CHIEF COMPLAINT: Surgical Wound Infection

PRESENT ILLNESS: 72F with PMH HTN, HLP, OA of the knee s/p multiple TKR
complicated by wound infection and subsequent AKA presents from
her rehab facility with 4d of pain, erythema, and purulent
drainage from her AKA stump.

MEDICAL HISTORY: PMH:
Dementia, HTN, HL, Depression, Dementia, organic brain
syndrome; unknown etiology; SDH
requiring surgical intervention, osteoarthritis

MEDICATION ON ADMISSION: Abilify 5 mg qhs
ASA 325 mg qday
Colace/Dulcolax
Lisinopril 5 mg qday
MVI
Omeprazole 20 mg qday
Paxil 20 mg qday
Senna
Simvastatin 20 mg qday
Vitamin C 500 mg ER [**Hospital1 **]
Klonopin 0.5 mg TID prn

ALLERGIES: Tetracycline / Doxycycline

PHYSICAL EXAM: ADMISSION:
96.5 86 152/70 20 100% RA
GA: AOx3, NAD
HEENT:  PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: PMI palpable at 5/6th IC space. No RVH. RRR S1/S2 heard.
no murmurs/gallops/rubs.
Pulm: CTAB no crackles or wheezes
Abd: soft, NT, +BS. no g/rt. neg HSM. neg [**Doctor Last Name 515**] sign.
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: LLE AKA stump with 12cm area of circumferential erythema,
2 sites of purulent drainage along prior staple line.
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
DTRs 2+ BL (biceps, achilles, patellar). sensation intact to LT,
pain, temperature, vibration, proprioception. cerebellar fxn
intact (FTN, HTS). gait WNL.
.
Discharge:
VS - 96.5, HR: 78 (73-95), BP: 123/48 (118-157/40-80), RR: 21,
O2: 97%RA
GENERAL - A&Ox3, appears uncomfortable, shifting in bed,
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple
LUNGS - Decreased bs at bases, rales at bases, no respiratory
distress
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - obese, soft/ND, LLQ tenderness to palpation, no masses
or HSM, no rebound/guarding
EXTREMITIES - LLE AKA stump is surgically dressed, R LE with
pneumoboot, 1+ edema, cool feet; fullness in UE, cool hands, JP
drain on L stump with minimal sanguinous output
NEURO - lethargic but conversational, A&Ox3, moves both legs and
good hand grip bilaterally, EOMI

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Lives in [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] nursing home currently but originally [**Location (un) 107544**].  No Etoh or tobacco currently.
Infection (chronic) of amputation stump,Cellulitis and abscess of leg, except foot,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Urinary tract infection, site not specified,Infected postoperative seroma,Amputation of limb(s) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Accidents occurring in other specified places,Other iatrogenic hypotension,Unspecified essential hypertension,Unspecified nonpsychotic mental disorder following organic brain damage,Depressive disorder, not elsewhere classified,Anemia of other chronic disease,Esophageal reflux,Other specified cardiac dysrhythmias,Gouty arthropathy, unspecified
Infection amputat stump,Cellulitis of leg,Pseudomonas infect NOS,Urin tract infection NOS,Infected postop seroma,Abn react-limb amputat,Accident in place NEC,Iatrogenc hypotnsion NEC,Hypertension NOS,Nonpsychot brain syn NOS,Depressive disorder NEC,Anemia-other chronic dis,Esophageal reflux,Cardiac dysrhythmias NEC,Gouty arthropathy NOS
Admission Date:  [**2197-3-23**]              Discharge Date:   [**2197-3-29**]

Date of Birth:  [**2124-12-19**]             Sex:   F

Service: MEDICINE

Allergies:
Tetracycline / Doxycycline

Attending:[**First Name3 (LF) 20146**]
Chief Complaint:
Surgical Wound Infection

Major Surgical or Invasive Procedure:
Incision and Drainage of the Left Above the Knee Amputation
stump


History of Present Illness:
72F with PMH HTN, HLP, OA of the knee s/p multiple TKR
complicated by wound infection and subsequent AKA presents from
her rehab facility with 4d of pain, erythema, and purulent
drainage from her AKA stump.

She was intially given Moxifloxacin by her NH staff.

The patient was then brought to the [**Hospital1 18**] ED where initial VS
were:
97.2 126 111/71 16 100%

She was seen by the Orthopedics team who determined that her
wound required surgical incision and drainage.  Laboratory
evaluation was notable for a normal WBC count, but a lactate of
2.1.  IV Vancomycin was started.  The patient was thought to be
too medically complex at the time to be admitted to the
Orthopedic Surgery floor, and so the patient was admitted to the
Medicine service.

On the floor the patient is comfortable.  Not in any pain.
Admits to recent chills and night sweats, but no recent fevers.
Noticed that her stump began to "pink up" about 4 days ago.
Since then it has gotten progressively worse.  She denies any
other symptoms.

Past Medical History:
PMH:
Dementia, HTN, HL, Depression, Dementia, organic brain
syndrome; unknown etiology; SDH
requiring surgical intervention, osteoarthritis

PSH:  Total knee replacement on [**6-/2196**] Displaced fracture of
left knee one month later surgically repaired on [**2196-8-17**] by Dr.

[**Doctor Last Name 3646**] ([**Hospital3 **])   Re-rupture of patellar tendon. Failed
conservative approach given patella became more prominent in
skin and concern for breakdown; was admitted on [**2196-10-17**] and
underwent repair of left patellar fracutre by Dr. [**First Name (STitle) 3646**] ([**Hospital1 **]).  Multiple readmissions and reoperations on the L knee
for infection and dislocation leading to eventual AKA in 3/[**2196**].



Social History:
Lives in [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] nursing home currently but originally [**Location (un) 107544**].  No Etoh or tobacco currently.


Family History:
non-contributory

Physical Exam:
ADMISSION:
96.5 86 152/70 20 100% RA
GA: AOx3, NAD
HEENT:  PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: PMI palpable at 5/6th IC space. No RVH. RRR S1/S2 heard.
no murmurs/gallops/rubs.
Pulm: CTAB no crackles or wheezes
Abd: soft, NT, +BS. no g/rt. neg HSM. neg [**Doctor Last Name 515**] sign.
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: LLE AKA stump with 12cm area of circumferential erythema,
2 sites of purulent drainage along prior staple line.
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
DTRs 2+ BL (biceps, achilles, patellar). sensation intact to LT,
pain, temperature, vibration, proprioception. cerebellar fxn
intact (FTN, HTS). gait WNL.
.
Discharge:
VS - 96.5, HR: 78 (73-95), BP: 123/48 (118-157/40-80), RR: 21,
O2: 97%RA
GENERAL - A&Ox3, appears uncomfortable, shifting in bed,
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple
LUNGS - Decreased bs at bases, rales at bases, no respiratory
distress
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - obese, soft/ND, LLQ tenderness to palpation, no masses
or HSM, no rebound/guarding
EXTREMITIES - LLE AKA stump is surgically dressed, R LE with
pneumoboot, 1+ edema, cool feet; fullness in UE, cool hands, JP
drain on L stump with minimal sanguinous output
NEURO - lethargic but conversational, A&Ox3, moves both legs and
good hand grip bilaterally, EOMI



Pertinent Results:
LABS:
[**2197-3-23**] 03:30PM BLOOD WBC-7.4 RBC-3.09* Hgb-9.0* Hct-27.3*
MCV-89 MCH-29.3 MCHC-33.1 RDW-16.2* Plt Ct-347
[**2197-3-25**] 05:56AM BLOOD WBC-8.9 RBC-2.72* Hgb-8.2* Hct-23.9*
MCV-88 MCH-30.3 MCHC-34.5 RDW-15.8* Plt Ct-295
[**2197-3-29**] 04:47AM BLOOD WBC-8.0 RBC-3.36* Hgb-10.3* Hct-29.9*
MCV-89 MCH-30.5 MCHC-34.3 RDW-15.7* Plt Ct-269
.
BMP:
[**2197-3-23**] 03:30PM BLOOD Glucose-120* UreaN-19 Creat-1.1 Na-136
K-4.5 Cl-103 HCO3-24 AnGap-14
[**2197-3-24**] 02:31PM BLOOD Glucose-129* UreaN-17 Creat-0.8 Na-135
K-4.6 Cl-107 HCO3-20* AnGap-13
[**2197-3-25**] 05:32PM BLOOD Glucose-110* UreaN-18 Creat-0.9 Na-129*
K-4.9 Cl-102 HCO3-23 AnGap-9
[**2197-3-29**] 04:47AM BLOOD Glucose-104* UreaN-11 Creat-0.9 Na-140
K-4.2 Cl-106 HCO3-28 AnGap-10
[**2197-3-24**] 06:42AM BLOOD Calcium-8.3* Phos-3.9 Mg-1.8
[**2197-3-25**] 05:32PM BLOOD Calcium-8.2*
[**2197-3-28**] 06:12AM BLOOD Calcium-8.8 Phos-2.4* Mg-1.8 Iron-39
[**2197-3-29**] 04:47AM BLOOD Calcium-8.3* Phos-2.7 Mg-1.7
.
VANCO:
[**2197-3-28**] 09:04AM BLOOD Vanco-14.8
###########################################################
MICRO:
[**2197-3-23**] 5:30 pm ABSCESS

                            **FINAL REPORT [**2197-3-28**]**

   GRAM STAIN (Final [**2197-3-23**]):
      4+   (>10 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      2+   (1-5 per 1000X FIELD):   GRAM POSITIVE COCCI IN
PAIRS.

   WOUND CULTURE (Final [**2197-3-28**]):
      STAPH AUREUS COAG +.    SPARSE GROWTH.
         Oxacillin RESISTANT Staphylococci MUST be reported as
also
         RESISTANT to other penicillins, cephalosporins,
carbacephems,
         carbapenems, and beta-lactamase inhibitor combinations.

         Rifampin should not be used alone for therapy.
         This isolate is presumed to be resistant to clindamycin
based on
         the detection of inducible resistance .
      PSEUDOMONAS AERUGINOSA.    RARE GROWTH OF TWO COLONIAL
MORPHOLOGIES.
         sensitivity testing performed by Microscan.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |          PSEUDOMONAS AERUGINOSA
                             |          |
AMIKACIN--------------               16 S
CEFEPIME--------------               16 S
CEFTAZIDIME-----------                8 S
CIPROFLOXACIN---------              =>2 R
CLINDAMYCIN-----------       R
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S      =>8 R
LEVOFLOXACIN----------   =>8 R
MEROPENEM-------------                4 S
OXACILLIN-------------   =>4 R
PIPERACILLIN/TAZO-----               16 S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------   <=1 S
TOBRAMYCIN------------              =>8 R
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------     1 S

   ANAEROBIC CULTURE (Final [**2197-3-27**]):    NO ANAEROBES ISOLATED.
.
[**2197-3-24**] 11:00 am TISSUE      (L) STUMP.

                            **FINAL REPORT [**2197-3-28**]**

   GRAM STAIN (Final [**2197-3-24**]):
      4+   (>10 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.

   TISSUE (Final [**2197-3-27**]):
      STAPH AUREUS COAG +.    SPARSE GROWTH.
         Oxacillin RESISTANT Staphylococci MUST be reported as
also
         RESISTANT to other penicillins, cephalosporins,
carbacephems,
         carbapenems, and beta-lactamase inhibitor combinations.

         Rifampin should not be used alone for therapy.
         This isolate is presumed to be resistant to clindamycin
based on
         the detection of inducible resistance .

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------       R
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------   =>8 R
OXACILLIN-------------   =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------   <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------     1 S
.
[**2197-3-24**] 11:00 am FLUID,OTHER      LEFT STUMP.

                            **FINAL REPORT [**2197-3-28**]**

   GRAM STAIN (Final [**2197-3-24**]):
      2+   (1-5 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      1+    (<1 per 1000X FIELD):   GRAM POSITIVE COCCI IN
PAIRS.
      Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ON [**2197-3-24**] @
740 PM.

   FLUID CULTURE (Final [**2197-3-27**]):
      STAPH AUREUS COAG +.    SPARSE GROWTH.
         SENSITIVITIES PERFORMED ON CULTURE # 321-1508F [**2197-3-24**].


   ANAEROBIC CULTURE (Final [**2197-3-28**]):    NO ANAEROBES ISOLATED.

.
[**2197-3-26**] 4:34 pm URINE      Source: Catheter.

                            **FINAL REPORT [**2197-3-28**]**

   URINE CULTURE (Final [**2197-3-28**]):
      PROTEUS MIRABILIS.    10,000-100,000 ORGANISMS/ML..
         PRESUMPTIVE IDENTIFICATION.
         Piperacillin/tazobactam sensitivity testing available
on request.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             PROTEUS MIRABILIS
                             |
AMPICILLIN------------  =>32 R
AMPICILLIN/SULBACTAM--     8 S
CEFAZOLIN-------------   <=4 S
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CIPROFLOXACIN---------   =>4 R
GENTAMICIN------------     4 S
MEROPENEM-------------<=0.25 S
TOBRAMYCIN------------     2 S
TRIMETHOPRIM/SULFA----  =>16 R
.
[**2197-3-26**] Blood cultures: pending
[**2197-3-26**] Blood cultures: pending
#
#
#
#
#
#
#
################################################################
IMAGING:
[**2197-3-24**] CXR:
FINDINGS: In comparison with study of [**2-13**], the patient has
taken a somewhat better inspiration. Cardiac silhouette is
within normal limits and the lungs are essentially clear except
for some retrocardiac atelectasis. No definite vascular
congestion.
.
[**2197-3-27**] ECHO: The left atrium is mildly dilated. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis or aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The pulmonary artery systolic
pressure could not be determined. There is an anterior space
which most likely represents a prominent fat pad.

IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. No valvular
pathology or pathologic flow identified.  Compared with the
prior study (images reviewed) of [**2197-2-8**]


Brief Hospital Course:
72F with PMH of multiple L knee infections, hx MRSA, presents
with a surgical wound infection of the L AKA stump.

# Wound infection:  She presented with 4 days of the patient was
seen by ortho, started on Vancomycin and brought to the OR for
debridement of the wound on her left stump.  After the surgery
she was transiently hypotensive and was brought to the Intensive
Care Unit for monitoring.  While in the ICU, her vancomycin
trough was very elevated and the medication was held for 2 days
while it trended down.  Her dose was also lowered to 500mg IV
Q12H.  The wound also also cultured and growing MRSA.  After
speaking with ID it was determined she will need Abx for a
prolonged period of time and so a PICC line was placed and she
was discharged on vancomycin until [**2197-4-7**] and ceftrizone until
[**2197-4-3**].
.
# UTI: patient had rising white count and found to have UTI
growing Proteus.  She was initially started on ciprofloxacin,
but sensitivities showed resistance and so was switched to
ceftriaxone.  She will need a 7 day course of ceftriaxone and
was send to [**Hospital1 1501**] with a prescription for 5 more days of therapy.
.
# Atrial tachycardia:  Had some bouts of tachycardia in the
intensive care unit and was started on metoprolol tartate 12.5mg
PO BID.  She was transferred to the floor and monitored on
telemetry overnight and had no events.  Telemetry was
disconitnued and the patient remained asymptomatic.  She was
discharged on metoprolol succinate 25mg PO Daily
.
# HTN: initially lisinopril was held after hypotensive episode,
but was restarted once BP was stabilized.  She remained
normotensive on home meds.
.
3) GERD: continued home prilosec
.
4) HLP: continued home simvastatin
.
5) Dementia: continued outpt abilify and paxil

6) Anemia: Patient had hct drop from oozing from wound site.
She was transfused total 3 units pRBC over the course of her
stay and H/H has since stabilized with control of patient's
bleeding.
.
TRANSITIONAL ISSUES:
- Follow up blood culture
- continue Abx (vancomycin until [**2197-4-7**], ceftriaxone until
[**2197-4-5**])
- wound care
- once antibiotic course is completed please discontinue PICC
line

Medications on Admission:
Abilify 5 mg qhs
ASA 325 mg qday
Colace/Dulcolax
Lisinopril 5 mg qday
MVI
Omeprazole 20 mg qday
Paxil 20 mg qday
Senna
Simvastatin 20 mg qday
Vitamin C 500 mg ER [**Hospital1 **]
Klonopin 0.5 mg TID prn


Discharge Medications:
1. aripiprazole 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q 12H (Every 12 Hours).
11. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
12. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for anxiety.
13. Vitamin C 500 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO twice a day.
14. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
15. ceftriaxone 1 gram Recon Soln Sig: One (1) gm Intravenous
once a day for 5 days: last dose [**2197-4-3**].


Discharge Disposition:
Extended Care

Facility:
[**Hospital **] Health Care - [**Hospital1 **]

Discharge Diagnosis:
Surgical Wound Infection of the L AKA stump


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

You were admitted to the [**Hospital1 18**] for management of your surgical
wound infection.  You were given antibiotics and then taken to
the OR for incision and drainage by the Orthopedic Surgery team.
 Unfortunately while you were waking up from Anesthesia your
heart went into an abnormal rhythm and your blood pressure
dropped very low.  You were then observed in the Intensive Care
Unit.  You did well and were transferred back to the floor for
further management.  You were also found to have a urinary tract
infection and we are treating you for that as well.  You also
had some fast heart rate an started on a low dose beta blocker.
You continued to be managed well with the antibiotics given to
you and you are ready for discharge.
.
The following medication was STARTED:
metoprolol succinate 25mg by mouth daily
Vancomycin 500mg IV every 12 hours until [**2197-4-7**].
Ceftriazone 1gm [**Last Name (un) **] 24 hours for 7 days (last dose [**2197-4-5**])
.
Please take your other medications as prescribed.
.
You will have labs drawn in one week to make sure that your
infection is improving and to make sure your kidneys and liver
are safe on these medications.

Followup Instructions:
Department: ORTHOPEDICS
When: TUESDAY [**2197-5-9**] at 2:25 PM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: ORTHOPEDICS
When: TUESDAY [**2197-5-9**] at 2:45 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Infection (chronic) of amputation stump,Cellulitis and abscess of leg, except foot,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Urinary tract infection, site not specified,Infected postoperative seroma,Amputation of limb(s) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Accidents occurring in other specified places,Other iatrogenic hypotension,Unspecified essential hypertension,Unspecified nonpsychotic mental disorder following organic brain damage,Depressive disorder, not elsewhere classified,Anemia of other chronic disease,Esophageal reflux,Other specified cardiac dysrhythmias,Gouty arthropathy, unspecified'}


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



### Clinical text :
CHIEF COMPLAINT: Surgical Wound Infection

PRESENT ILLNESS: 72F with PMH HTN, HLP, OA of the knee s/p multiple TKR
complicated by wound infection and subsequent AKA presents from
her rehab facility with 4d of pain, erythema, and purulent
drainage from her AKA stump.

MEDICAL HISTORY: PMH:
Dementia, HTN, HL, Depression, Dementia, organic brain
syndrome; unknown etiology; SDH
requiring surgical intervention, osteoarthritis

MEDICATION ON ADMISSION: Abilify 5 mg qhs
ASA 325 mg qday
Colace/Dulcolax
Lisinopril 5 mg qday
MVI
Omeprazole 20 mg qday
Paxil 20 mg qday
Senna
Simvastatin 20 mg qday
Vitamin C 500 mg ER [**Hospital1 **]
Klonopin 0.5 mg TID prn

ALLERGIES: Tetracycline / Doxycycline

PHYSICAL EXAM: ADMISSION:
96.5 86 152/70 20 100% RA
GA: AOx3, NAD
HEENT:  PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: PMI palpable at 5/6th IC space. No RVH. RRR S1/S2 heard.
no murmurs/gallops/rubs.
Pulm: CTAB no crackles or wheezes
Abd: soft, NT, +BS. no g/rt. neg HSM. neg [**Doctor Last Name 515**] sign.
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: LLE AKA stump with 12cm area of circumferential erythema,
2 sites of purulent drainage along prior staple line.
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
DTRs 2+ BL (biceps, achilles, patellar). sensation intact to LT,
pain, temperature, vibration, proprioception. cerebellar fxn
intact (FTN, HTS). gait WNL.
.
Discharge:
VS - 96.5, HR: 78 (73-95), BP: 123/48 (118-157/40-80), RR: 21,
O2: 97%RA
GENERAL - A&Ox3, appears uncomfortable, shifting in bed,
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple
LUNGS - Decreased bs at bases, rales at bases, no respiratory
distress
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - obese, soft/ND, LLQ tenderness to palpation, no masses
or HSM, no rebound/guarding
EXTREMITIES - LLE AKA stump is surgically dressed, R LE with
pneumoboot, 1+ edema, cool feet; fullness in UE, cool hands, JP
drain on L stump with minimal sanguinous output
NEURO - lethargic but conversational, A&Ox3, moves both legs and
good hand grip bilaterally, EOMI

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Lives in [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] nursing home currently but originally [**Location (un) 107544**].  No Etoh or tobacco currently. 

### Response:
{'Infection (chronic) of amputation stump,Cellulitis and abscess of leg, except foot,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Urinary tract infection, site not specified,Infected postoperative seroma,Amputation of limb(s) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Accidents occurring in other specified places,Other iatrogenic hypotension,Unspecified essential hypertension,Unspecified nonpsychotic mental disorder following organic brain damage,Depressive disorder, not elsewhere classified,Anemia of other chronic disease,Esophageal reflux,Other specified cardiac dysrhythmias,Gouty arthropathy, unspecified'}
