CHIEF COMPLAINT: Infected knee prothesis

PRESENT ILLNESS: 31F with h/o osteosarcoma of femur as a teenager, s/p resection
and mult surgeries, c/b infection, who underwent a 8 hour
operation to remove her of femoral antibiotic spacer and the
tibial component of previous endoprosthesis, and place a of new
femoral and tibial antibiotic spacer.
Operative course: EBL = 1.5-2 L. Required Neo intraop to
maintain her BP. Transfused 2 units PRBC's and 6L crystalloid.
Post op: Continued to have borderline BP in PACU post op (SBP
60-80, with MAP in 50's), therefore, neo was restarted with
increase in MAP to 60s. HR was tachy in 100s-110s. Extubated
without complication, quickly weaned to room air. Transferred to
the [**Hospital Unit Name 153**] for further monitoring and evaluation of hypotension.
.
Regarding her osteosarcoma: Tumor initially removed and replaced
with prosthesis at age 13; this eventually failed. In [**Month (only) 404**]
[**2143**] she underwent replacement; complicated by coag-neg staph
infection of her distal femur. Treated through this infection
with 10 weeks with vanco and started on minocycline suppression.
She developed recurrent infection 6 weeks after stopping therapy
with coag-neg staph. Her prosthesis was removed at that time
with washout and placement of vanco-impregnanted cement,
followed by 8 weeks of vanco.
One week after stopping abx (approx 2 weeks PTA) she had
recurrent pain with elevated ESR and CRP; aspiration showed 4000
WBC with poly predominance, cultures grew coag-neg staph. She
was restarted on Vanco at that time. She was brought to the OR
on the day of admission for removal of the remainder of the
prosthesis, vanco cement, and for placement of spacer
impregnated with tobra (per ID).

MEDICAL HISTORY: Osteoscarcoma L distal femur,
Depression
H/O EtOH abuse
H/O cocaine
H/O tobacco use: quit [**2-5**]; prev smoked 10 cigarettes a day
H/O CHF: echo [**2142**]: EF = 30%, repeat echo with ACE-I: Normal EF

MEDICATION ON ADMISSION: aspirin 81 mg qday
Calcium + Vit D 500 mg qday
Fluconazole 100 mg Tablet qday while on Vanco
Guaifenesin [**Hospital1 **] PRN
Hydromorphone 4-8 mg q4H PRN up to 8 tabs qday
Lorazepam 1 mg TID PRN
Magnesium 84 mg [**Hospital1 **]
Multivitamin w/ minerals
Miralax 17 g qday PRN
Sertraline 100 mg qday
Valacyclovir 500 mg Tablet [**Hospital1 **] x 3days when active lesion
Vancomycin
Flonase

ALLERGIES: Morphine / Codeine / Rifampin

PHYSICAL EXAM: VS:AFVSS
Gen: Sitting in bed, anxious, not acutely distressed
HEENT: MMM but lips dry. EOMI.
PULM: CTA in all fields
CV: RRR, tachy, no M/R/G
ABD: +BS, soft, NT/ND. EXT:
triceps. PICC in place without erythema or tenderness.
LLE: in LLE brace
RLE: no c/c/e.

FAMILY HISTORY: Mother with osteoporosis and arthritis.  Father
with hypertension.  Siblings:  Brother with bipolar disorder.

SOCIAL HISTORY: Unemployed.  Currently living with her mom who
lives in the area and has plans to move to the [**State 4565**] area
after her surgery.  She is divorced.  Tobacco:  Ten cigarettes a
day x15 years.  Alcohol:  As stated above.  Drugs:  As stated
above.
Infection and inflammatory reaction due to internal joint prosthesis,Chronic osteomyelitis, lower leg,Pulmonary collapse,Acute posthemorrhagic anemia,Chronic systolic heart failure,Hypovolemia,Osteoporosis, unspecified,Personal history of malignant neoplasm of bone,Knee joint replacement
React-inter joint prost,Chr osteomyelit-l/leg,Pulmonary collapse,Ac posthemorrhag anemia,Chr systolic hrt failure,Hypovolemia,Osteoporosis NOS,Hx of bone malignancy,Joint replaced knee
Admission Date:  [**2144-10-26**]              Discharge Date:   [**2144-11-6**]

Date of Birth:  [**2113-8-27**]             Sex:   F

Service: ORTHOPAEDICS

Allergies:
Morphine / Codeine / Rifampin

Attending:[**First Name3 (LF) 14197**]
Chief Complaint:
Infected knee prothesis

Major Surgical or Invasive Procedure:
[**10-26**]-Explantation tibial component L knee arthroplasty,
explantation antibiotic spacer, L prixmal femur debridement,
Irrigation and debridment of L lower extremity

[**10-29**]-Complex open reduction internal
fixation of left pathologic subtrochanteric periprosthetic
femur fracture.


History of Present Illness:
 31F with h/o osteosarcoma of femur as a teenager, s/p resection
and mult surgeries, c/b infection, who underwent a 8 hour
operation to remove her of femoral antibiotic spacer and the
tibial component of previous endoprosthesis, and place a of new
femoral and tibial antibiotic spacer.
Operative course: EBL = 1.5-2 L. Required Neo intraop to
maintain her BP. Transfused 2 units PRBC's and 6L crystalloid.
Post op: Continued to have borderline BP in PACU post op (SBP
60-80, with MAP in 50's), therefore, neo was restarted with
increase in MAP to 60s. HR was tachy in 100s-110s. Extubated
without complication, quickly weaned to room air. Transferred to
the [**Hospital Unit Name 153**] for further monitoring and evaluation of hypotension.
.
Regarding her osteosarcoma: Tumor initially removed and replaced
with prosthesis at age 13; this eventually failed. In [**Month (only) 404**]
[**2143**] she underwent replacement; complicated by coag-neg staph
infection of her distal femur. Treated through this infection
with 10 weeks with vanco and started on minocycline suppression.
She developed recurrent infection 6 weeks after stopping therapy
with coag-neg staph. Her prosthesis was removed at that time
with washout and placement of vanco-impregnanted cement,
followed by 8 weeks of vanco.
One week after stopping abx (approx 2 weeks PTA) she had
recurrent pain with elevated ESR and CRP; aspiration showed 4000
WBC with poly predominance, cultures grew coag-neg staph. She
was restarted on Vanco at that time. She was brought to the OR
on the day of admission for removal of the remainder of the
prosthesis, vanco cement, and for placement of spacer
impregnated with tobra (per ID).


Past Medical History:
Osteoscarcoma L distal femur,
Depression
H/O EtOH abuse
H/O cocaine
H/O tobacco use: quit [**2-5**]; prev smoked 10 cigarettes a day
H/O CHF: echo [**2142**]: EF = 30%, repeat echo with ACE-I: Normal EF

ANXIETY

Allograft prosthetic composite left distal femur (fracture
allograft) used for limb salvage reconstruction for osteosarcoma
left distal femur [**2127-5-14**]. History of alcohol and cocaine
abuse, history of Adriamycin, a history of abnormal Pap smear.


Social History:

Unemployed.  Currently living with her mom who
lives in the area and has plans to move to the [**State 4565**] area
after her surgery.  She is divorced.  Tobacco:  Ten cigarettes a
day x15 years.  Alcohol:  As stated above.  Drugs:  As stated
above.


Family History:
Mother with osteoporosis and arthritis.  Father
with hypertension.  Siblings:  Brother with bipolar disorder.


Physical Exam:
VS:AFVSS
Gen: Sitting in bed, anxious, not acutely distressed
HEENT: MMM but lips dry. EOMI.
PULM: CTA in all fields
CV: RRR, tachy, no M/R/G
ABD: +BS, soft, NT/ND. EXT:
triceps. PICC in place without erythema or tenderness.
LLE: in LLE brace
RLE: no c/c/e.


Pertinent Results:
[**2144-10-26**] 04:45PM BLOOD WBC-11.4*# RBC-3.07*# Hgb-8.3*#
Hct-24.6*# MCV-80* MCH-27.1 MCHC-33.8 RDW-14.1 Plt Ct-244
[**2144-10-26**] 04:45PM BLOOD PT-13.8* PTT-28.3 INR(PT)-1.2*
[**2144-10-26**] 04:45PM BLOOD Fibrino-161
[**2144-10-26**] 09:17PM BLOOD Glucose-130* UreaN-15 Creat-0.6 Na-138
K-4.1 Cl-108 HCO3-27 AnGap-7*
[**2144-10-27**] 08:43AM BLOOD ALT-17 AST-37 CK(CPK)-1295* AlkPhos-39
TotBili-0.4
[**2144-10-26**] 09:17PM BLOOD Calcium-8.1* Phos-4.9* Mg-1.2*
[**2144-10-29**] 10:20AM BLOOD VitB12-471 Folate-13.1
[**2144-10-29**] 10:20AM BLOOD TSH-0.98
[**2144-10-26**] 02:59PM BLOOD Glucose-101 Lactate-2.0 Na-138 K-3.8
Cl-104
[**2144-10-26**] 02:59PM BLOOD Hgb-9.7* calcHCT-29
[**2144-10-26**] 02:59PM BLOOD freeCa-1.08*

FEMUR (AP & LAT) LEFT PORT  [**2144-10-27**] 2:09 PM

FEMUR (AP & LAT) LEFT PORT; TIB/FIB (AP & LAT) LEFT PORT

Reason: ? alignment

[**Hospital 93**] MEDICAL CONDITION:
31 year old woman POD1 s/p resection/spacer placement
REASON FOR THIS EXAMINATION:
? alignment
LEFT FEMUR AND LEFT LOWER LEG, FOUR VIEWS

HISTORY: Post-operative day 1 status post resection and spacer
placement.

FINDINGS: Extensive post-operative changes of the left lower
extremity are seen. There has been removal distal femoral
allograft and placement of a methylmethacrylate spacer as well
as removal of the tibial component of a constrained total knee
prosthesis and placement of a methylmethacrylate spacer
replacing the proximal articular surface of the tibia. The
intramedullary rod within the proximal tibial shaft is still
present. Two cerclage wires are seen in this region. No
immediate complication is noted following surgery. Soft tissue
drains and skin staples are seen.

UNILAT UP EXT VEINS US LEFT  [**2144-10-27**] 1:14 PM

UNILAT UP EXT VEINS US LEFT

Reason: Thrombus of left upper extremity.

[**Hospital 93**] MEDICAL CONDITION:
31 year old woman s/p removal of hardware from femur, found to
have PE, LUE swelling.
REASON FOR THIS EXAMINATION:
Thrombus of left upper extremity.
CLINICAL HISTORY: 31-year-old female status post removal of
hardware from femur, found to have questionable PE. Evaluate for
left upper extremity thrombus.

LEFT UPPER EXTREMITY VENOUS ULTRASOUND: Grayscale and Doppler
son[**Name (NI) **] of the left internal jugular, subclavian, axillary,
brachial, cephalic and basilic veins are performed. Normal
waveform, compressibility, augmentation, and flow is
demonstrated. No intraluminal thrombus is identified. Note is
made of a PIC catheter coursing from the basilic vein into the
subclavian vein.

IMPRESSION: No evidence of left upper extremity DVT.

CTA CHEST W&W/O C&RECONS, NON-CORONARY  [**2144-10-27**] 12:20 AM

CTA CHEST W&W/O C&RECONS, NON-

Reason: CTA-- assess for PE
Field of view: 32 Contrast: OPTIRAY

[**Hospital 93**] MEDICAL CONDITION:
31 year old woman with 31 year old woman s/p major orthopedic
surgery today, and several major recent ortho surgeries, now
hypotensive post op. Has L arm pain/edema, has chronic PICC in L
arm.
REASON FOR THIS EXAMINATION:
CTA-- assess for PE
CONTRAINDICATIONS for IV CONTRAST: None.

CLINICAL HISTORY: 31-year-old female status post several major
recent orthopedic surgeries, now with hypertensive postop.
Patient with left arm pain and edema. Evaluate for pulmonary
embolus.

COMPARISON: None.

TECHNIQUE: Contrast-enhanced MDCT acquired axial images of the
chest from the thoracic inlet to the upper abdomen. Multiplanar
reformatted images were obtained.

CT OF THE CHEST WITH INTRAVENOUS CONTRAST: Respiratory motion
somewhat limits sensitivity for detection of pulmonary embolus
within the subsegmental pulmonary arteries. Apparent filling
defect is identified within the left lower lobe subsegmental
pulmonary artery on axial images (series 2, image 69), which is
not confirmed on multiplaner reformatted images and likely
represents partial volume averaging. No central or segmental
pulmonary embolus is identified. The thoracic aorta maintains a
normal contour without evidence of dissection.

The lungs are clear, without evidence of mass, nodule or
consolidation. Minimal atelectasis is seen within the dependent
portions of the lung. No pleural or pericardial effusion is
detected. The heart and great vessels are within normal limits.
A left subclavian central venous catheter is present with tip in
the distal SVC. No axillary or central lymphadenopathy is
appreciated. Limited views of the upper abdomen are
unremarkable.

BONE WINDOWS: No suspicious lytic or sclerotic lesion is
identified.

IMPRESSION: Limited sensitivity for detection of subsegmental
pulmonary embolus given respiratory motion. Apparent filling
defect is seen within the left lower lobe subsegmental pulmonary
artery on axial images, not clearly identified on multiplanar
reformatted images and likely represent partial volume
averaging. No conclusive evidence of PE.

FEMUR (AP & LAT) LEFT  [**2144-10-28**] 6:44 PM

FEMUR (AP & LAT) LEFT

Reason: r/o femur fracture, please perform on long cassette

[**Hospital 93**] MEDICAL CONDITION:
31 year old woman w/ h/o osteosarcoma, now s/p TKR revision [**1-3**]
infection with new onset pain in left upper leg
REASON FOR THIS EXAMINATION:
r/o femur fracture, please perform on long cassette
LEFT FEMUR, THREE VIEWS.

INDICATION: History of osteosarcoma.

FINDINGS: Comparison to [**2144-10-27**]. There is a new fracture of
the residual aspect of the proximal left femur with malalignment
of the intramedullary rod and methylmethacrylate spacer compared
to the immediate previous exam. Spacer itself is intact. Clips
are noted in the soft tissues. Drains are in place. Soft tissues
are diffusely atrophic.

IMPRESSION:

Fracture of the residual aspect of the proximal left femur with
malalignment of the long intramedullary rod and
methylmethacrylate spacer, new compared to the previous exam
from [**2144-10-27**].


Brief Hospital Course:
A/P: 31F w/ history of h/o osteosarcoma of femur s/p resection
and mult surgeries c/b infection, POD 3 from hardware
removal/washout/tobra spacer placement initially admitted to
[**Hospital Unit Name 153**] with post op hypotension, now POD 0 s/p ORIF of proximal
femur again with post-op hypotension.
.
#) ORIF: POD 0 with hypotension post-op. Intra-op blood loss
approx 1L. Patient s/p 1 unit PRBCs and 3L NS IVF resuscitation.
Patient did not require pressors during this episode of
hypotension.
- Transfuse 2 more units of PRBCs
- Resume lovenox this afternoon at prophylaxis dose
- continue pain control w/ dilaudid PCA, appreciate pain recs
- f/u Ortho recs
- non weight wearing LLE
.
#) Post- op Fever: Likely secondary to atelectasis as patient
with no other localizing symptoms on history or exam.
- will check Blood and urine cultures, tylenol prn
.
#) Hypotension: Patient reports baseline BP 100/50. Current SBP
90-110. Most likely hypovolemic s/p surgery from inadequate
fluid resusitation.
- check post-tranfusion Hct
- Continue fluid boluses prn symptomatic hypotension
.
#) Infected Hardware/Osteomyelitis: s/p washout and removal of
all hardware with placement of tobra impregnated spacer on
[**10-27**].
ID team following, antibiotic regimen per ID. Needs at least 8
wks abx, then plan for prosthesis in ~12 weeks.
- Dapto 360 mg IV Q24H, Levo 500 mg q24
- f/u ID team recs
.
#) L arm pain: post op, now resolved. Per ortho and PACU nursing
staff, likely [**1-3**] muscle spasm after prolonged surgery. However,
given PICC, and PE at risk for DVT, has mild edema.
- negative U/S for DVT
.
#) Depression/Anxiety: chronic. Aleviated somewhat when mother
present. Medical work-up for depression negative.
-continue sertaline, ativan
- SW consult ordered
- psych consulted, appreciate recs
.
.
#)FEN: IVF prn symptomatic hypotension. Advance diet as
tolerated. Follow/replete lytes PRN
.
#)PPX: Pneumoboots, Lovenox, bowel regimen
.
#)Access: PICC (L) and PIV (R)
.
#)Code: Full
.
Communication: pt and mother - [**Name (NI) 402**] [**Telephone/Fax (1) 14198**]
Dispo: to floor, ortho service

**** after being transferred to the orthopaedic service the
patient was transferred to the floor in stable condition.
Throughout the rest of her hostpial course the patient's vitals
remained stable. The patient was seen and evlauated thorughout
her course by the pain mgt team, physica therapy and Infectious
disease. Her course on the floor was complicated by difficulty
with pain control. Her epidural was d/c on POD #5  After a few
days of being on the IV PCA after being transferred to the floor
she was switched to PO pain medications and her pain was
tolerable.  Prior to discharge the patient was tolerating po,
her pain was well controlled, and she was cleared by PT.
Alsp, prior to being discharge her PICC line that was placed on
[**10-8**] was changed due to concerns that her PICC line was not
appropriately flushing/drawing.  Her PICC line was changed
without event


Medications on Admission:
aspirin 81 mg qday
Calcium + Vit D 500 mg qday
Fluconazole 100 mg Tablet qday while on Vanco
Guaifenesin [**Hospital1 **] PRN
Hydromorphone 4-8 mg q4H PRN up to 8 tabs qday
Lorazepam 1 mg TID PRN
Magnesium 84 mg [**Hospital1 **]
Multivitamin w/ minerals
Miralax 17 g qday PRN
Sertraline 100 mg qday
Valacyclovir 500 mg Tablet [**Hospital1 **] x 3days when active lesion
Vancomycin
Flonase


Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q 3-4 H PRN ().
Disp:*120 Tablet(s)* Refills:*0*
3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
4. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
Disp:*90 Tablet(s)* Refills:*0*
5. Tizandine  Sig: One (1) 2 mg tab  three times a day.
6. OxyContin 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO see tapered dose below: -4
tabs three times a day x 3 days
- 4 tabs two times day x 3 days
- 2 tabs two times a day x 3 days
- 1 tab two times a day times 3 days
-1 tab once a day x 3 days.
Disp:*81 Tablet Sustained Release 12 hr(s)* Refills:*0*
7. Daptomycin 500 mg Recon Soln Sig: 360mg Recon Solns
Intravenous Q24H (every 24 hours) for 8 weeks.
Disp:*54 Recon Soln(s)* Refills:*0*
8. Rifabutin 150 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily) for 8 weeks.
Disp:*54 Capsule(s)* Refills:*0*
9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 8 weeks.
Disp:*54 Tablet(s)* Refills:*0*
10. heparin flushes  Sig: One (1) 10U/3cc  every twenty-four(24)
hours.
Disp:*25 * Refills:*2*
11. saline flushes  Sig: One (1) 5 cc  once a day.
Disp:*25 * Refills:*2*
12. Outpatient Lab Work
laboratory monitoring required
weekly CBC, BUN/Cr, LFTs, CPK to be faed to [**First Name8 (NamePattern2) 803**] [**Last Name (NamePattern1) **] in [**Hospital **]
clinic at [**Telephone/Fax (1) 432**].

All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 6313**]
All questions regarding outpatient antibiotics should be
directed
to the infectious disease R.Ns. at ([**Telephone/Fax (1) 14199**]

13. Hexavitamin     Tablet Sig: One (1) Cap PO DAILY (Daily).
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
15. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
16. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
17. Magnesium Oxide 140 mg Capsule Sig: One (1) Capsule PO TID
(3 times a day).
18. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
19. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
20. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous DAILY (Daily).
Disp:*4 syringe* Refills:*1*


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 511**] Home Therapies

Discharge Diagnosis:
L lower extremity osteomyelitis


Discharge Condition:
stable


Discharge Instructions:
1. Non-weight bearing Left Lower extremity
2. Lovenox
3. Abx: per ID protocol- Levaquin, Daptomycin, Rifabutin
4. weekly labs- per ID recs
5. dressing changes PRn, may leave the incision open to air if
more comforable

Physical Therapy:
Non-weight bearing Left Lower extremity
Treatments Frequency:
administration of daptomycin as ordered 360mg IV q 24 (recon
soln)
PICC line care-- normal saline flushes, heparin flushes once
daily

Followup Instructions:
-Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 14200**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2144-11-12**] 10:30-- Ortho

-Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2144-11-12**] 4:00- opthalmology

-Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) 1670**] [**Last Name (un) 1671**] Phone:[**Telephone/Fax (1) 1387**]
Date/Time:[**2144-11-17**] 12:00-- Psych

- Pain management Clinic-- [**2144-11-26**] 11:00AM in [**Hospital1 18**] [**Hospital Ward Name **]
[**Hospital Ward Name 1950**] Building level 5

- [**2144-11-18**]  11:00a   ID,[**Doctor Last Name **]
  LM [**Hospital Unit Name **], BASEMENT
  ID WEST (SB)

-Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD



Completed by:[**2144-11-6**]
{'Infection and inflammatory reaction due to internal joint prosthesis,Chronic osteomyelitis, lower leg,Pulmonary collapse,Acute posthemorrhagic anemia,Chronic systolic heart failure,Hypovolemia,Osteoporosis, unspecified,Personal history of malignant neoplasm of bone,Knee joint replacement'}


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: Infected knee prothesis

PRESENT ILLNESS: 31F with h/o osteosarcoma of femur as a teenager, s/p resection
and mult surgeries, c/b infection, who underwent a 8 hour
operation to remove her of femoral antibiotic spacer and the
tibial component of previous endoprosthesis, and place a of new
femoral and tibial antibiotic spacer.
Operative course: EBL = 1.5-2 L. Required Neo intraop to
maintain her BP. Transfused 2 units PRBC's and 6L crystalloid.
Post op: Continued to have borderline BP in PACU post op (SBP
60-80, with MAP in 50's), therefore, neo was restarted with
increase in MAP to 60s. HR was tachy in 100s-110s. Extubated
without complication, quickly weaned to room air. Transferred to
the [**Hospital Unit Name 153**] for further monitoring and evaluation of hypotension.
.
Regarding her osteosarcoma: Tumor initially removed and replaced
with prosthesis at age 13; this eventually failed. In [**Month (only) 404**]
[**2143**] she underwent replacement; complicated by coag-neg staph
infection of her distal femur. Treated through this infection
with 10 weeks with vanco and started on minocycline suppression.
She developed recurrent infection 6 weeks after stopping therapy
with coag-neg staph. Her prosthesis was removed at that time
with washout and placement of vanco-impregnanted cement,
followed by 8 weeks of vanco.
One week after stopping abx (approx 2 weeks PTA) she had
recurrent pain with elevated ESR and CRP; aspiration showed 4000
WBC with poly predominance, cultures grew coag-neg staph. She
was restarted on Vanco at that time. She was brought to the OR
on the day of admission for removal of the remainder of the
prosthesis, vanco cement, and for placement of spacer
impregnated with tobra (per ID).

MEDICAL HISTORY: Osteoscarcoma L distal femur,
Depression
H/O EtOH abuse
H/O cocaine
H/O tobacco use: quit [**2-5**]; prev smoked 10 cigarettes a day
H/O CHF: echo [**2142**]: EF = 30%, repeat echo with ACE-I: Normal EF

MEDICATION ON ADMISSION: aspirin 81 mg qday
Calcium + Vit D 500 mg qday
Fluconazole 100 mg Tablet qday while on Vanco
Guaifenesin [**Hospital1 **] PRN
Hydromorphone 4-8 mg q4H PRN up to 8 tabs qday
Lorazepam 1 mg TID PRN
Magnesium 84 mg [**Hospital1 **]
Multivitamin w/ minerals
Miralax 17 g qday PRN
Sertraline 100 mg qday
Valacyclovir 500 mg Tablet [**Hospital1 **] x 3days when active lesion
Vancomycin
Flonase

ALLERGIES: Morphine / Codeine / Rifampin

PHYSICAL EXAM: VS:AFVSS
Gen: Sitting in bed, anxious, not acutely distressed
HEENT: MMM but lips dry. EOMI.
PULM: CTA in all fields
CV: RRR, tachy, no M/R/G
ABD: +BS, soft, NT/ND. EXT:
triceps. PICC in place without erythema or tenderness.
LLE: in LLE brace
RLE: no c/c/e.

FAMILY HISTORY: Mother with osteoporosis and arthritis.  Father
with hypertension.  Siblings:  Brother with bipolar disorder.

SOCIAL HISTORY: Unemployed.  Currently living with her mom who
lives in the area and has plans to move to the [**State 4565**] area
after her surgery.  She is divorced.  Tobacco:  Ten cigarettes a
day x15 years.  Alcohol:  As stated above.  Drugs:  As stated
above. 

### Response:
{'Infection and inflammatory reaction due to internal joint prosthesis,Chronic osteomyelitis, lower leg,Pulmonary collapse,Acute posthemorrhagic anemia,Chronic systolic heart failure,Hypovolemia,Osteoporosis, unspecified,Personal history of malignant neoplasm of bone,Knee joint replacement'}
