CHIEF COMPLAINT: Transferred from [**Hospital 8641**] Hospital for MRSA bacteremia, septic
knee, respiratory failure

PRESENT ILLNESS: Mr. [**Known lastname 3321**] is a 67 yo man with COPD, morbid obesity, OSA,
h/o coronary artery aneurysm reparin, osteoartritis with recent
B total-knee replacements and septic arthritis who is
transferred from [**Hospital 8641**] Hospital for further management. Mr.
[**Known lastname 3321**] was in his USOH until [**3-31**] when he underwent his TKR.
His post-operative course was complicated by persistant drainage
of fluid from his left knee for which he was placed on
clindamycin as an outpatient, he then developed C diff colitis.
He also developed a stage 4 decubitus ulcer.
.
He was admitted to an OSH on [**4-14**] where he was found to have
MRSA septic arthritis and C diff colitis. He was documented to
be bacteremic with MRSA for much of this time (last blood
culture taken on [**4-20**] was positive 1/4 bottles). He was treated
with vancomycin for the knee infection and underwent removal of
his L knee arthroplasy and placement of a tobramycin spacer on
[**4-20**] (and decubitus ulcer debridement). Post-operatively he has
had continued spiking fevers to 102 and progressive dyspnea. He
has had approximately 40-60 lbs weight-gain since his initial
surgery and has been on bumex IV for diuresis
.
His C diff was initially treated with flagyl but he has had
persistantly + stool, so this was changed to vancomycin. He
denies abdominal pain but has had increasing abdominal
distension.
.
He has had progressive dyspnea, no orthopnea. It appears that he
has been treated for CHF exacerbation with IV bumex and was
placed on BiPAP at 26/20. The patient much prefers being on
BiPAP and has been on it for most of the past 2-3 days.
.
Currently he complains of severe fatigue, no appetite, thirst,
general malaise. He also endorses back and LLE pain. No abdomial
pain, nausea, vomiting. Within an hour of being at [**Hospital1 18**] he was
febrile to 101.5 with 1/4 blood cultures positive for GPCs

MEDICAL HISTORY: Obesity
OSA on home bipap
h/o RCA aneurysm ligation in [**2151**]; post-op atrial fibrillation.

MEDICATION ON ADMISSION: MEDICATIONS ON TRANSFER
Vancomycin 250mg po Q6 hrs
vancomycin 1.25g IV Q18 hrs
aztreonam? 2gm IV Q?
paxil 20mg po daily
potassium 20meQ po bid
coumadin 7mg po daily
MVI
bentyl prn pain
metoprolol 5mg IV prn
tylenol 650mg po prn
protonix 40mg po bid
rifampin 300mg po bid
duoneb
zinc
bumex 2mg IV q 8
.
HOME MEDICATIONS
ambien, nystatin, acidophilus, foradil, spireva, zyrec, lasix,
micro K, zinc, MVI, celebrex, asmanex, MS contin, tylenol,
humibid-LA, nexium, Lopid, Nasonex

ALLERGIES: Penicillins / Oxycodone

PHYSICAL EXAM: T 100.7 BP 129-76 HR 114 RR SaO2 95% on 4L n/c CVP 3 when
upright, 24 when supine
General: obese man, uncomfortable, NAD
HEENT: MM dry. PERRL, EOMI
CV: tachycardic, unable to auscultate heart sounds.
Lungs: In moderate distress, using accessory muscles and pursing
lips. CTA B, poor airmovement. No wheezing, rales, ronchi.
Abdomen: very distended and tympanic, non-tender, hypoactive
bowel sounds. No rebound, guarding, or masses. flexiseal with
brown loose stool
Back: large decubitus ulcer, 3-cm deep area of debridement, scar
tissue and scab ontop of granulation tissue. surrounding
superficial
extremities: L knee wrapped. R knee with sutures, no erythema or
drainage. 3+BLE edema

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Married, from NH, lives with wife. Retired product manager in a
steel manufacturing plant. Enjoys playing blues harmonica.
Former heavy smoker (quit 18 yrs ago). No EtOH or drugs.
Other postoperative infection,Acute respiratory failure,Pyogenic arthritis, lower leg,Pressure ulcer, lower back,Acute diastolic heart failure,Pneumonia, organism unspecified,Obstructive chronic bronchitis with (acute) exacerbation,Acute kidney failure, unspecified,Iron deficiency anemia secondary to blood loss (chronic),Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Infection with microorganisms resistant to penicillins,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other specified cardiac dysrhythmias,Morbid obesity,Obstructive sleep apnea (adult)(pediatric)
Other postop infection,Acute respiratry failure,Pyogen arthritis-l/leg,Pressure ulcer, low back,Ac diastolic hrt failure,Pneumonia, organism NOS,Obs chr bronc w(ac) exac,Acute kidney failure NOS,Chr blood loss anemia,Mth sus Stph aur els/NOS,Inf mcrg rstn pncllins,DMII wo cmp nt st uncntr,Cardiac dysrhythmias NEC,Morbid obesity,Obstructive sleep apnea
Admission Date:  [**2157-4-23**]              Discharge Date:   [**2157-5-11**]

Date of Birth:  [**2090-3-24**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins / Oxycodone

Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Transferred from [**Hospital 8641**] Hospital for MRSA bacteremia, septic
knee, respiratory failure

Major Surgical or Invasive Procedure:
Radial arterial line placement
PICC placement


History of Present Illness:
Mr. [**Known lastname 3321**] is a 67 yo man with COPD, morbid obesity, OSA,
h/o coronary artery aneurysm reparin, osteoartritis with recent
B total-knee replacements and septic arthritis who is
transferred from [**Hospital 8641**] Hospital for further management. Mr.
[**Known lastname 3321**] was in his USOH until [**3-31**] when he underwent his TKR.
His post-operative course was complicated by persistant drainage
of fluid from his left knee for which he was placed on
clindamycin as an outpatient, he then developed C diff colitis.
He also developed a stage 4 decubitus ulcer.
.
He was admitted to an OSH on [**4-14**] where he was found to have
MRSA septic arthritis and C diff colitis. He was documented to
be bacteremic with MRSA for much of this time (last blood
culture taken on [**4-20**] was positive 1/4 bottles). He was treated
with vancomycin for the knee infection and underwent removal of
his L knee arthroplasy and placement of a tobramycin spacer on
[**4-20**] (and decubitus ulcer debridement). Post-operatively he has
had continued spiking fevers to 102 and progressive dyspnea. He
has had approximately 40-60 lbs weight-gain since his initial
surgery and has been on bumex IV for diuresis
.
His C diff was initially treated with flagyl but he has had
persistantly + stool, so this was changed to vancomycin. He
denies abdominal pain but has had increasing abdominal
distension.
.
He has had progressive dyspnea, no orthopnea. It appears that he
has been treated for CHF exacerbation with IV bumex and was
placed on BiPAP at 26/20. The patient much prefers being on
BiPAP and has been on it for most of the past 2-3 days.
.
Currently he complains of severe fatigue, no appetite, thirst,
general malaise. He also endorses back and LLE pain. No abdomial
pain, nausea, vomiting. Within an hour of being at [**Hospital1 18**] he was
febrile to 101.5 with 1/4 blood cultures positive for GPCs


Past Medical History:
Obesity
OSA on home bipap
h/o RCA aneurysm ligation in [**2151**]; post-op atrial fibrillation.

h/o post-operative atrial fibrillation
Stroke (1.5 yrs ago) with L-sided weakness (now resolved)
COPD on home inhalers
Osteoarthritis
Hypertension

Social History:
Married, from NH, lives with wife. Retired product manager in a
steel manufacturing plant. Enjoys playing blues harmonica.
Former heavy smoker (quit 18 yrs ago). No EtOH or drugs.

Family History:
Non-contributory

Physical Exam:
T 100.7 BP 129-76 HR 114 RR SaO2 95% on 4L n/c CVP 3 when
upright, 24 when supine
General: obese man, uncomfortable, NAD
HEENT: MM dry. PERRL, EOMI
CV: tachycardic, unable to auscultate heart sounds.
Lungs: In moderate distress, using accessory muscles and pursing
lips. CTA B, poor airmovement. No wheezing, rales, ronchi.
Abdomen: very distended and tympanic, non-tender, hypoactive
bowel sounds. No rebound, guarding, or masses. flexiseal with
brown loose stool
Back: large decubitus ulcer, 3-cm deep area of debridement, scar
tissue and scab ontop of granulation tissue. surrounding
superficial
extremities: L knee wrapped. R knee with sutures, no erythema or
drainage. 3+BLE edema


Pertinent Results:
Admission labs:
[**2157-4-23**] 10:29PM   WBC-10.2 RBC-3.53* HGB-10.1* HCT-31.5* MCV-89
MCH-28.5 MCHC-31.9 RDW-16.6*
[**2157-4-23**] 10:29PM   NEUTS-65 BANDS-9* LYMPHS-13* MONOS-4 EOS-4
BASOS-0 ATYPS-2* METAS-2* MYELOS-1*
[**2157-4-23**] 10:29PM   PLT SMR-NORMAL PLT COUNT-374
[**2157-4-23**] 10:29PM   GLUCOSE-156* UREA N-19 CREAT-1.2 SODIUM-140
POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-26 ANION GAP-10
[**2157-4-23**] 10:29PM   CALCIUM-6.7* PHOSPHATE-3.0 MAGNESIUM-2.1
[**2157-4-23**] 10:29PM   PT-32.2* PTT-35.0 INR(PT)-3.3*
.
Discharge labs:
[**2157-5-5**] 03:49AM BLOOD WBC-8.0 RBC-3.29* Hgb-9.0* Hct-29.1*
MCV-89 MCH-27.5 MCHC-31.1 RDW-16.8* Plt Ct-434
[**2157-5-5**] 03:49AM BLOOD PT-27.0* PTT-29.3 INR(PT)-2.7*
[**2157-5-5**] 03:49AM BLOOD Glucose-142* UreaN-40* Creat-1.4* Na-146*
K-4.4 Cl-107 HCO3-31 AnGap-12
[**2157-5-5**] 03:49AM BLOOD Calcium-8.2* Phos-3.3 Mg-2.5
[**2157-4-28**] 08:30AM BLOOD ALT-17 AST-36 LD(LDH)-341* AlkPhos-103
Amylase-43 TotBili-0.3
[**2157-4-23**] 10:29PM BLOOD proBNP-1176*
[**2157-4-24**] 04:38AM BLOOD calTIBC-185* VitB12-1808* Folate-13.0
Ferritn-240 TRF-142*
[**2157-4-30**] 02:33AM BLOOD TSH-1.1
[**2157-5-3**] 05:01AM BLOOD CRP-27.7*
[**2157-5-3**] 05:01AM BLOOD ESR-17*
.
Studies:
KNEE (2 VIEWS) BILAT  [**2157-4-24**]
RIGHT KNEE: Three views of the right knee demonstrate
tricompartmental prosthesis in standard position, with no
evidence of loosening or hardware failure. Corticated osseous
density inferolateral to distal femur is likely related to prior
injury or surgery. A 6-mm opacity within the knee joint is may
potentially represent a foreign body. There is an apparent
suprapatellar joint effusion.
LEFT KNEE: Hardware has apparently been removed. A large, 13.6
cm x 7.2 cm diameter lobulated opaque structure extends from the
distal femoral shaft to the proximal tibia and has likely been
surgically placed for the provided history of washout for
treatment of septic left knee joint following knee replacement
procedure. The tibiofemoral joint space has apparently been
obliterated. Apparent diffuse soft tissue swelling is present
within the left lower extremity based upon increased thickness
of the soft tissues compared to the contralateral right
extremity. Additionally, the cortical margin of the
posterior-inferior aspect of the left femur is not well
demonstrated. The possibility of osteomyelitis cannot be
excluded. Direct comparison to previous outside postoperative
radiographs would be helpful. Alternatively, if clinical
suspicion is high, nuclear medicine white blood cell scan or MRI
could be considered.
.
US EXTREMITY NONVASCULAR  [**2157-5-2**]
FINDINGS: Small amount of fluid was noted anterior and superior
to the patella. No definite fluid collection was noted above the
patella to suggest knee joint effusion. Moderate amount of edema
was noted within the anterior thigh region.
.
CHEST (PORTABLE AP)  [**2157-4-23**]
IMPRESSION:
1. Limited radiograph due to large body habitus and portable
technique. Apparent widening of mediastinum which may reflect
prominent vascular structures, but standard PA and lateral views
are suggested for more complete assessment of this finding as
well as a peripheral pleural opacity in the left mid lung, when
the patient's condition permits.
2. Likely volume overload.
3. Bilateral effusions.
.
CHEST (PORTABLE AP)  [**2157-5-3**]
FINDINGS: AP single view obtained with patient in sitting
semi-upright position is analyzed in comparison with a similar
preceding study of [**5-1**]. There is status post sternotomy, and
there are at least three small surgical clips identified in the
right-sided mediastinum overlying the heart shadow. There is
moderate cardiomegaly, and a rather marked widening and
elongation of the thoracic aorta is present. This coincides with
a congestive vascular pattern and diffuse hazy densities at the
lung bases and most likely representing bilateral pleural
effusions. There is no evidence of pneumothorax. The technical
quality of the portable chest examination suffers from the
patient's extreme dimensions (morbid obesity), and discrete
local pneumonic infiltrates cannot be identified with certainty.
Review of the total seven portable chest examinations from [**4-23**] through [**5-1**] is performed. All these studies suffer from
difficulties to penetrate the lungs appropriately. It is noted
that a previously present right jugular vein approach central
venous line has been removed. Also a previously identified
right-sided PICC line remains in unchanged position.
Rather prominent distended azygos vein is compatible with
hypervolemia as mentioned on previous reports.
IMPRESSION: Stable chest findings are seen on technically
limited single view exposures of this very obese patient.

Brief Hospital Course:
Assessment and Plan: 67 yo man with COPD, morbid obesity, OSA,
osteoartritis with recent B total-knee replacements who is
transferred from OSH with MRSA septic arthritis s/p removal of
hardware in L knee, C. diff colitis, volume overload.
.
# Respiratory failure:  This is multifactorial with components
of 1) OSA on bipap at home, 2) obesity hypoventilation, 3) COPD
exacerbation (sig. wheezing on exam), 4) volume overload
(reported 50 lb weight gain in last month, anasarca on exam),
and possible pneumonia (difficult to image due to obesity).
Patient has been reportedly ruled out for PE at OSH and is
anticoagulated on coumadin for atrial fibrillation.  For his
OSA, his bipap setting was adjusted to 25/21 with 4 L O2.  For
COPD, he was started on solumedrol on [**4-29**] and was gradually
tapered; he has two remaining days of prednisone 10 mg daily.
He was also started on monteleukast.  He is also on standing
albuterol/ipratropium nebulizers and home inhalers.  For his
volume overload, he was aggressively diuresed with Lasix. For
empiric coverage of pneumonia, he was started on ceftazidime,
quickly defervesed, and thus completed a 10-day course prior to
discharge.  For waxing and [**Doctor Last Name 688**] mental status and hyercarbia,
patient was placed intermittently on BiPAP.
.
# L prosthetic knee infection/bactermia with MRSA:  Orthopaedics
was consulted and recommended outpatient follow up with his
original orthopedic surgeon.  An ultrasound of the left knee did
not show any collection amenable to drainage.  Blood cultures at
[**Hospital1 18**] are all negative/ngtd.  He had a TTE that did not show
vegetations; a TEE was not pursued as there was low suspicion
for endocarditis and patient would require 6 week course of
vancomycin regardless of result.  He was continued on vancomycin
with a goal trough of 15-25; last day of planned course is [**5-27**].  He will follow up with the [**Hospital **] clinic at [**Hospital1 18**] as an
outpatient.  He remains non-weight bearing on his left lower
extremity and should wear his knee immobilizer at all times.
Sutures remain intact and he will need to follow-up with his
Orthopaedic Surgeon at [**Hospital 8641**] Hospital for further care plan.
.
# C. diff colitis:  Pt was transferred on vancomycin therapy.
Pt tested negative for C. diff toxin on admission.  He was
started on IV flagyl and transitioned to PO.  His diarrhea had
resolved by discharge.  He is to continue flagyl to complete an
additional two week course following completion of his
vancomycin course.
.
# Acute renal failure: This occurred in the setting of diuresis
with a UNa <10, 11 hyaline casts.  He is likely intravascularly
dry.  No urine eos.  Cr slowy improved to 1.3 by discharge.
Medications were renally dose (vancomycin).
.
# Delirium:  Patient's mental status waxed and waned throughout
hospital course, likely related to worsening hypercarbia in the
setting of COPD and OSA.  Sedating medications were avoided.  On
[**5-8**] he was noted to have acute mental status changes in the
setting of high-normal pCO2; a 25 mcg fentanyl patch that had
been placed for pain control was removed, and his mental status
quickly improved.
.
# Acute diastolic congestive heart failure/extravascular volume
overload:  Pt has no clinical history of CHF and BNP was
measured at 1176.  On exam, pt does have significant 3rd
spacing, likely compounded by hypoalbuminemia.  He did not have
proteinuria on U/A.  Patient was 21.5 liters negative for length
of stay at [**Hospital1 18**].  On day of discharge, his lasix dose was
reduced from 80 mg [**Hospital1 **] to his home dose of 40 mg [**Hospital1 **].  He should
continue to be diuresed with a goal fluid balance of 1 liter
negative for at least the next 7 days.  Electrolytes should be
carefully monitored with diuresis.
.
# Sinus tachycardia:  This was initially thought to be due to
intravascular depletion as pt c/o thirst and had dry mucous
membranes; however, his HR did not respond to IVF boluses.  He
remained tachycardic throughout his entire hospital course
although his heart rate did improve to the low 100-110 range.
Etiology of his tachycardia is presumed multifactorial.
.
# Atrial fibrillation:  Pt remained in sinus tachycardia while
in house.  His coumadin was adjusted to INR goal of [**1-16**]; he is
currently on coumadin 3 mg daily (down from home dose of 7 mg
daily) due to concurrent abx dose.  If patient goes into a. fib
with RVR, calcium channel blocker is recommended over
beta-blocker due to significant bronchospasm.  INR will need to
be closely monitored with coumadin dose adjusted during and
after completion of antiobiotic course.
.
# Decubitus ulcer, stage 4: This is s/p debridement at [**Hospital 8641**]
Hospital and did not appear grossly infected.  Per report, there
was no evidence of osteomyelitis.  This was followed by wound
care nursing with dressing changes as per detailed discharge
instructions.  Wound was cultured and positive for VRE.
.
# Anemia:  This is likely combination of blood loss from OR
procedures and bone marrow suppression from infection. Vit
b12/folate levels WNL. Iron studies were consistent with anemia
of chronic disease. Hemolysis labs were neg. HCT is stable at
29.
.
# Code status: Full.
.
# Access: midline(1 lumen), placed by Interventional Radiology
at [**Hospital1 18**] on [**2157-4-26**].

Medications on Admission:
MEDICATIONS ON TRANSFER
Vancomycin 250mg po Q6 hrs
vancomycin 1.25g IV Q18 hrs
aztreonam? 2gm IV Q?
paxil 20mg po daily
potassium 20meQ po bid
coumadin 7mg po daily
MVI
bentyl prn pain
metoprolol 5mg IV prn
tylenol 650mg po prn
protonix 40mg po bid
rifampin 300mg po bid
duoneb
zinc
bumex 2mg IV q 8
.
HOME MEDICATIONS
ambien, nystatin, acidophilus, foradil, spireva, zyrec, lasix,
micro K, zinc, MVI, celebrex, asmanex, MS contin, tylenol,
humibid-LA, nexium, Lopid, Nasonex


Discharge Medications:
1. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
2. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) neb Inhalation every four (4) hours as needed.
3. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Hexavitamin     Tablet Sig: One (1) Cap PO DAILY (Daily).
5. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk
with Device Inhalation Q12H (every 12 hours).
6. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) inhalation
Inhalation Q6H (every 6 hours).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime):
Please give after evening dressing change.
11. Megestrol 400 mg/10 mL Suspension Sig: One (1)  PO BID (2
times a day): [**Month (only) 116**] d/c after patient regains appetite and resumes
normal caloric intake.
12. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days.
16. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
17. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
18. Insulin Lispro 100 unit/mL Solution Sig: Per sliding scale
Subcutaneous qACHS.
19. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
20. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day): Continue for two weeks following completion of
vancomycin course; end date [**6-10**].
21. Coumadin 3 mg Tablet Sig: One (1) Tablet PO at bedtime:
Target INR [**1-16**].
22. Vancomycin 500 mg Recon Soln Sig: Seven [**Age over 90 1230**]y (750)
mL Intravenous Q 12H (Every 12 Hours): end date [**5-27**].
23. BiPAP mask ventilation  Sig: apply mask   at bedtime:
Settings 25/21.


Discharge Disposition:
Extended Care

Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]

Discharge Diagnosis:
MRSA bacteremia
Septic joint
COPD
Hypoxic hypercarbic respiratory failure
Clostridium difficile colitis
Delirium
Stage IV decubitus ulcer
CHF exacerbation
Chronic renal insufficiency
Pneumonia


Discharge Condition:
A&Ox3, HR 110s, BP 114/70


Discharge Instructions:
You were admitted for a infected left knee with MRSA bacteremia.
 You were treated with the antibiotic vancomycin.  You will need
to continue this antibiotic for a total of 6 weeks, ending on
[**5-27**].  You will also need to follow up with your Orthopedic
surgeon.
.
You also had respiratory difficulties while you were
hospitalized.  This is likely due to a combination of entities.
For your sleep apnea, you were continued on your bipap machine
at settings of 25/21.  For your COPD exacerbation, you were
started on steroids and you have two additional days remaining
in your taper.  You also have fluid in your lungs; you have been
getting the medication Lasix to help you urinate out extra
fluids.


Followup Instructions:
Please keep the following appointments:
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] BLOOD
Division of Infectious Disease
Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2157-6-1**] at 11:30 am
.
Please also see your Orthopaedic Surgeon Dr. [**Last Name (STitle) 35012**] at [**Hospital 8641**]
Hospital within the next two weeks.  You will need to contact
him regarding plans for suture removal.
.
You have been referred to see a Pulmonologist at [**Hospital1 18**] who is
also a sleep specialist.  If possible, please obtain a copy of
your prior sleep study and bring this with you to this
appointment:
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2157-5-13**] 9:20
.
Finally, please follow up with your primary care physician [**Last Name (NamePattern4) **].
[**Last Name (STitle) 35013**] within 1-2 weeks following your discharge from the
rehabilitation facility.  Her clinic number is [**Telephone/Fax (1) 35014**].


                             [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
{'Other postoperative infection,Acute respiratory failure,Pyogenic arthritis, lower leg,Pressure ulcer, lower back,Acute diastolic heart failure,Pneumonia, organism unspecified,Obstructive chronic bronchitis with (acute) exacerbation,Acute kidney failure, unspecified,Iron deficiency anemia secondary to blood loss (chronic),Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Infection with microorganisms resistant to penicillins,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other specified cardiac dysrhythmias,Morbid obesity,Obstructive sleep apnea (adult)(pediatric)'}


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: Transferred from [**Hospital 8641**] Hospital for MRSA bacteremia, septic
knee, respiratory failure

PRESENT ILLNESS: Mr. [**Known lastname 3321**] is a 67 yo man with COPD, morbid obesity, OSA,
h/o coronary artery aneurysm reparin, osteoartritis with recent
B total-knee replacements and septic arthritis who is
transferred from [**Hospital 8641**] Hospital for further management. Mr.
[**Known lastname 3321**] was in his USOH until [**3-31**] when he underwent his TKR.
His post-operative course was complicated by persistant drainage
of fluid from his left knee for which he was placed on
clindamycin as an outpatient, he then developed C diff colitis.
He also developed a stage 4 decubitus ulcer.
.
He was admitted to an OSH on [**4-14**] where he was found to have
MRSA septic arthritis and C diff colitis. He was documented to
be bacteremic with MRSA for much of this time (last blood
culture taken on [**4-20**] was positive 1/4 bottles). He was treated
with vancomycin for the knee infection and underwent removal of
his L knee arthroplasy and placement of a tobramycin spacer on
[**4-20**] (and decubitus ulcer debridement). Post-operatively he has
had continued spiking fevers to 102 and progressive dyspnea. He
has had approximately 40-60 lbs weight-gain since his initial
surgery and has been on bumex IV for diuresis
.
His C diff was initially treated with flagyl but he has had
persistantly + stool, so this was changed to vancomycin. He
denies abdominal pain but has had increasing abdominal
distension.
.
He has had progressive dyspnea, no orthopnea. It appears that he
has been treated for CHF exacerbation with IV bumex and was
placed on BiPAP at 26/20. The patient much prefers being on
BiPAP and has been on it for most of the past 2-3 days.
.
Currently he complains of severe fatigue, no appetite, thirst,
general malaise. He also endorses back and LLE pain. No abdomial
pain, nausea, vomiting. Within an hour of being at [**Hospital1 18**] he was
febrile to 101.5 with 1/4 blood cultures positive for GPCs

MEDICAL HISTORY: Obesity
OSA on home bipap
h/o RCA aneurysm ligation in [**2151**]; post-op atrial fibrillation.

MEDICATION ON ADMISSION: MEDICATIONS ON TRANSFER
Vancomycin 250mg po Q6 hrs
vancomycin 1.25g IV Q18 hrs
aztreonam? 2gm IV Q?
paxil 20mg po daily
potassium 20meQ po bid
coumadin 7mg po daily
MVI
bentyl prn pain
metoprolol 5mg IV prn
tylenol 650mg po prn
protonix 40mg po bid
rifampin 300mg po bid
duoneb
zinc
bumex 2mg IV q 8
.
HOME MEDICATIONS
ambien, nystatin, acidophilus, foradil, spireva, zyrec, lasix,
micro K, zinc, MVI, celebrex, asmanex, MS contin, tylenol,
humibid-LA, nexium, Lopid, Nasonex

ALLERGIES: Penicillins / Oxycodone

PHYSICAL EXAM: T 100.7 BP 129-76 HR 114 RR SaO2 95% on 4L n/c CVP 3 when
upright, 24 when supine
General: obese man, uncomfortable, NAD
HEENT: MM dry. PERRL, EOMI
CV: tachycardic, unable to auscultate heart sounds.
Lungs: In moderate distress, using accessory muscles and pursing
lips. CTA B, poor airmovement. No wheezing, rales, ronchi.
Abdomen: very distended and tympanic, non-tender, hypoactive
bowel sounds. No rebound, guarding, or masses. flexiseal with
brown loose stool
Back: large decubitus ulcer, 3-cm deep area of debridement, scar
tissue and scab ontop of granulation tissue. surrounding
superficial
extremities: L knee wrapped. R knee with sutures, no erythema or
drainage. 3+BLE edema

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Married, from NH, lives with wife. Retired product manager in a
steel manufacturing plant. Enjoys playing blues harmonica.
Former heavy smoker (quit 18 yrs ago). No EtOH or drugs. 

### Response:
{'Other postoperative infection,Acute respiratory failure,Pyogenic arthritis, lower leg,Pressure ulcer, lower back,Acute diastolic heart failure,Pneumonia, organism unspecified,Obstructive chronic bronchitis with (acute) exacerbation,Acute kidney failure, unspecified,Iron deficiency anemia secondary to blood loss (chronic),Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Infection with microorganisms resistant to penicillins,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other specified cardiac dysrhythmias,Morbid obesity,Obstructive sleep apnea (adult)(pediatric)'}
