CHIEF COMPLAINT: lumbar wound infection

PRESENT ILLNESS: History of the Present Illness: Ms. [**Known lastname **] is a 63 year old woman
who underwent an elective L3-L5 laminectomy and fusion as well
as
L5-S1 microdiscectomy on [**9-1**] with Dr. [**Last Name (STitle) 739**]. On [**9-3**] she
was evaluated and her dressing was removed from her surgical
site. The area had staples and had some mild serosanguinous
drainage and a new dressing was placed.  At this time her
Hemovac
drain was also removed. On [**9-4**] she was discharged to rehab.

MEDICAL HISTORY: dyslipidemia, hypertension, bronchitis, PNA, gout, hiatal hernia

MEDICATION ON ADMISSION: 1. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for spasm.
Disp:*20 Tablet(s)* Refills:*0*
2. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2

ALLERGIES: Penicillins

PHYSICAL EXAM: Temp: 100.4 HR: 78 BP:116/66 Resp:18 O(2)Sat: 94 RA

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: denies tobacco, EOTh, or recreational drug use
Other postoperative infection,Acute respiratory failure,Bacteremia,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Acute bronchospasm,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Obesity, unspecified,Arthrodesis status,Personal history of Methicillin resistant Staphylococcus aureus,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation
Other postop infection,Acute respiratry failure,Bacteremia,Mth sus Stph aur els/NOS,Acute bronchospasm,Hypertension NOS,Hyperlipidemia NEC/NOS,Obesity NOS,Arthrodesis status,Hx Methicln resist Staph,Abn react-surg proc NEC
Admission Date:  [**2104-9-20**]              Discharge Date:   [**2104-9-29**]

Date of Birth:  [**2040-7-5**]             Sex:   F

Service: NEUROSURGERY

Allergies:
Penicillins

Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
lumbar wound infection

Major Surgical or Invasive Procedure:
[**2104-9-21**] lumbar wound washout
[**2104-9-24**] PICC line placement


History of Present Illness:
History of the Present Illness: Ms. [**Known lastname **] is a 63 year old woman
who underwent an elective L3-L5 laminectomy and fusion as well
as
L5-S1 microdiscectomy on [**9-1**] with Dr. [**Last Name (STitle) 739**]. On [**9-3**] she
was evaluated and her dressing was removed from her surgical
site. The area had staples and had some mild serosanguinous
drainage and a new dressing was placed.  At this time her
Hemovac
drain was also removed. On [**9-4**] she was discharged to rehab.

The patient reports that she had not been feeling well over the
past two days. Recently, she was noted to have a UTI and was
given a course of Cipro. Today, patient spiked to 103 and it was
noted that there was copious serosnginous and purulent drainage
from wound. Patient was given vancomycin and rocephin and was
transferred from [**Hospital3 417**] hospital to [**Hospital1 18**].


Past Medical History:
dyslipidemia, hypertension, bronchitis, PNA, gout, hiatal hernia

Social History:
denies tobacco, EOTh, or recreational drug use


Family History:
noncontributory

Physical Exam:
Temp: 100.4 HR: 78 BP:116/66 Resp:18 O(2)Sat: 94 RA

HEENT:
Chest: CTA b/l
Cardiovascular: Regular Rate and Rhythm
Normal first and second heart sounds
Abdominal: Soft, Nontender
Extr/Back: There is extensive serosanginous drainage from the
wound site with occasional frank purulent drainage.

NEURO:
Mental Status: Alert and fully oriented. Fluent and prosodic.
Naming and repetition intact. + 3 step commands.

Cranial nerves: PEERL, VFF. EOM full. V1-V3 intact to PP, LT and
temp. Face symmetric Tongue and palate midline. No dysarthria or
dysphonia.

Motor examination: No cogwheeling or tremor. Finger and toe
tapping symmetric. No pronator drift.

   Delt Bic Tric Grasp APB Quad Ham TA Gastroc DF PF
R   5    5   5    5     5   5   5   5    5     5   5
L   5    5   5    5     5   5   5   5    5     5   5

Coordination: FNF and HTS without dysmetria. No checking or
dysdiadokinesia.

Sensation intact in legs to LT, JPS, Vib, temp, PP. There is no
sensory level.

Reflexes: 2+ and symmetric with toes downgoing bilaterally

Gait: Deferred


Pertinent Results:
CT L-SPINE W/ CONTRAST Study Date of [**2104-9-20**] 11:45 PM

Final Report
HISTORY: Status post L3-L5 laminectomy and fusion on [**9-4**]
presenting with
fever and purulent discharge.

CT L-SPINE: Helical imaging was performed through the lumbar
spine after
uneventful administration of IV contrast. Sagittal and coronal
reformats were
prepared.

COMPARISON: L-spine radiograph [**2104-9-3**].

FINDINGS: Patient is status post laminectomy from L3 to L5 with
posterior
fusion hardware. The appearance of the posterior fusion hardware
including
morselized bone graft material appears intact. Evaluation of the
region
posterior to the laminectomy is limited by streak artifact.
Posterior to the L1-L2 spinous process is a 1.7 x 1.3 cm fluid
collection with peripheral rim enhancement. There is stable
grade 1 anterolisthesis of L4 on L5.

Limited views of the abdomen and pelvis appear grossly normal.

IMPRESSION:

1. Status post laminectomy from L3 to L5 with posterior fusion.
Hardware
appears intact.

2. Evaluation limited by streak artifact and fluid collection at
the site of laminectomy cannot be excluded. Intrathecal detail
is markedly limited.

3. Small fluid collection posterior to the spinous process of L1
and L2.

Final Attending Comment:

Also noted is an illdefined hypodensity in the right psoas
muscle which may represent a fluid collection or evolving
hematoma. Consider MRI for further evaluation.

The study and the report were reviewed by the staff radiologist.



[**Known lastname **],[**Known firstname **] [**Age over 90 97858**] F  64  [**2040-7-5**]

Radiology Report CHEST (PORTABLE AP) Study Date of [**2104-9-21**] 8:04
PM


[**2104-9-21**] 8:04 PM
CHEST (PORTABLE AP)   Clip # [**Clip Number (Radiology) 97859**]


Final Report
REASON FOR EXAMINATION: Re-intubation, evaluation of ET tube
placement.

Portable AP chest radiograph was compared to prior study
obtained on [**2104-7-21**].

The ET tube tip is 5.3 cm above the carina. The NG tube tip is
in the
stomach. Cardiomediastinal silhouette is stable. There is no
evidence of
interval increase in pleural effusion or pneumothorax. Bibasal
opacities are most likely consistent with areas of atelectasis.
The patient is after lumbar surgery.

CT CHEST
1. Bilateral segmental and subsegmental atelectasis
predominantly basal,
without bronchial obstruction.
2. Right upper lobe infarct or abscess. Presuming there is no
indication of active venous thrombosis or pulmonary embolus,
evaluation would be to obtain concurrent routine radiographs
including oblique views to see if a baseline can be established
for followup study in four weeks.
3. 4.5-mm right upper lobe lung nodule warrants repeat chest CT
in six months if the patient is a smoker, 12 months if there is
no particular risk of bronchogenic carcinoma.

CXR [**2104-9-29**] done / final report pending

[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT

[**Known lastname **], [**Known firstname **]       [**Hospital1 18**] [**Numeric Identifier 97860**]TTE (Complete) Done
[**2104-9-29**] at 10:06:43 AM      PRELIMINARY
Referring Physician     [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 742**]
[**Hospital1 18**]-Division of Neurosurgery
[**Hospital Unit Name 18400**]
[**Location (un) 86**], [**Numeric Identifier 718**]  Status: Inpatient DOB: [**2040-7-5**]
Age (years): 64 F  Hgt (in): 62
BP (mm Hg): 124/66  Wgt (lb): 230
HR (bpm): 84  BSA (m2): 2.03 m2
Indication: Endocarditis. Staph bacteremia
ICD-9 Codes: 424.90
Test Information
Date/Time: [**2104-9-29**] at 10:06    Interpret MD: [**Name6 (MD) **] [**Name8 (MD) 4082**], MD
Test Type: TTE (Complete) Son[**Name (NI) 930**]: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4587**], RDCS
Doppler: Full Doppler and color Doppler Test Location: West Echo
Lab
Contrast: None Tech Quality: Suboptimal
Tape #: 2010W054-0:00 Machine: Vivid [**8-7**]
Echocardiographic Measurements
Results  Measurements  Normal Range
Left Atrium - Long Axis Dimension:  *4.1 cm  <= 4.0 cm
Left Atrium - Four Chamber Length:  4.5 cm  <= 5.2 cm
Left Atrium - Peak Pulm Vein S:  0.6 m/s
Left Atrium - Peak Pulm Vein D:  0.5 m/s
Left Atrium - Peak Pulm Vein A:  0.3 m/s  < 0.4 m/s
Right Atrium - Four Chamber Length:  5.0 cm  <= 5.0 cm
Left Ventricle - Septal Wall Thickness:  0.9 cm  0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness:  0.8 cm  0.6 - 1.1 cm

Left Ventricle - Diastolic Dimension:  4.3 cm  <= 5.6 cm
Left Ventricle - Systolic Dimension:  2.7 cm
Left Ventricle - Fractional Shortening:  0.37  >= 0.29
Left Ventricle - Ejection Fraction:  50% to 55%  >= 55%
Left Ventricle - Lateral Peak E':  *0.07 m/s  > 0.08 m/s
Left Ventricle - Septal Peak E':  0.12 m/s  > 0.08 m/s
Left Ventricle - Ratio E/E':  8  < 15
Aorta - Sinus Level:  2.8 cm  <= 3.6 cm
Aorta - Ascending:  3.3 cm  <= 3.4 cm
Aortic Valve - Peak Velocity:  1.5 m/sec  <= 2.0 m/sec
Aortic Valve - LVOT diam:  2.1 cm
Mitral Valve - E Wave:  0.8 m/sec
Mitral Valve - A Wave:  1.1 m/sec
Mitral Valve - E/A ratio:  0.73
Mitral Valve - E Wave deceleration time:  160 ms  140-250 ms

Findings
LEFT ATRIUM: Normal LA and RA cavity sizes.

LEFT VENTRICLE: Normal LV wall thickness and cavity size. Low
normal LVEF.

RIGHT VENTRICLE: RV not well seen.

AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels.

AORTIC VALVE: ?# aortic valve leaflets.

MITRAL VALVE: Normal mitral valve leaflets. Mild mitral annular
calcification.

TRICUSPID VALVE: Tricuspid valve not well visualized.

GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal image quality - poor parasternal views. Suboptimal
image quality as the patient was difficult to position.
Suboptimal image quality - body habitus.
Conclusions
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses and cavity size are normal. Overall
left ventricular systolic function is low normal (LVEF 50-55%).
The diameters of aorta at the sinus, ascending and arch levels
are normal. The number of aortic valve leaflets cannot be
determined. The mitral valve leaflets are structurally normal.

IMPRESSION: Suboptimal image quality.
If clinically suggested, the absence of a vegetation by 2D
echocardiography does not exclude endocarditis.

PRELIMINARY REPORT developed by a Cardiology Fellow. Not
reviewed/approved by the Attending Echo Physician.


Brief Hospital Course:
Patient presented to [**Hospital3 417**] hospital on [**9-20**] for fever
and drainage from her surgical incision and was subsequently
transferred to [**Hospital1 18**] for further treatment.  She was evalauted
in the emergency room  and was admitted to the neurosurgery
service.  Upon exam her incision from her L3-5 laminectomy and
L5-S1 microdiscectomy had copious amounts of drainage.  A CT of
the lumbar spine was obtained to evalaute for abcess as well as
the extent of the fluid collection which showed a small fluid
collection posterior to the spinous process of L1 and L2.  Blood
wound and urine cultures were also obtained upon admission.
Blood and wound cultures grew coagulase positive staph aureus
and Infectious disease consult was obtained to assist in
selecting the appropriate antibiotic regimen for her bacteremia.
They recommended treating her with vancomycin and meropenem and
these recommendations were initiated and treatment begun.

On [**9-21**] she went to the operating room for washout of her lumbar
incision. A hemovac drain was placed in the operating room to
assist with drainage of the wound. She was extubated in the OR
however required reintubation in the PACU for hypoxia and
obstruction versus bronchospasm. She was transferred to the SICU
from the PACU where she remained stable overnight.

On [**9-22**] she remained intubated in the SICU with a good exam.
she was following all commands off of sedation and had good
motor strength which was limited by pain and effort.  The SICU
attempted to wean her from the vent but they were unsuccessful
as she had no cuff leak. She remained stable and intubated
overnight on [**9-22**] into [**9-23**] and they again performed an SBT
which was unsuccessful. They began to sit her up while wearing
her TLSO with hopes that this would improve her respiratory
status.  She was given lasix as well.

In the morning of [**9-24**] her motor exam was improved and she
continued with following commands appropriately while off
sedation. On the afternoon of [**9-24**] her hemovac drain was pulled
from her lumbar incision and she was extubated. She remained
stable in the SICU after extubation overnight on [**9-24**] into [**9-25**].
She recieved two units of packed cell for a Hct of 22.

On [**9-28**], patient's exam remains unchanged. Her incision had
minimal drainaged. She was encouraged to work with physical
therapy. An echo to r/o vegitation and a baseline cxr was
obtained for ? of abscess vs infarct / she will have a follow up
cxr in 4 weeks as well as a follow up CT of the chest in one
year.

She is tolerating po intake, voiding freeling and stooling.  She
agrees with plan for d.c to rehab.  She will follow up with ID
and neurosurgery in 2 weeks.

Medications on Admission:
1. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for spasm.
Disp:*20 Tablet(s)* Refills:*0*
2. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2

times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
6. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
9. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H

(every 6 hours) as needed for Itching.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
12. Ondansetron 4 mg IV Q8H:PRN Nausea
13. Prochlorperazine 10 mg IV Q6H:PRN n/v


Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Fluoxetine 10 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
6. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
7. Glucagon (Human Recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
8. Diltiazem HCl 30 mg Tablet Sig: Two (2) Tablet PO QID (4
times a day).
9. Acetaminophen 650 mg/20.3 mL Solution Sig: One (1)  PO Q6H
(every 6 hours) as needed for fever.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
12. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Four (4) Puff Inhalation Q4H (every 4 hours) as needed for
wheezes.
13. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler
Sig: Four (4) Puff Inhalation Q4H (every 4 hours).
14. Ondansetron 4 mg IV Q8H:PRN nausea
15. HYDROmorphone (Dilaudid) 0.25-0.5 mg IV Q3H:PRN pain
16. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
17. Pantoprazole 40 mg IV Q24H
18. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
19. Sodium Chloride 0.9%  Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
20. Vancomycin 500 mg Recon Soln Sig: 1250 MG  Recon Solns
Intravenous Q 12H (Every 12 Hours): WILL NEED [**7-8**] WEEK COURSE
PER INFECTIOUS DISEASE / HOLD IF VANCO LEVEL >20.
Disp:*0 Recon Soln(s)* Refills:*0*
21. Alteplase 1mg/2mL ( Clearance ie. PICC, tunneled access line
) 1 mg IV ONCE piccline clot clearance Duration: 1 Doses
to be instilled in line for PICCLINE clot clearance- by IV RN
only per protocol-
NOT for systemic use
22. Outpatient Lab Work
Q MONDAY

CBC WITH DIFFERENTIAL / BUN / CR/ ESR /CRP /VANCO TROUGH

PLEASE FAX RESULTS TO DR [**Last Name (STitle) **] / [**Hospital **] CLINIC [**Hospital1 18**] AT [**Telephone/Fax (1) **]


Discharge Disposition:
Extended Care

Facility:
[**Hospital **] Rehabilitation and Nursing Center - [**Location (un) 701**]

Discharge Diagnosis:
Lumbar wound infection
Bronchospasm requiring intubation
MRSA in lumbar wound
Bacteremia
POST OP ANEMIA REQUIRING TRANSFUSION


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:
Lumbar (Low Back) Spine Surgery
******PLEASE CONTINUE TO WEAR TLSO BRACE WHEN OUT OF BED********

Diet:
?????? You may resume your normal diet.
?????? You can help avoid constipation by eating a balanced diet
including:  fruits, vegetables, and
whole grains (like multi-grain bread, cereals, and bran
muffins).
?????? You may also take fiber supplements and over-the-counter stool
softeners or laxatives such as Colace or Dulcolax

Activity:
?????? Walk at least three times a day and gradually increase your
distance and light activities each day.
?????? Do not exercise other than walking until after your first
6-week office visit.
?????? Do not sit longer than one hour at a time for the first two
weeks ?????? get up and move around.
?????? You will be more comfortable reclining in an easy chair or on
pillows in bed than sitting upright.
?????? Avoid twisting, turning, stopping, bending or reaching over
your head for six weeks.
?????? Do not return to the gym, play golf, swim, run, mow grass
until 3 months after surgery.
?????? Avoid exercises like aerobics, heavy house cleaning and
lifting over [**6-9**] pounds (a gallon of milk weighs 8.5 pounds).

?????? Do your breathing exercises every two hours.
?????? Use your incentive spirometer 10 times every hour that you are
awake.
?????? Do not drive if you are taking pain medications, muscle
relaxants, or if you are in pain.
?????? You may resume sexual activity when this is comfortable for
you.
?????? You can return to work when you feel ready.  However, you must
stay within the [**6-9**] pound weight lifting restriction ?????? half
days might be better at first.

Lumbar Spine patients:
?????? Do not drive 1-2 weeks after surgery.
?????? Do not ride in the car longer than one hour at a time ?????? get
out to stretch your back each
hour.

Wound Care:
??????	You may shower after [**Month/Year (2) 2729**] have been removed. Prior to that
time frame, you may take a sponge bath, or shower such that the
water does not directly run over your incision. You [**Month (only) **] NOT soak
the incision in a bathtub or pool for 4 weeks.   If your wound
gets wet, gently [**Last Name (LF) **], [**First Name3 (LF) **] NOT RUB the wound dry.
??????	Your incision was closed with staples or stitches.
??????	You may remove the dressing after 2 days after surgery.  If
there is still a small amount of bloody drainage, you can place
a new sterile gauze dressing, otherwise you can leave the wound
open to air
Pain:
??????	The second day after surgery will be the most painful due to
swelling and the anesthetic wearing off, and increased muscle
spasms as the lower back muscles begin to heal.
??????	 You may also experience some back pain from muscle spasm as
you increase your daily activity, this is to be expected and
will improve with time.
??????	Around the fifth week after surgery, you may experience
discomfort for a few days due to scar tissue forming.
??????	You may also have some pain, numbness and tingling in the legs
and feet for the first 6-8 weeks as normal nerve function
returns.
??????	Some pain is normal as you resume your daily activities.  You
may tire more easily for several months after surgery.

Medications:
?????? Take all of your medications as ordered.  You do not have to
take pain medication unless it is needed.  It is important that
you are able to cough, breathe deeply, and be comfortable enough
to walk.
?????? Do not use alcohol while taking pain medication.
?????? Medications that may be prescribed include:
??????	Narcotic pain medication such as Dilaudid, Percocet or Vicodin

??????	Muscle relaxant such as Robaxin, Flexeril or Valium.  Take
these as needed for muscle spasm.  They will make you sleepy, so
do not drive while taking these medications
??????	You may be prescribed an anti-inflammatory medication such as
Indomethacin or Ibuprofen.
??????	Take these as prescribed on a regular basis to reduce
inflammation and pain
??????	An over the counter stool softener for constipation (try
Dulcolax, Milk of Magnesia or
??????	Correctal at first and Magnesium Citrate or Fleets enema if
needed).

Miscellaneous:
??????	If you have had a fusion, do not use non-steroidal
anti-inflammatory drugs (NSAIDs) (e.g., aspirin; ibuprofen,
Advil, Motrin, Nuprin; naproxen sodium, Aleve) for 6 months
after surgery. NSAIDs may cause bleeding and interfere with bone
healing.
??????	Do not smoke. Smoking delays healing by increasing the risk of
complications (e.g., infection) and inhibits the bones' ability
to fuse.

WHEN TO CALL THE DOCTOR
??????	Call the doctor at ([**Telephone/Fax (1) 88**] if you have:
?????? A temperature of 101??????F or above
?????? Increased redness, soreness, swelling or foul-smelling
drainage from the incision
?????? Clear drainage from the incision
?????? Inadequate pain relief
?????? Nausea or vomiting
?????? Shortness of breath
?????? Pain in your calf

Important Instructions Regarding Emergencies and After-Hour
Calls
??????	If you have what you feel is a true emergency at any time,
please present immediately to your local emergency room, where a
doctor there will evaluate you and contact us if needed. Due to
the complexity of neurosurgical procedures and treatment of
neurosurgical problems, effective advice regarding emergency
situations cannot be given over the telephone.
??????	Should you have a situation which is not life-threatening, but
you feel needs addressing before normal office hours or on the
weekend, please present to the local emergency room, where the
physician there will evaluate you and contact us if needed.
Follow-Up Appointment Instructions
Please return to the office in [**8-9**] days (from your date of
surgery) for removal of your staples/[**Date Range 2729**] and a wound check.
Although we try to be thorough, we may miss [**First Name (Titles) 2730**] [**Last Name (Titles) 2729**] or
staples. Be sure to point out any incisions, which may be
covered by clothing


Followup Instructions:
1>  PLEASE FOLLOW-UP WITH YOUR PCP REGARDING THE RESULTS OF THE
CT OF THE CHEST THAT WAS OBTAINED WHILE YOU WERE ADMITTED
******YOU WILL NEED A CT SCAN OF THE CHEST IN 12 MONTHS  -
PLEASE MARK YOUR CALENDAR WHEN YOU GET HOME.  YOU WILL ALSO NEED
TO FOLLOW UP WITH YOUR PRIMARY CARE REGARDING THE RESULTS OF
YOUR CHEST XRAY.

2>  Please Follow-Up with Dr. [**Last Name (STitle) 739**] in 2 weeks / WITH
XRAYS.
[**Location (un) 830**] / [**Hospital Ward Name **] / [**Location (un) **]
[**Telephone/Fax (1) 3736**] Date/Time:[**2104-10-16**] to follow your xray
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2104-10-16**] 10:45 am
Your [**Month/Day/Year 2729**] will stay in until you're follow-up appointment.

3> You will need a CXR [**10-30**] / Please go to the [**Location (un) **] [**Location (un) **] RADIOLOGY AS A WALK IN.  THE ADDRESS
IS '[**Hospital1 **]'. CONTACT YOUR PRIMARY CARE FOR THESE
RESULTS.

4> YOU NEED TO FOLLOW UP IN THE [**Hospital **] CLINIC IN TWO WEEKS
AN APPOINTMENT HAS BEEN SET FOR YOU ON [**2104-10-21**] AT
4:00 PM
WITH DR. [**Last Name (STitle) **] / DR. [**Last Name (STitle) **].  THE OFFICE IN ON THE GROUND FLOOR
/ BASEMENT OF THE [**Hospital Unit Name **] / [**Doctor First Name **].
[**Telephone/Fax (1) **]


                             [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]

Completed by:[**2104-9-29**]
{'Other postoperative infection,Acute respiratory failure,Bacteremia,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Acute bronchospasm,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Obesity, unspecified,Arthrodesis status,Personal history of Methicillin resistant Staphylococcus aureus,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation'}


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: lumbar wound infection

PRESENT ILLNESS: History of the Present Illness: Ms. [**Known lastname **] is a 63 year old woman
who underwent an elective L3-L5 laminectomy and fusion as well
as
L5-S1 microdiscectomy on [**9-1**] with Dr. [**Last Name (STitle) 739**]. On [**9-3**] she
was evaluated and her dressing was removed from her surgical
site. The area had staples and had some mild serosanguinous
drainage and a new dressing was placed.  At this time her
Hemovac
drain was also removed. On [**9-4**] she was discharged to rehab.

MEDICAL HISTORY: dyslipidemia, hypertension, bronchitis, PNA, gout, hiatal hernia

MEDICATION ON ADMISSION: 1. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for spasm.
Disp:*20 Tablet(s)* Refills:*0*
2. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2

ALLERGIES: Penicillins

PHYSICAL EXAM: Temp: 100.4 HR: 78 BP:116/66 Resp:18 O(2)Sat: 94 RA

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: denies tobacco, EOTh, or recreational drug use 

### Response:
{'Other postoperative infection,Acute respiratory failure,Bacteremia,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Acute bronchospasm,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Obesity, unspecified,Arthrodesis status,Personal history of Methicillin resistant Staphylococcus aureus,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation'}
