulfate
Ergocalciferol (Vitamin D2) [Vitamin D]
Gabapentin
Heparin (Porcine)
Insulin Aspart [Novolog]
Insulin Glargine [Lantus]
Levetiracetam
Metoprolol Tartrate
Metronidazole
Morphine
Pantoprazole
Acetaminophen [Tylenol]
Ascorbic Acid
Aspirin
Cyanocobalamin
Lactobacillus Acidophilus
Multivitamin
Zinc Sulfate

ALLERGIES: Vicodin

PHYSICAL EXAM: ON ADMISSION:
Vital Signs: Temp: 98.1 RR: 18 Pulse: 68 BP: 150/68
Neuro/Psych: NAD.
Skin: Abnormal: Stage 2 decub ulcers.
Heart: Regular rate and rhythm.
Lungs: Clear, Normal respiratory effort.
Gastrointestinal: No masses, abnormal: Obese.
Rectal: Not Examined.
Extremities: No RLE edema, No LLE Edema, abnormal: R BKA with
exposed bone edges.

FAMILY HISTORY: n/c

SOCIAL HISTORY: - married
.
HABITS:
- Tobacco: remote
- ETOH:
- Recreational Drug Use:
Infection (chronic) of amputation stump,Encephalopathy, unspecified,Acute kidney failure, unspecified,Pressure ulcer, stage III,Intestinal infection due to Clostridium difficile,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Background diabetic retinopathy,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Unspecified essential hypertension
Infection amputat stump,Encephalopathy NOS,Acute kidney failure NOS,Pressure ulcer,stage III,Int inf clstrdium dfcile,DMII neuro nt st uncntrl,Neuropathy in diabetes,Diabetic retinopathy NOS,Nephritis NOS in oth dis,Hypertension NOS
Admission Date:  [**2121-2-5**]              Discharge Date:   [**2121-2-18**]

Date of Birth:  [**2061-3-20**]             Sex:   F

Service: NEUROLOGY

Allergies:
Vicodin

Attending:[**Doctor Last Name 15044**]
Chief Complaint:
Dehisence of right below-knee amputation site with bone exposure


Major Surgical or Invasive Procedure:
* Revision of right below-knee amputation


History of Present Illness:
PER ADMITTING VASCULAR TEAM:
Patient is a 59F who initially [**Doctor Last Name 1834**] a R BKA by Dr. [**Last Name (STitle) 83920**]
at [**Hospital2 **] [**Hospital3 6783**] hospital for severe PVD on [**2120-9-29**].  Patient
later developed wound dehiscense with exposed bone.  R BKA wound
culture grew out multi-resistent pseudomonas sensitive only to
vanc and tobramycin.  She was treated with vanc from
[**Date range (1) 80992**], when abx were stopped due to her needing
surgical treatment for osteomyelitis.  A wound vac was placed,
and she was set up for a follow-up appointment with Dr. [**Last Name (STitle) 1391**]
on [**2-12**].  However, at rehab she developed elevated
temperatures to 100.7 and was brought back to [**Hospital2 **] [**Hospital3 6783**]
Hospital on [**2121-2-1**].  An MRA of the R BKA showed 2.58cm of
distal tibia/fibula osteo with
surrounding myositis.

Past Medical History:
- HTN
- DM2 associated with retinopathy, neuropathy, nephropathy
- Hyperlipidemia
- PVD
- Osteomyelities with MRSA
- OA
- obesity
- seizures
.
PAST SURGICAL HISTORY:
- [**2-25**] R CEA
- [**9-25**] R BKA
- [**10-25**] Tracheostomy in the setting of seizure, PEA, arrest and
vocal cord edema


Social History:
- married
.
HABITS:
- Tobacco: remote
- ETOH:
- Recreational Drug Use:



Family History:
n/c

Physical Exam:
ON ADMISSION:
Vital Signs: Temp: 98.1 RR: 18 Pulse: 68 BP: 150/68
Neuro/Psych: NAD.
Skin: Abnormal: Stage 2 decub ulcers.
Heart: Regular rate and rhythm.
Lungs: Clear, Normal respiratory effort.
Gastrointestinal: No masses, abnormal: Obese.
Rectal: Not Examined.
Extremities: No RLE edema, No LLE Edema, abnormal: R BKA with
exposed bone edges.

Pulse Exam (P=Palpation, D=Dopplerable, N=None)
RUE Radial: P.
LUE Radial: P.
RLE Femoral: P. Popiteal: P.
LLE Femoral: P. Popiteal: P. DP: D. PT: D.

DESCRIPTION OF WOUND: open R BKA wound with exposed tib/fib,
tissue planes easily separated, no prurulent material expressed
from wound


Pertinent Results:
Admission Labs:
WBC-13.9*# RBC-3.79* Hgb-11.1* Hct-33.3* MCV-88 MCH-29.3
MCHC-33.4 RDW-13.9 Plt Ct-416
Glucose-127* UreaN-23* Creat-1.0 Na-141 K-3.5 Cl-96 HCO3-36*
AnGap-13
Calcium-9.1 Phos-4.4 Mg-1.6
.
Microbiology Data
[**2121-2-6**] 12:54 am SWAB      Source: R BKA wound.

                            **FINAL REPORT [**2121-2-9**]**

   WOUND CULTURE (Final [**2121-2-9**]):
      PSEUDOMONAS AERUGINOSA.    SPARSE GROWTH.
         OF THREE COLONIAL MORPHOLOGIES.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             PSEUDOMONAS AERUGINOSA
                             |
CEFEPIME--------------    32 R
CEFTAZIDIME-----------    32 R
CIPROFLOXACIN---------   =>4 R
GENTAMICIN------------     2 S
MEROPENEM-------------  =>16 R
PIPERACILLIN/TAZO----- =>128 R
TOBRAMYCIN------------   <=1 S

.
[**2121-2-6**] 1:10 am STOOL     CONSISTENCY: NOT APPLICABLE
      Source: Stool.

                            **FINAL REPORT [**2121-2-6**]**

   CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2121-2-6**]):
      [**2121-2-6**] REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 83921**] AT 10:35 AM.
      CLOSTRIDIUM DIFFICILE.
         FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
           (Reference Range-Negative).

.
Blood Cx ([**2121-2-6**]) x 2: No Growth
Urine Cx ([**2121-2-6**]): contaminated
Urine Cx ([**2121-2-11**]): No Growth
MRSA screen ([**2121-2-11**]): Positive
.
Discharge Labs:
.
IMAGING:
Non-contrast CT of Head ([**2121-2-11**]):
IMPRESSION: No acute hemorrhage or large territorial infarct.
Chronic right lacunar infarct.
.
CT Angiogram and Perfusion ([**2121-2-11**]):
IMPRESSION:
1. Highly unusual perfusion pattern, involving the left cerebral
hemisphere, globally, with marked abnormally-low MTT
(supranormal and increased CBV/CBF. In light of patient's
history and right-sided localizing symptoms, this may represent
global hyperperfusion related to focal seizure activity, with
generalization. This appearance should be correlated with
clinical semiology and EEG results.
2. No region of prolonged MTT or reduced CBV to suggest either
ischemia or
infarction.
3. 50% stenosis of the mid-right basilar artery. No other
intracranial
vascular abnormality including stenosis, occlusion or aneurysm.
.
EEG ([**2121-2-12**]):
IMPRESSION: This is an abnormal portable EEG due to slowing,
disorganization, and attenuation of the background rhythm
consistent
with a mild to moderate encephalopathy. Medications,
toxic/metabolic
disturbances, and infection are common causes. No focal,
lateralized,
or epileptiform features were seen during this recording.
.
EEG ([**2121-2-13**]):
IMPRESSION: This is an abnormal video EEG study due to sharp
transients, focal delta slowing, and attenuatio in the left mid
to
posterior temporal region. These findings suggest cortical
irritability
and cortical and subcortical dysfunction in this region. This
telemetry
captured no pushbutton activations. There were no electrographic

seizures contained in this study.
.
MRI Head ([**2121-2-12**]):
IMPRESSION:
1. Limited examination demonstrates no evidence for acute
infarct.
2. The hyperperfusion previously seen within the left cerebral
hemisphere has no definite correlate. Focus of abnormal T2
signal involving the left
postcentral gyrus is of unclear etiology, though could relate to
seizure
activity, accounting for the hyperperfusion. Alternatively, this
could
represent an old infarct, particularly given the mild associated
volume loss.
3. Subtle region of signal abnormality within the left thalamus
on the
diffusion sensitive sequence could potentially relate to a
subacute evolving
infarct and/or artifact.
4. Bilateral mastoid air cell effusions.

Discharge Labs:

140 | 100 | 16
---------------< 143
3.9 |  35 | 0.7

Ca: 8.3 Mg: 1.7 PO4: 3.4

      10.2
11.1 >-----< 412
      32.1

Tobra trough: 0.5


Brief Hospital Course:
Ms. [**Known lastname **] is a 59 year-old woman with a complex past medical
history including hypertension, hyperlipidemia, DM, seizure
disorder, and PVD s/p right below the knee amputation (BKA) who
was transferred from [**Hospital2 **] [**Hospital3 6783**] Hospital to the [**Hospital1 18**]
Vascular Surgery Service [**2121-2-5**] for a revision of the right
BKA.  She was admitted to the Vascular Service from [**2121-2-5**] to
[**2121-2-12**].  She was then transferred to the Neurology Service
[**2121-2-12**] to [**2121-2-18**] following a change in mental status.
.
PERIPHERAL VASCULAR
# Historical Data:
Ms. [**Known lastname **] initially [**Known lastname 1834**] a right BKA in [**9-25**].
[**Doctor Last Name 6783**].  She was re-admitted to [**Hospital2 **] [**Hospital3 6783**] at the end of
[**12-25**] in the setting of respiratory distress and fever.  After a
bronch demonstrated a possible tracheal tissue mass, she was
transferred to the [**Hospital1 18**] for further pulmonary evaluation.  In
the course of that admission, a vascular consult was called for
apparent wound right BKA wound dehisence and exposure of bone.
It was recommended that cultures of the wound be obtained and
the patient returnin a few weeks for a right BKA revision.
.
# Current Data:
As planned, Ms. [**Known lastname **] [**Last Name (Titles) 1834**] the planned right below-knee
amputation revision on [**2121-2-6**] in the setting of right distal
tibia osteomyelitis with surrounding myositis and dehisence of
the amputation site wound.  Operative notes suggest the
procedure went smoothly and was associated with minimal blood
loss.  Following the operation, she reportedly noted phantom
pain which remained at a baseline level of discomfort.
.
RESPIRATORY
# Historical Data
According to records, a tracheostomy was initially placed in
[**10-25**] for "seizures, respiratory failure, and vocal cord edema."
 The patient suffered a hypoxic episode in [**12-25**] for which a
tracheostomy tube was placed at [**Hospital2 **] [**Hospital3 6783**] Hospital.
Following transfer to the [**Hospital1 18**] in [**1-26**], bronchoscopy revealed a
false passage in the pre-tracheal area in addition  to a
tracheal laceration and necrotic cartilage in the vicinity of
the tracheal defect.  She was then intubated and decanulated
while at [**Hospital1 18**].  She was extubated [**2121-1-23**]; since that time, her
respiratory status was reported to be stable.
.
# Current Data
On [**2121-2-11**], the patient was transported to the Interventional
Pulmonology Clinic for a scheduled re-assessment of the tracheal
defect s/p tracheostomy and decannulation.  Prior to the
procedure, she was noted to be unresponsive with open eyes.  A
code stroke was called (please see below).
.
NEUROLOGY
In the setting of a bronchoscopy on [**2121-2-11**], the patient was
thought to develop an acute change in mental status.  A code
stroke was called.  Physical examination was thought to be
concerning for a seizure versus stroke.  Since the patient was
on keppra (500 mg po bid), a keppra load was administered and
the dose was increased to 1 gram [**Hospital1 **].  She also [**Hospital1 1834**] CT
with angiography and perfusion studies.  The neuroimaging
revealed a decreased mean transit time with increased cerebral
blood flow and blood volume in the left parieto-occipital lobe.
Converse to the appearance of scans indicative of stroke (with
which increased mean transit time and decreased cerebral blood
flow and volume are often observed), the findings were thought
to possibly be consistent with seizure activity with a left
focus.  An EEG revealed changes consistent with encephalopathy.
While an MRI revealed a hyperintensity in the left post-central
gyrus, the finding was thought to be non-contributory to the
patient's syndrome.
.
In the setting of the event, the patient was transferred to the
Neurology Service and Keppra was increased to 1g [**Hospital1 **].  No
clinical seizure activity was observed.  On physical
examination, the patient continued to demonstrate
disorientation, an inability to consistently follow verbal
requests correctly, and verbal and motor perseveration.  In the
absence of focal findings on neuroimaging, EEG, and laboratory
studies (eg metabolic, electrolytes, the etiology of the change
in mental status remained unclear.
.
CARDIOVASCULAR
In the course of the hospitalization, the patient's blood
pressure was quite difficult to maintain in normal range.
Therefore, a nicardipine drip was started with a goal SBP of
160.  She was then transitioned back to her home blood pressure
regimen of HCTZ and metoprolol

INFECTIOUS DISEASE
# Historical Data
During the patient's admission in early [**2121-1-17**], right BKA
wound cultures demonstrated multi-drug resistant pseudomonas.
An ID consult at that time recommended the team refrain from
antibiotic treatment.  She was discharged to rehab and returned
for the current admission without the start of antibiotic
treatment.  The wound cultures were repeated during the current
admission, presumably in the setting of leukocytosis.
.
# Current Data:
C. Difficile Colitis:
Stool cultures from [**2121-2-6**] returned positive for c. difficile
colitis.  Accordingly, a 14-day course of treatment with Flagyl
was initiated to be continued through [**2121-2-20**].
.
Pseudomonal Wound Infection:
Repeat cultures of the right BKA site ([**2121-2-6**]) again
demonstarted pseudomonas; further analysis ultimately revealed
the organism was sensitive to tobramycin.  Therefore, a 6-week
course of the antibiotic was started to be continued through
[**2121-3-20**].
.
Blood cultures and urine cultures have been negative. A routine
MRSA screen suggests that Ms. [**Known lastname **] is a carrier.
.
ENDOCRINE
Insulin scale was initiated with a goal of normoglycemia.
.
REHAB
Members of the physical therapy, occupational therapy, and
speech therapy teams contributed to Ms. [**Known lastname 83922**] care throughout
the hospitalization.

Medications on Admission:
Albuterol Sulfate
Ergocalciferol (Vitamin D2) [Vitamin D]
Gabapentin
Heparin (Porcine)
Insulin Aspart [Novolog]
Insulin Glargine [Lantus]
Levetiracetam
Metoprolol Tartrate
Metronidazole
Morphine
Pantoprazole
Acetaminophen [Tylenol]
Ascorbic Acid
Aspirin
Cyanocobalamin
Lactobacillus Acidophilus
Multivitamin
Zinc Sulfate



Discharge Medications:
1. Multivitamin     Tablet [**Known lastname **]: One (1) Tablet PO DAILY (Daily).

2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Known lastname **]: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
3. Ergocalciferol (Vitamin D2) 50,000 unit Capsule [**Known lastname **]: One (1)
Capsule PO 1X/WEEK (TU).
4. Ascorbic Acid 500 mg Tablet [**Known lastname **]: Two (2) Tablet PO DAILY
(Daily).
5. Zinc Sulfate 220 mg Capsule [**Known lastname **]: One (1) Capsule PO DAILY
(Daily).
6. Aspirin 325 mg Tablet [**Known lastname **]: One (1) Tablet PO DAILY (Daily).
7. Cyanocobalamin 500 mcg Tablet [**Known lastname **]: One (1) Tablet PO DAILY
(Daily).
8. Simvastatin 10 mg Tablet [**Known lastname **]: One (1) Tablet PO DAILY
(Daily).
9. Gabapentin 300 mg Capsule [**Known lastname **]: One (1) Capsule PO DAILY
(Daily).
10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Known lastname **]: One (1)  Inhalation twice a day as needed for
SOB.
11. Outpatient Lab Work
Tobramycin through every 4th day (goal <0.5 and under)

CBC, Chem 10, CRP weekly.

Fax results to Dr. [**Last Name (STitle) 1391**] ([**Telephone/Fax (1) 72961**],
Phone: [**Telephone/Fax (1) 1393**]
12. Insulin sliding Scale
Humalog Glucose Insulin Dose
0-70   mg/dL Proceed with hypoglycemia protocol Proceed with
hypoglycemia protocol Proceed with hypoglycemia protocol Proceed
with hypoglycemia protocol
71-150   mg/dL 0   Units 0   Units 0   Units 0   Units
151-200   mg/dL 1   Units 1   Units 1   Units 1   Units
201-250   mg/dL 4   Units 4   Units 4   Units 4   Units
251-300   mg/dL 7   Units 7   Units 7   Units 7   Units

13. Glargine  [**Telephone/Fax (1) **]: 15  Units injection subcutaneously  at
bedtime.
14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Telephone/Fax (1) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
15. Heparin (Porcine) 5,000 unit/mL Solution [**Telephone/Fax (1) **]: One (1)
injection Injection TID (3 times a day).
16. Levetiracetam 500 mg Tablet [**Telephone/Fax (1) **]: Two (2) Tablet PO BID (2
times a day).
17. Tobramycin Sulfate 40 mg/mL Solution [**Telephone/Fax (1) **]: Five Hundred (500)
mg Injection Q48H (every 48 hours) for 4 weeks: Please check
trough level every 4 days, goal <1.0.
18. Aspirin 325 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY (Daily).

19. Metronidazole 500 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO Q8H
(every 8 hours) for 1 days.
20. Metoprolol Tartrate 50 mg Tablet [**Telephone/Fax (1) **]: Two (2) Tablet PO BID
(2 times a day).
21. Hydrochlorothiazide 12.5 mg Capsule [**Telephone/Fax (1) **]: Three (3) Capsule
PO DAILY (Daily).
22. Miconazole Nitrate 2 % Powder [**Telephone/Fax (1) **]: One (1) Appl Topical PRN
(as needed) as needed for incontinence/fungal irritation.


Discharge Disposition:
Extended Care

Facility:
[**Location (un) 32674**] - [**Location (un) **]

Discharge Diagnosis:
Breakdown of right below-knee amputation stump,
osteomyelitis-cultures came back positive for Psuedumonas
sensitive to Tobramycin, d/c'd on Tobramycin for 6 weeks.
History of:
HTN
DM2
Hyperlipidemia
PVD
OM with MRSA
OA
Retinopathy
Neuropathy
Nephropathy
ARF
Obesity
Seizures
Aspiration PNA
Dysphagia bedside swallow - pureed honey thick diet
PSH:
[**2-25**] R CEA
[**9-25**] R BKA
[**10-25**] Tracheostomy [**2-18**] seizure, PEA arrest and vocal cord edema



Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)


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

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

Please continue po ciprofloxacin for 2 weeks
Please continue IV vancomycin and tobramycin for 6 weeks

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

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

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

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

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

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

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

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

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

Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-26**] lbs until you follow-up with your
surgeon.

Avoid driving or operating heavy machinery while taking pain
medications.

Incision Care:

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

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

*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.


Followup Instructions:
Please call Dr.[**Name (NI) 1392**] office to schedule an appointment
([**Telephone/Fax (1) 4852**]. Please follow up in clinic in 3 weeks.
{'Infection (chronic) of amputation stump,Encephalopathy, unspecified,Acute kidney failure, unspecified,Pressure ulcer, stage III,Intestinal infection due to Clostridium difficile,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Background diabetic retinopathy,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Unspecified essential hypertension'}


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: Dehisence of right below-knee amputation site with bone exposure

PRESENT ILLNESS: PER ADMITTING VASCULAR TEAM:
Patient is a 59F who initially [**Doctor Last Name 1834**] a R BKA by Dr. [**Last Name (STitle) 83920**]
at [**Hospital2 **] [**Hospital3 6783**] hospital for severe PVD on [**2120-9-29**].  Patient
later developed wound dehiscense with exposed bone.  R BKA wound
culture grew out multi-resistent pseudomonas sensitive only to
vanc and tobramycin.  She was treated with vanc from
[**Date range (1) 80992**], when abx were stopped due to her needing
surgical treatment for osteomyelitis.  A wound vac was placed,
and she was set up for a follow-up appointment with Dr. [**Last Name (STitle) 1391**]
on [**2-12**].  However, at rehab she developed elevated
temperatures to 100.7 and was brought back to [**Hospital2 **] [**Hospital3 6783**]
Hospital on [**2121-2-1**].  An MRA of the R BKA showed 2.58cm of
distal tibia/fibula osteo with
surrounding myositis.

MEDICAL HISTORY: - HTN
- DM2 associated with retinopathy, neuropathy, nephropathy
- Hyperlipidemia
- PVD
- Osteomyelities with MRSA
- OA
- obesity
- seizures
.
PAST SURGICAL HISTORY:
- [**2-25**] R CEA
- [**9-25**] R BKA
- [**10-25**] Tracheostomy in the setting of seizure, PEA, arrest and
vocal cord edema

MEDICATION ON ADMISSION: Albuterol Sulfate
Ergocalciferol (Vitamin D2) [Vitamin D]
Gabapentin
Heparin (Porcine)
Insulin Aspart [Novolog]
Insulin Glargine [Lantus]
Levetiracetam
Metoprolol Tartrate
Metronidazole
Morphine
Pantoprazole
Acetaminophen [Tylenol]
Ascorbic Acid
Aspirin
Cyanocobalamin
Lactobacillus Acidophilus
Multivitamin
Zinc Sulfate

ALLERGIES: Vicodin

PHYSICAL EXAM: ON ADMISSION:
Vital Signs: Temp: 98.1 RR: 18 Pulse: 68 BP: 150/68
Neuro/Psych: NAD.
Skin: Abnormal: Stage 2 decub ulcers.
Heart: Regular rate and rhythm.
Lungs: Clear, Normal respiratory effort.
Gastrointestinal: No masses, abnormal: Obese.
Rectal: Not Examined.
Extremities: No RLE edema, No LLE Edema, abnormal: R BKA with
exposed bone edges.

FAMILY HISTORY: n/c

SOCIAL HISTORY: - married
.
HABITS:
- Tobacco: remote
- ETOH:
- Recreational Drug Use: 

### Response:
{'Infection (chronic) of amputation stump,Encephalopathy, unspecified,Acute kidney failure, unspecified,Pressure ulcer, stage III,Intestinal infection due to Clostridium difficile,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Background diabetic retinopathy,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Unspecified essential hypertension'}
