CHIEF COMPLAINT: transfer for ICD extraction

PRESENT ILLNESS: Mr. [**Known lastname **] is a 59 year-old male with pmh of HTN, HL, CHF w/ EF
30% CAD s/p CABG and stent to left main, s/p pacemaker and [**Hospital 3941**]
transferred from NEBH for ICD extraction after vegetation noted
on ICD lead.  Patient initially presented to an outside hospital
with increasing knee pain over 2-3 weeks time.  At the OSH
impression was for a septic knee.  Aspirate on [**2106-2-12**] revealed
WBC count of 255K in the knee, 8000 rbc's, 100% polys.  Treated
initially with vancomycin, and later daptomycin.  Culture
subsequently grew MSSA, and patient subsequently grew MSSA from
the blood as well.
.
Patient taken to the OR for wash out and liner exchange.  He was
electively intubated for that procedure.  Never extubated
post-op b/c what was felt to be clinical CHF although partly was
to facilitate TEE.  Intra-op cultures confirmed MSSA.
.
In the ICU he was febrile to 103.8.  Patient bacteremic at NEBH
and on [**2106-2-15**], and [**2106-2-16**]. TEE performed and noted veg on
AICD wire.  Due to Cr 1.9 on presentation to OSH patient was
initially treated with CTX/daptomycin given concern for hardware
infection and renal failure.  Diuresis was attempted with 40mg
IV lasix prior to transfer but patient left intubated.
.
Last VS prior to transfer were HR 80-90 in sinus, 115-120/50, RR
16, on fent/versed 150/12.
.
On arrival, patient's VS were T102.5, HR 83, BP 152/72, RR 17,
O2 100%RA.  He was intubated and sedated.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS:
- Diabetes, + Dyslipidemia, + Hypertension
2. CARDIAC HISTORY:
-CABG: s/p CABG in [**2090**] with LIMA to LAD, saphenous vein graft
to
PDA and saphenous vein graft to OM-2.  Had known 80% left main,
100% RCA, 90% LAD, and 70% OM on cath.
-PERCUTANEOUS CORONARY INTERVENTIONS:
Repeat Cardiac Cath in [**2095**] showed LMCA with an 80% eccentric
stenosis in the distal portion (unchanged). The LAD had a 70%
lesion in the proximal mid segment just after the S1 origin. The
LCX supplied two major OMs, the second of which had an 80 %
lesion near the origin. The RCA was totally occluded proximally.
 Vein graft to OM was occluded proximally, LIMA to LAD open, and
RCA filled retrograde from open SVG to mid-RCA/PDA.  At that
time patient had direct stenting of the protected left main with
a 4.5 x 13 mm Bx Velocity stent.  Successful PTCA of the OM2
with a 2.5 mm Raptor balloon with 20% residual stenosis.
.
-PACING/ICD:  s/p [**Company 1543**] [**Last Name (un) 24119**] single chamber ICD and
[**Company 1543**] Kappa dual chamber pacemaker first placed in [**2095**] for
pauses, ICD functionality added [**2098**] and single lead ICD placed
on the left.
.
3. OTHER PAST MEDICAL HISTORY:
-CAD s/p CABG as above
-Inferior myocardial infarction
-Atrial fibrillation
-Hypertension
-Hyperlipidemia
-OSA on CPAP
-Chronic kidney disease (history of tubulointersitital disease
due to NSAIDS and atherosclerotic renal artery disease)
-Gout
-Peripheral neuropathy complicated by progressive gait
difficulty
-Knee arthritis s/p multiple knee surgeries
-Depression
-Motor vehicle accident in [**2074**], status post arm tendon transfer
-Obesity
-Progressive supranuclear palsy
-Drop Attacks

MEDICATION ON ADMISSION: MEDICATIONS ON TRANSFER FROM [**Hospital1 **]:
-Ceftriaxone 2grams q12
-daptomycin 1gram daily IV
-Versed gtt
-fentanyl gtt
-allopurinol 200mg PO daily
-zetia 10mg PO daily
-welbutrin 75mg PO qhs, 100mg [**Hospital1 **]
-toprol XL 200mg daily
-pepcid 20mg daily
-combivent 4 puffs QID
-cymbalta 30mg PO daily
-Aspirin 81 mg daily
-Amitriptyline 75mg daily
-Heparin 5000 SQ TID
-Digoxin 250ucg daily
.
Home Medications
Lasix 40mg daily
digoxin 125 ucg daily
coumadin 6mg qPM
Prilosec 20mg daily
zyloprim 300mg daily
EC ASA 81mg daily
Zetia 10mg daily
Cymbalta 30mg daily
Elavil 250mg daily
Tramadol 100mg TID
Wellbutrin 300mg qAM, 75mg qPM
Lyrica 75 TID
Toprol 200mg daily
.
Medications on transfer to [**Hospital1 **]:
ALLOPURINOL 200 mg po daily
AMITRIPTYLINE 75 mg po qhs
Aspirin 81mg daily
BUPROPION 75 mg po q24, and 75mg qHS
colace 100mg [**Hospital1 **]
DIGOXIN 375 mcg po daily
Cymbalta 30mg daily
Zetia 10mg daily
Pepcid 20mg daily
Heparin 5000 SQ TID
Toprol XL 200mg daily
Lyrica 50mg TID
Daptomycin 1gram IV daily
Dilaudid 2mg SQ q4-6H PRN
Zofran 4mg PO q8H PRN
Percocet 1-2 tabs q6H PRN

ALLERGIES: Lipitor

PHYSICAL EXAM: General Appearance: Well nourished, Overweight / Obese

FAMILY HISTORY: Mother died of complications from cancer. Father died at age 75
of natural causes.

SOCIAL HISTORY: Currently unemployed. Lives alone. Drinks occasionally with his
son.
Infection and inflammatory reaction due to cardiac device, implant, and graft,Methicillin susceptible Staphylococcus aureus septicemia,Severe sepsis,Acute respiratory failure,Metabolic encephalopathy,Acute kidney failure, unspecified,Acute on chronic systolic heart failure,Cerebral embolism with cerebral infarction,Pyogenic arthritis, lower leg,Hyposmolality and/or hyponatremia,Other degenerative diseases of the basal ganglia,Knee joint replacement,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Other alteration of consciousness,Depressive disorder, not elsewhere classified,Abdominal aneurysm without mention of rupture,Pain in joint, ankle and foot,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Old myocardial infarction,Atrial fibrillation,Long-term (current) use of anticoagulants,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Other and unspecified hyperlipidemia,Obstructive sleep apnea (adult)(pediatric),Atherosclerosis of renal artery,Gout, unspecified,Unspecified hereditary and idiopathic peripheral neuropathy,Obesity, unspecified
React-cardiac dev/graft,Meth susc Staph aur sept,Severe sepsis,Acute respiratry failure,Metabolic encephalopathy,Acute kidney failure NOS,Ac on chr syst hrt fail,Crbl emblsm w infrct,Pyogen arthritis-l/leg,Hyposmolality,Degen basal ganglia NEC,Joint replaced knee,Abn react-artif implant,Other alter consciousnes,Depressive disorder NEC,Abdom aortic aneurysm,Joint pain-ankle,Cor ath unsp vsl ntv/gft,Aortocoronary bypass,Old myocardial infarct,Atrial fibrillation,Long-term use anticoagul,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Hyperlipidemia NEC/NOS,Obstructive sleep apnea,Renal artery atheroscler,Gout NOS,Idio periph neurpthy NOS,Obesity NOS
Admission Date:  [**2106-2-17**]              Discharge Date:   [**2106-3-2**]

Date of Birth:  [**2046-11-24**]             Sex:   M

Service: MEDICINE

Allergies:
Lipitor

Attending:[**Doctor First Name 2080**]
Chief Complaint:
transfer for ICD extraction

Major Surgical or Invasive Procedure:
Removal of ICD/Pacemaker

History of Present Illness:
Mr. [**Known lastname **] is a 59 year-old male with pmh of HTN, HL, CHF w/ EF
30% CAD s/p CABG and stent to left main, s/p pacemaker and [**Hospital 3941**]
transferred from NEBH for ICD extraction after vegetation noted
on ICD lead.  Patient initially presented to an outside hospital
with increasing knee pain over 2-3 weeks time.  At the OSH
impression was for a septic knee.  Aspirate on [**2106-2-12**] revealed
WBC count of 255K in the knee, 8000 rbc's, 100% polys.  Treated
initially with vancomycin, and later daptomycin.  Culture
subsequently grew MSSA, and patient subsequently grew MSSA from
the blood as well.
.
Patient taken to the OR for wash out and liner exchange.  He was
electively intubated for that procedure.  Never extubated
post-op b/c what was felt to be clinical CHF although partly was
to facilitate TEE.  Intra-op cultures confirmed MSSA.
.
In the ICU he was febrile to 103.8.  Patient bacteremic at NEBH
and on [**2106-2-15**], and [**2106-2-16**]. TEE performed and noted veg on
AICD wire.  Due to Cr 1.9 on presentation to OSH patient was
initially treated with CTX/daptomycin given concern for hardware
infection and renal failure.  Diuresis was attempted with 40mg
IV lasix prior to transfer but patient left intubated.
.
Last VS prior to transfer were HR 80-90 in sinus, 115-120/50, RR
16, on fent/versed 150/12.
.
On arrival, patient's VS were T102.5, HR 83, BP 152/72, RR 17,
O2 100%RA.  He was intubated and sedated.


Past Medical History:
1. CARDIAC RISK FACTORS:
- Diabetes, + Dyslipidemia, + Hypertension
2. CARDIAC HISTORY:
-CABG: s/p CABG in [**2090**] with LIMA to LAD, saphenous vein graft
to
PDA and saphenous vein graft to OM-2.  Had known 80% left main,
100% RCA, 90% LAD, and 70% OM on cath.
-PERCUTANEOUS CORONARY INTERVENTIONS:
Repeat Cardiac Cath in [**2095**] showed LMCA with an 80% eccentric
stenosis in the distal portion (unchanged). The LAD had a 70%
lesion in the proximal mid segment just after the S1 origin. The
LCX supplied two major OMs, the second of which had an 80 %
lesion near the origin. The RCA was totally occluded proximally.
 Vein graft to OM was occluded proximally, LIMA to LAD open, and
RCA filled retrograde from open SVG to mid-RCA/PDA.  At that
time patient had direct stenting of the protected left main with
a 4.5 x 13 mm Bx Velocity stent.  Successful PTCA of the OM2
with a 2.5 mm Raptor balloon with 20% residual stenosis.
.
-PACING/ICD:  s/p [**Company 1543**] [**Last Name (un) 24119**] single chamber ICD and
[**Company 1543**] Kappa dual chamber pacemaker first placed in [**2095**] for
pauses, ICD functionality added [**2098**] and single lead ICD placed
on the left.
.
3. OTHER PAST MEDICAL HISTORY:
-CAD s/p CABG as above
-Inferior myocardial infarction
-Atrial fibrillation
-Hypertension
-Hyperlipidemia
-OSA on CPAP
-Chronic kidney disease (history of tubulointersitital disease
due to NSAIDS and atherosclerotic renal artery disease)
-Gout
-Peripheral neuropathy complicated by progressive gait
difficulty
-Knee arthritis s/p multiple knee surgeries
-Depression
-Motor vehicle accident in [**2074**], status post arm tendon transfer
-Obesity
-Progressive supranuclear palsy
-Drop Attacks


Social History:
Currently unemployed. Lives alone. Drinks occasionally with his
son.

Family History:
Mother died of complications from cancer. Father died at age 75
of natural causes.

Physical Exam:
General Appearance: Well nourished, Overweight / Obese

Eyes / Conjunctiva: PERRL

Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG
tube

Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, (Murmur:
No(t) Systolic)

Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)

Respiratory / Chest: (Breath Sounds: Wheezes : anteriorly)

Abdominal: Soft, Non-tender, Bowel sounds present, No(t)
Distended, No(t) Tender: , Obese

Extremities: Right lower extremity edema: Trace, Left lower
extremity edema: Trace, No(t) Cyanosis, No(t) Clubbing

Musculoskeletal: No(t) Muscle wasting

Skin:  Warm, Rash: papular rash over chest/arms


Pertinent Results:
[**2106-2-17**] 03:43PM   WBC-6.8 RBC-2.92*# HGB-9.2*# HCT-28.1*#
MCV-96 MCH-31.5 MCHC-32.8 RDW-15.3
[**2106-2-17**] 03:43PM   NEUTS-74* BANDS-2 LYMPHS-15* MONOS-3 EOS-3
BASOS-0 ATYPS-0 METAS-2* MYELOS-1*
[**2106-2-17**] 03:43PM   PLT SMR-NORMAL PLT COUNT-243#
[**2106-2-17**] 03:43PM   PT-14.9* PTT-25.8 INR(PT)-1.3*
[**2106-2-17**] 03:43PM   GLUCOSE-94 UREA N-25* CREAT-1.3* SODIUM-150*
POTASSIUM-4.2 CHLORIDE-113* TOTAL CO2-31 ANION GAP-10
[**2106-2-17**] 03:43PM   ALT(SGPT)-45* AST(SGOT)-86* LD(LDH)-255*
CK(CPK)-758* ALK PHOS-281* TOT BILI-1.8*
[**2106-2-17**] 03:43PM   CK-MB-3 cTropnT-0.04*
[**2106-2-17**] 03:43PM   ALBUMIN-2.5* CALCIUM-8.0* PHOSPHATE-3.5
MAGNESIUM-2.5 IRON-20*
[**2106-2-18**] 05:09AM BLOOD WBC-5.8 RBC-2.92* Hgb-8.7* Hct-27.8*
MCV-95 MCH-29.8 MCHC-31.3 RDW-15.2 Plt Ct-223
[**2106-2-19**] 04:29AM BLOOD WBC-7.6 RBC-3.11* Hgb-9.2* Hct-29.7*
MCV-96 MCH-29.7 MCHC-31.0 RDW-15.3 Plt Ct-269
[**2106-2-20**] 02:43AM BLOOD WBC-6.8 RBC-2.81* Hgb-8.2* Hct-26.7*
MCV-95 MCH-29.3 MCHC-30.7* RDW-15.3 Plt Ct-260
[**2106-2-21**] 03:59AM BLOOD WBC-9.6 RBC-3.16* Hgb-9.6* Hct-29.7*
MCV-94 MCH-30.3 MCHC-32.3 RDW-15.0 Plt Ct-280
[**2106-2-22**] 03:44AM BLOOD WBC-9.1 RBC-3.33* Hgb-9.8* Hct-31.0*
MCV-93 MCH-29.4 MCHC-31.6 RDW-15.7* Plt Ct-277
[**2106-2-23**] 06:42AM BLOOD WBC-9.3 RBC-3.04* Hgb-9.7* Hct-28.8*
MCV-95 MCH-31.8 MCHC-33.5 RDW-15.8* Plt Ct-343
[**2106-2-23**] 05:46PM BLOOD WBC-16.4*# RBC-3.65* Hgb-11.2* Hct-34.7*
MCV-95 MCH-30.6 MCHC-32.2 RDW-15.9* Plt Ct-475*
[**2106-2-24**] 12:10AM BLOOD WBC-14.1* RBC-3.05* Hgb-9.3* Hct-28.6*
MCV-94 MCH-30.5 MCHC-32.5 RDW-16.1* Plt Ct-344
[**2106-2-24**] 06:47AM BLOOD Hct-28.3*
[**2106-2-25**] 03:00AM BLOOD WBC-9.5 RBC-3.14* Hgb-9.8* Hct-29.5*
MCV-94 MCH-31.2 MCHC-33.2 RDW-16.2* Plt Ct-395
[**2106-2-26**] 06:26AM BLOOD WBC-9.8 RBC-3.17* Hgb-10.1* Hct-29.7*
MCV-94 MCH-31.7 MCHC-33.8 RDW-16.1* Plt Ct-423
[**2106-2-27**] 06:13AM BLOOD WBC-7.5 RBC-3.35* Hgb-10.4* Hct-31.4*
MCV-94 MCH-31.1 MCHC-33.2 RDW-16.0* Plt Ct-425
[**2106-2-28**] 06:21AM BLOOD WBC-8.3 RBC-3.61* Hgb-10.7* Hct-32.7*
MCV-91 MCH-29.5 MCHC-32.6 RDW-15.9* Plt Ct-416
[**2106-3-1**] 05:32AM BLOOD WBC-7.9 RBC-3.49* Hgb-10.7* Hct-31.8*
MCV-91 MCH-30.6 MCHC-33.6 RDW-16.0* Plt Ct-374
[**2106-3-2**] 03:32AM BLOOD WBC-7.4 RBC-3.55* Hgb-10.5* Hct-32.1*
MCV-90 MCH-29.7 MCHC-32.9 RDW-15.9* Plt Ct-391
[**2106-2-17**] 03:43PM BLOOD PT-14.9* PTT-25.8 INR(PT)-1.3*
[**2106-2-19**] 04:29AM BLOOD PT-15.6* PTT-25.8 INR(PT)-1.4*
[**2106-2-22**] 03:44AM BLOOD PT-14.2* PTT-28.0 INR(PT)-1.2*
[**2106-2-23**] 05:46PM BLOOD PT-14.2* PTT-28.9 INR(PT)-1.2*
[**2106-2-24**] 06:47AM BLOOD PT-14.6* PTT-27.8 INR(PT)-1.3*
[**2106-2-26**] 06:26AM BLOOD PT-22.3* PTT-34.6 INR(PT)-2.1*
[**2106-2-27**] 06:13AM BLOOD PT-19.7* PTT-33.2 INR(PT)-1.8*
[**2106-2-28**] 06:21AM BLOOD PT-16.2* PTT-29.1 INR(PT)-1.4*
[**2106-3-1**] 05:32AM BLOOD PT-16.1* PTT-78.2* INR(PT)-1.4*
[**2106-3-2**] 03:32AM BLOOD PT-19.2* PTT-62.5* INR(PT)-1.8*
[**2106-2-18**] 05:09AM BLOOD ESR-141*
[**2106-2-19**] 04:29AM BLOOD ESR-137*
[**2106-2-17**] 03:43PM BLOOD Glucose-94 UreaN-25* Creat-1.3* Na-150*
K-4.2 Cl-113* HCO3-31 AnGap-10
[**2106-2-18**] 05:09AM BLOOD Glucose-121* UreaN-28* Creat-1.5* Na-150*
K-3.9 Cl-113* HCO3-32 AnGap-9
[**2106-3-1**] 05:32AM BLOOD Glucose-125* UreaN-13 Creat-1.1 Na-137
K-3.9 Cl-100 HCO3-24 AnGap-17
[**2106-3-2**] 03:32AM BLOOD Glucose-123* UreaN-11 Creat-1.1 Na-137
K-3.3 Cl-100 HCO3-27 AnGap-13
[**2106-2-17**] 03:43PM BLOOD ALT-45* AST-86* LD(LDH)-255* CK(CPK)-758*
AlkPhos-281* TotBili-1.8*
[**2106-2-19**] 06:32PM BLOOD ALT-70* AST-104* LD(LDH)-269*
AlkPhos-264* TotBili-4.0*
[**2106-2-21**] 03:59AM BLOOD ALT-53* AST-57* AlkPhos-225* TotBili-2.6*
[**2106-2-23**] 05:46PM BLOOD CK(CPK)-115
[**2106-2-24**] 12:10AM BLOOD CK(CPK)-84
[**2106-2-24**] 06:47AM BLOOD CK(CPK)-81
[**2106-2-27**] 06:13AM BLOOD ALT-26 AST-26 AlkPhos-148* TotBili-1.8*
[**2106-2-28**] 06:21AM BLOOD ALT-26 AST-28 AlkPhos-138* TotBili-1.9*
[**2106-3-1**] 05:32AM BLOOD ALT-30 AST-33 AlkPhos-126 TotBili-2.0*
DirBili-1.1* IndBili-0.9
[**2106-2-19**] 06:32PM BLOOD Lipase-57
[**2106-2-17**] 03:43PM BLOOD CK-MB-3 cTropnT-0.04*
[**2106-2-23**] 05:46PM BLOOD CK-MB-3 cTropnT-<0.01
[**2106-2-24**] 12:10AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2106-2-24**] 06:47AM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2106-2-17**] 03:43PM BLOOD Albumin-2.5* Calcium-8.0* Phos-3.5 Mg-2.5
Iron-20*
[**2106-2-18**] 05:09AM BLOOD Calcium-8.1* Phos-3.8 Mg-2.7*
[**2106-3-1**] 05:32AM BLOOD Calcium-9.0 Phos-3.7 Mg-2.1
[**2106-3-2**] 03:32AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.1
[**2106-2-17**] 03:43PM BLOOD calTIBC-183* Ferritn-680* TRF-141*
[**2106-2-24**] 12:10AM BLOOD %HbA1c-4.9 eAG-94
[**2106-2-24**] 12:10AM BLOOD Triglyc-272* HDL-22 CHOL/HD-9.5
LDLcalc-132*
[**2106-2-25**] 03:00AM BLOOD TSH-3.7
[**2106-2-17**] 03:43PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2106-2-18**] 05:09AM BLOOD CRP-156.7*
[**2106-2-19**] 04:29AM BLOOD CRP-121.1*
[**2106-2-21**] 07:13PM BLOOD Vanco-16.8
[**2106-2-17**] 03:43PM BLOOD Digoxin-0.7*
[**2106-3-2**] 03:32AM BLOOD Digoxin-0.5*
[**2106-2-17**] 03:43PM BLOOD HCV Ab-NEGATIVE

EKG ([**2106-2-17**])- Sinus rhythm with ventricular premature beats.
Left atrial abnormality. Right bundle-branch block. Prior
inferior myocardial infarction. Consider left  anterior
fascicular block although is non-diagnostic. ST-T wave
abnormalities  are primary and are non-specific but cannot
exclude myocardial ischemia.  Clinical correlation is suggested.
Since the previous tracing of [**2100-10-12**] further intraventricular
conduction delay with left axis shift is now present and lateral
limb lead ST-T wave changes are more prominent.

Knee X-ray ([**2-18**])- LEFT KNEE: There is a left total knee
arthroplasty. There is prominent
amount of gas within the joint space. Please correlate with
recent
intervention. If there has been no instrumentation, then this is
highly
concerning for infection. No periprosthetic lucency is
identified. There are medial surgical skin staples.

ECHO ([**2-19**])- No spontaneous echo contrast is seen in the body of
the left atrium or left atrial appendage. Mild spontaneous echo
contrast is seen in the body of the right atrium. A thin, freely
mobile, filamentous mass/thrombus associated with a
catheter/pacing wire is seen in the right atrium. No atrial
septal defect is seen by 2D or color Doppler. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
are complex (>4mm) atheroma in the descending thoracic aorta.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis. No masses or
vegetations are seen on the aortic valve. Trace aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. No mass or vegetation
is seen on the mitral valve. No vegetation/mass is seen on the
pulmonic valve. There is no pericardial effusion.

IMPRESSION: Thin, filamentous, freely mobile mass associated
with a catheter in the right atrium suggestive of vegetation or
thrombus. No valvular vegetations or significant regurgitant
valvular disease seen.

CT Torso ([**2106-2-19**])-
1. Dependent opacities in bilateral lung bases are mostly
atelectasis; small
amount of aspiration or infection cannot be excluded in this
case in the lower
lobes. Calcified granulomas indicate prior granulomatous
disease.

2. Two nodules in the right upper lobe measurting 5 and 8 mm are
non-specific
and not likely septic emboli. Recommend followup CT in six
months.

3. Splenomegaly measuring up to 21 cm.

4. Aneurysmal dilatation of the infrarenal aorta up to 3.7 cm.
Aneurysmal
dilatation of the proximal right common iliac artery up to 2.3
cm.

5. Cystic lesion in the upper pole of the left kidney
incompletely
characterized. Comparison to prior is recommended. If not
available, follow-up
in 6 months with MRI or CT is recommended as ultrasound will not
be able to
assess.

6. Anterior compression deformity of T11 not acute, but age
indeterminate

ECHO [**2-23**]- Compared with the prior study (images reviewed) of
[**2106-2-19**], left ventricular systolic function appears more
depressed.

ECHO [**2-24**]- The left atrium is mildly dilated. The left
ventricular cavity is moderately dilated with
inferior/inferolateral hypokinesis/akinesis. Right ventricular
chamber size and free wall motion are normal. The aortic root is
moderately dilated at the sinus level. The ascending aorta is
mildly dilated. The aortic arch is mildly dilated. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are mildly thickened. No mitral regurgitation is seen in
suboptimal views. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.

Compared with the prior study (images reviewed) of [**2106-2-23**],
left ventricular systolic function is better visualized with the
assistance of contrast [**Doctor Last Name 360**].

CT Head ([**2106-2-25**])-
IMPRESSION: No definite evidence of intracranial hemorrhage or
septic emboli. Previously identified subtle area of
hypoattenuation within the left frontal lobe, equivocal for
small vessel ischemic disease or possible septic emboli, remain
unchanged. No new lesion is identified.

EEG ([**2106-2-26**])-
IMPRESSION: This is an abnormal extended routine EEG recording
due to
diffuse slowing suggestive of a mild to moderate encephalopathy.

Infection and metabolic disturbances are among the most common
causes.

CTA Head ([**2106-2-27**])-
CONCLUSION: No evidence of infarction, hemorrhage, aneurysm
formation, or
vascular occlusion.

ABI ([**2106-3-1**])-
IMPRESSION:
1. No evidence of peripheral arterial disease in the right lower
extremity.

2. Mild outflow arterial disease in the left lower extremity.
Disease is
likely located at the popliteal arterial level or more distal.


Brief Hospital Course:
Patient is a 59 year old gentleman with history of CAD, s/p CABG
with PPM/ICD, prior bilateral total knee replacement surgery,
who presented with MSSA bacteremia with seeding of ICD wire and
septic arthritis of the left knee.

MICU Course-
Successfully extubated in MICU to room air within 12 hours of
transfer.  ID continued to follow and recommended continued
Vanc/Nafcillin and ortho consult to remove L knee spacer.  Cards
with no further recommendations, need not be anticoagulated for
Afib. Patient stable overnight and called out to the floor.

# MSSA Bacteremia/Vegetation on Pacer wire/Septic Arthritis:
Found to have MSSA and coag negative staph in blood cultures at
OSH.  Cr elevated on admission to NEBH prompting treatment with
high dose CTX/daptomycin.  Patient was initially persistently
febrile and bacteremic.  Last positive cultures were [**2-16**].
Creatinine improved so he was switched to nafcillin and
vancomycin.  ID held on gentamycin and rifampin at this time and
kept the patient on vanc and nafcillin.  Nafcillin was briefly
discontinued from [**Date range (1) 10230**] as patient was still being covered
with vancomycin.  Once cultures had been negative for >7 days,
he was switched back to nafcillin with plans for an extended
course.  Rifampin (300mg PO BID) was added on [**2106-2-27**].  TEE was
done to look for valve vegetations as another nidus of
infection; tricuspid valve did not have any vegetations, but a
thin fibrin sheath was left in the right atrium from the ICD
wire.  This was confirmed via chest CT.  Cardiology and ID felt
there was no need to remove the sheath and to treat through it
with antibiotics.  CTA head did not show any septic emboli or
mycotic aneurysms.  Patient will follow-up with ID on [**3-24**].
While at rehab, he will need weekly CBC w/diff, LFTs, BUN,
creatinine faxed to the [**Hospital **] clinic at ([**Telephone/Fax (1) 1353**].

Regarding knee washout, he was followed by orthopedics here- did
not feel that left knee was septic.  We called NEBH orthopedics.
 The patient will follow-up with them on discharge ([**2106-3-10**] at
1:30pm) regarding plans for hardware and sutures in knee.

# Respiratory Failure, s/p Intubation:
Patient was intubated for three days prior to arrival at [**Hospital1 **].
Barriers to extubation included mental status, extreme
agitation, and high level of PEEP required.  Appears to be
ventilating well.  He was diuresed to keep even.  He was
transferred to the MICU for vent weaning.  PEEP was quickly
weaned and he passed an SBT on the first day in the MICU.  He
was extubated without difficulty.  Although he was briefly
confused after extubation, this improved quickly and he was calm
and conversant on callout from the MICU to the medical floor.
He satted well on room air while on the floor.

# Chronic Systolic CHF: EF 30-40%. JVP difficult to assess; CXR
showed mild fluid overload on presentation.  He was diuresed to
keep even.  He developed chest pain and shortness of breath on
[**2-23**] and was sent to the CCU.  It was determined that he did not
have an MI and that its thought that his symptoms were due to
his heartfailure.  He was diuresed with lasix and responded
well.  He was sent back to the floor on 20mg IV lasix daily and
did well (transitioned to 40mg PO daily on discharge).  He was
started on lisinopril 10mg daily.

# Hx Atrial Fibrillation:  On coumadin at home (6mg daily) and
OSH ECG's suggest possible A. flutter.  PPM was removed on [**2-18**]
due to bacteremia.  He was monitored closely on tele.  He had
some 2 second pauses on tele so his metoprolol was decreased
from 200mg daily to 25mg [**Hospital1 **].  He remained hemodynamically
stable. Patient at high risk for systemic embolization given
septic knee, high grade bacteremia.  Given concern for
transformation, coumadin was initially held.  Patient ruled out
for embolic phenomenon so coumadin was resumed on [**2-28**] (with
heparin drip bridge).  INR on discharge was 1.8.  Patient to
continue heparin gtt at rehab until INR is therapeutic
(2.0-3.0).  He will need INR check on [**2106-3-3**] to determine if
dose of coumadin needs to be decreased.  Discharged on digoxin
.250mg daily.  Patient will follow-up with cardiology on
discharge.

# Altered Mental Status- Patient showed some signs of delerium
while here including inattention and occasionally was
disoriented (AAO x 2).  Neurology consulted.  Recommended EEG
which showed no signs of seizure.  It was thought symptoms were
due to toxic or infecttious etiology.  CTA did not show any
signs of infection, infarct of aneurysm.  Patient's symptoms
improved while here.  He has follow-up with neurology on
[**2106-3-8**].

#  Left ankle pain- Patient complained of vague left ankle
discomfort on [**2-28**].  ABI showed mild left arterial outflow
disease.

# Hypernatremia:   Persistent hyponatremia, presented with 8L
free water defecit.  This was repleted IV and PO per OG tube.
Sodium was 137 on discharge

# CAD:  The patient has a history of CAD s/p CABG and PCI with
stent placement.  Anatomy as above. Continued on statin, aspirin
and beta-blocker.  Started on lisinopril 10mg daily.

# OSA: Continued on CPAP.

# Depression: Home meds initially held.  Resumed wellbutrin and
amitryptiline on discharge.

# Gout: Allopurinol and colchine were continued.

# HTN: Beta-blocker continued but decreased to 25mg PO BID given
pauses on tele.  Hemodynamically stable on discharge.

# Hyperlipidemia: Home medications continued.


Medications on Admission:
MEDICATIONS ON TRANSFER FROM [**Hospital1 **]:
-Ceftriaxone 2grams q12
-daptomycin 1gram daily IV
-Versed gtt
-fentanyl gtt
-allopurinol 200mg PO daily
-zetia 10mg PO daily
-welbutrin 75mg PO qhs, 100mg [**Hospital1 **]
-toprol XL 200mg daily
-pepcid 20mg daily
-combivent 4 puffs QID
-cymbalta 30mg PO daily
-Aspirin 81 mg daily
-Amitriptyline 75mg daily
-Heparin 5000 SQ TID
-Digoxin 250ucg daily
.
Home Medications
Lasix 40mg daily
digoxin 125 ucg daily
coumadin 6mg qPM
Prilosec 20mg daily
zyloprim 300mg daily
EC ASA 81mg daily
Zetia 10mg daily
Cymbalta 30mg daily
Elavil 250mg daily
Tramadol 100mg TID
Wellbutrin 300mg qAM, 75mg qPM
Lyrica 75 TID
Toprol 200mg daily
.
Medications on transfer to [**Hospital1 **]:
ALLOPURINOL 200 mg po daily
AMITRIPTYLINE 75 mg po qhs
Aspirin 81mg daily
BUPROPION 75 mg po q24, and 75mg qHS
colace 100mg [**Hospital1 **]
DIGOXIN 375 mcg po daily
Cymbalta 30mg daily
Zetia 10mg daily
Pepcid 20mg daily
Heparin 5000 SQ TID
Toprol XL 200mg daily
Lyrica 50mg TID
Daptomycin 1gram IV daily
Dilaudid 2mg SQ q4-6H PRN
Zofran 4mg PO q8H PRN
Percocet 1-2 tabs q6H PRN

Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Four (4) Puff Inhalation Q4H (every 4 hours) as needed for
Wheezing.
5. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).

6. Nafcillin 2 g IV Q4H Start: Stat
7. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
8. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed) as needed for sore throat.
9. Amitriptyline 75 mg Tablet Sig: One (1) Tablet PO at bedtime.

10. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
11. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for Constipation.
12. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for cramping.
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Wellbutrin 75 mg Tablet Sig: One (1) Tablet PO at bedtime.
15. Lyrica 50 mg Capsule Sig: One (1) Capsule PO three times a
day.
16. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Warfarin 2 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM.
18. Zofran 4 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea.
19. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
20. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
21. Rifampin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
22. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
23. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
24. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
25. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
26. Famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day.

27. Wellbutrin 100 mg Tablet Sig: Three (3) Tablet PO qAM.
28. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
29. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
30. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
31. Heparin sliding scale
Continue per attached sliding scale.  PTT goal- 60-80.  Please
stop when INR is therapeutic (2.0-3.0)


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]

Discharge Diagnosis:
Primary: Septic arthritis, bacteremia

Secondary: Atrial fibrillation, hypertension, hyperlipidemia


Discharge Condition:
Good.  Vital signs stable.
Mental Status: Confused - sometimes
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - requires assistance or aid (walker
or cane)


Discharge Instructions:
You were admitted to the hospital after a washout procedure for
your knee.  We found that you had bacteria in your blood so you
were treated with IV antibiotics while here.  You will need an
extended course of these antibiotics on discharge.  While here,
you experienced an episode of chest pain which required a brief
stay in the CCU.  They determined that you did NOT have a heart
attack.  You were transferred back to the floor once you were
stabilized and did well.  You remained afebrile with no more
signs of bacteria in your blood.  You are being discharged to a
rehab facility to build up your strength.  Upon discharge, you
were hemodynamically stable.

The following changes were made to your medications:
1.  Please start taking nafcillin 2g IV daily (Day 1- [**2-17**]).
You will need an extended course of this medication.  The
infectious disease team will determine the exact duration of the
medication.
2.  Pleast start taking rifampin 300mg by mouth twice a day (Day
1- [**2-27**]).  You will need an extended course of this medication.
The infectious disease team will determine the exact duration of
the medication.
3.  Please continue your coumadin at 6mg daily.  We ask that
your rehabilitation facility check an INR on [**3-3**] and that they
adjust your dose as needed.
4.  Please continue the heparin drip until your INR is
therapeutic (2.0-3.0).
5.  Please start taking lisinopril 10mg by mouth daily
6.  Please STOP taking your Toprol XL
7.  Please start taking metoprolol tartrate 25mg by mouth twice
a day
8.  Please STOP taking your tramadol

Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.

Followup Instructions:
Please remove chest staples on [**2106-3-5**].

Please follow-up in Sleep Clinic (Dr. [**Last Name (STitle) **] and Dr. [**First Name (STitle) **]
on [**2106-3-5**] at 7:40am.  You can contact them at [**Telephone/Fax (1) 612**].

Please follow-up with neurology on [**2106-3-8**] at 3:30pm.  You can
contact them at [**Telephone/Fax (1) 558**]

Please follow-up with your orthopedic surgeon (Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]) on [**2106-3-10**] at 1:30pm.  This will be at [**Street Address(2) 32113**]- [**Location (un) 470**], [**Location (un) **], MA.  You can contact him at
[**Telephone/Fax (1) 32114**].

Please follow-up with infectious disease (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) on
[**2106-3-24**] at 10:30am.  You can contact them at [**Telephone/Fax (1) 457**].

Please follow-up with the cardiology team in 3 months.  You can
contact them at [**Telephone/Fax (1) 62**].

Please follow-up with your primary care physician (Dr. [**Last Name (STitle) 9751**]
within 1 month.  You can contact him at [**Telephone/Fax (1) 9752**].


Completed by:[**2106-3-2**]
{'Infection and inflammatory reaction due to cardiac device, implant, and graft,Methicillin susceptible Staphylococcus aureus septicemia,Severe sepsis,Acute respiratory failure,Metabolic encephalopathy,Acute kidney failure, unspecified,Acute on chronic systolic heart failure,Cerebral embolism with cerebral infarction,Pyogenic arthritis, lower leg,Hyposmolality and/or hyponatremia,Other degenerative diseases of the basal ganglia,Knee joint replacement,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Other alteration of consciousness,Depressive disorder, not elsewhere classified,Abdominal aneurysm without mention of rupture,Pain in joint, ankle and foot,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Old myocardial infarction,Atrial fibrillation,Long-term (current) use of anticoagulants,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Other and unspecified hyperlipidemia,Obstructive sleep apnea (adult)(pediatric),Atherosclerosis of renal artery,Gout, unspecified,Unspecified hereditary and idiopathic peripheral neuropathy,Obesity, 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: transfer for ICD extraction

PRESENT ILLNESS: Mr. [**Known lastname **] is a 59 year-old male with pmh of HTN, HL, CHF w/ EF
30% CAD s/p CABG and stent to left main, s/p pacemaker and [**Hospital 3941**]
transferred from NEBH for ICD extraction after vegetation noted
on ICD lead.  Patient initially presented to an outside hospital
with increasing knee pain over 2-3 weeks time.  At the OSH
impression was for a septic knee.  Aspirate on [**2106-2-12**] revealed
WBC count of 255K in the knee, 8000 rbc's, 100% polys.  Treated
initially with vancomycin, and later daptomycin.  Culture
subsequently grew MSSA, and patient subsequently grew MSSA from
the blood as well.
.
Patient taken to the OR for wash out and liner exchange.  He was
electively intubated for that procedure.  Never extubated
post-op b/c what was felt to be clinical CHF although partly was
to facilitate TEE.  Intra-op cultures confirmed MSSA.
.
In the ICU he was febrile to 103.8.  Patient bacteremic at NEBH
and on [**2106-2-15**], and [**2106-2-16**]. TEE performed and noted veg on
AICD wire.  Due to Cr 1.9 on presentation to OSH patient was
initially treated with CTX/daptomycin given concern for hardware
infection and renal failure.  Diuresis was attempted with 40mg
IV lasix prior to transfer but patient left intubated.
.
Last VS prior to transfer were HR 80-90 in sinus, 115-120/50, RR
16, on fent/versed 150/12.
.
On arrival, patient's VS were T102.5, HR 83, BP 152/72, RR 17,
O2 100%RA.  He was intubated and sedated.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS:
- Diabetes, + Dyslipidemia, + Hypertension
2. CARDIAC HISTORY:
-CABG: s/p CABG in [**2090**] with LIMA to LAD, saphenous vein graft
to
PDA and saphenous vein graft to OM-2.  Had known 80% left main,
100% RCA, 90% LAD, and 70% OM on cath.
-PERCUTANEOUS CORONARY INTERVENTIONS:
Repeat Cardiac Cath in [**2095**] showed LMCA with an 80% eccentric
stenosis in the distal portion (unchanged). The LAD had a 70%
lesion in the proximal mid segment just after the S1 origin. The
LCX supplied two major OMs, the second of which had an 80 %
lesion near the origin. The RCA was totally occluded proximally.
 Vein graft to OM was occluded proximally, LIMA to LAD open, and
RCA filled retrograde from open SVG to mid-RCA/PDA.  At that
time patient had direct stenting of the protected left main with
a 4.5 x 13 mm Bx Velocity stent.  Successful PTCA of the OM2
with a 2.5 mm Raptor balloon with 20% residual stenosis.
.
-PACING/ICD:  s/p [**Company 1543**] [**Last Name (un) 24119**] single chamber ICD and
[**Company 1543**] Kappa dual chamber pacemaker first placed in [**2095**] for
pauses, ICD functionality added [**2098**] and single lead ICD placed
on the left.
.
3. OTHER PAST MEDICAL HISTORY:
-CAD s/p CABG as above
-Inferior myocardial infarction
-Atrial fibrillation
-Hypertension
-Hyperlipidemia
-OSA on CPAP
-Chronic kidney disease (history of tubulointersitital disease
due to NSAIDS and atherosclerotic renal artery disease)
-Gout
-Peripheral neuropathy complicated by progressive gait
difficulty
-Knee arthritis s/p multiple knee surgeries
-Depression
-Motor vehicle accident in [**2074**], status post arm tendon transfer
-Obesity
-Progressive supranuclear palsy
-Drop Attacks

MEDICATION ON ADMISSION: MEDICATIONS ON TRANSFER FROM [**Hospital1 **]:
-Ceftriaxone 2grams q12
-daptomycin 1gram daily IV
-Versed gtt
-fentanyl gtt
-allopurinol 200mg PO daily
-zetia 10mg PO daily
-welbutrin 75mg PO qhs, 100mg [**Hospital1 **]
-toprol XL 200mg daily
-pepcid 20mg daily
-combivent 4 puffs QID
-cymbalta 30mg PO daily
-Aspirin 81 mg daily
-Amitriptyline 75mg daily
-Heparin 5000 SQ TID
-Digoxin 250ucg daily
.
Home Medications
Lasix 40mg daily
digoxin 125 ucg daily
coumadin 6mg qPM
Prilosec 20mg daily
zyloprim 300mg daily
EC ASA 81mg daily
Zetia 10mg daily
Cymbalta 30mg daily
Elavil 250mg daily
Tramadol 100mg TID
Wellbutrin 300mg qAM, 75mg qPM
Lyrica 75 TID
Toprol 200mg daily
.
Medications on transfer to [**Hospital1 **]:
ALLOPURINOL 200 mg po daily
AMITRIPTYLINE 75 mg po qhs
Aspirin 81mg daily
BUPROPION 75 mg po q24, and 75mg qHS
colace 100mg [**Hospital1 **]
DIGOXIN 375 mcg po daily
Cymbalta 30mg daily
Zetia 10mg daily
Pepcid 20mg daily
Heparin 5000 SQ TID
Toprol XL 200mg daily
Lyrica 50mg TID
Daptomycin 1gram IV daily
Dilaudid 2mg SQ q4-6H PRN
Zofran 4mg PO q8H PRN
Percocet 1-2 tabs q6H PRN

ALLERGIES: Lipitor

PHYSICAL EXAM: General Appearance: Well nourished, Overweight / Obese

FAMILY HISTORY: Mother died of complications from cancer. Father died at age 75
of natural causes.

SOCIAL HISTORY: Currently unemployed. Lives alone. Drinks occasionally with his
son. 

### Response:
{'Infection and inflammatory reaction due to cardiac device, implant, and graft,Methicillin susceptible Staphylococcus aureus septicemia,Severe sepsis,Acute respiratory failure,Metabolic encephalopathy,Acute kidney failure, unspecified,Acute on chronic systolic heart failure,Cerebral embolism with cerebral infarction,Pyogenic arthritis, lower leg,Hyposmolality and/or hyponatremia,Other degenerative diseases of the basal ganglia,Knee joint replacement,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Other alteration of consciousness,Depressive disorder, not elsewhere classified,Abdominal aneurysm without mention of rupture,Pain in joint, ankle and foot,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Old myocardial infarction,Atrial fibrillation,Long-term (current) use of anticoagulants,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Other and unspecified hyperlipidemia,Obstructive sleep apnea (adult)(pediatric),Atherosclerosis of renal artery,Gout, unspecified,Unspecified hereditary and idiopathic peripheral neuropathy,Obesity, unspecified'}
