CHIEF COMPLAINT: Fever and emesis.

PRESENT ILLNESS: This is a 64-year-old woman with
a past medical history notable for endocarditis resulting in
aortic valve replacement and mitral repair and tricuspid
repair in [**2196-1-25**], Evans' syndrome, recent sepsis
while at [**Hospital6 1708**] secondary to bilateral
lymphoceles, atrial fibrillation with rapid ventricular
response, cerebrovascular accident, and endometrial cancer,
who presents from [**Hospital3 2558**] with a fever to 104 and a
systolic blood pressure of 70.

MEDICAL HISTORY: 1.  Evans' syndrome which is autoimmune hemolytic anemia and
thrombocytopenia associated with rheumatoid arthritis.
2.  Atrial fibrillation, rate controlled with Lopressor.
3.  Hypertension.
4.  Bovine aortic valve replacement with mitral and tricuspid
repair in [**2196-1-25**].
5.  Endocarditis in [**2196-1-25**] resulting in aortic valve
replacement.
6.  Left-sided cerebrovascular accident in [**2196-1-25**].
7.  Endometrial cancer; status post total abdominal
hysterectomy, chemotherapy, and radiation.
8.  Lymphocele infection with methicillin-resistant
Staphylococcus aureus, Proteus, carinii bacterium at [**Hospital6 4193**]; hospitalized from [**Month (only) 216**] through
[**10-2**].  Status post splenic infarct at [**Hospital6 15291**] during past hospitalization in [**2196-9-24**].

MEDICATION ON ADMISSION: 1.  Compazine 10 mg p.o. q.d.
 2.  Plavix 75 mg p.o. q.d.
 3.  Celexa 10 mg p.o. q.d.
 4.  MS Contin 15 mg p.o. b.i.d.
 5.  Lasix 80 mg p.o. q.d.
 6.  Ativan p.r.n.
 7.  Trazodone 25 mg p.o. q.d.
 8.  Prednisone 20 mg p.o. q.d.
 9.  Prilosec 40 mg p.o. q.d.
10.  Milk of Magnesia.
11.  Dulcolax p.r.n.
12.  Folate 1 mg p.o. q.d.
13.  Atenolol 37.5 mg p.o. q.d.
14.  Danazol 400 mg p.o. b.i.d.
15.  Atrovent.
16.  Multivitamin.

ALLERGIES: PENICILLIN causes anaphylaxis, SULFA, AZTREONAM.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Methicillin susceptible Staphylococcus aureus septicemia,Endocarditis, valve unspecified, unspecified cause,Congestive heart failure, unspecified,Unspecified pleural effusion,Hemorrhage of gastrointestinal tract, unspecified,Atrial fibrillation,Rheumatoid arthritis,Heart valve replaced by transplant
Meth susc Staph aur sept,Endocarditis NOS,CHF NOS,Pleural effusion NOS,Gastrointest hemorr NOS,Atrial fibrillation,Rheumatoid arthritis,Heart valve transplant
Admission Date:  [**2196-11-4**]     Discharge Date:  [**2196-11-10**]

Date of Birth:   [**2132-5-15**]     Sex:  F

Service:  MICU

CHIEF COMPLAINT:  Fever and emesis.

HISTORY OF PRESENT ILLNESS:  This is a 64-year-old woman with
a past medical history notable for endocarditis resulting in
aortic valve replacement and mitral repair and tricuspid
repair in [**2196-1-25**], Evans' syndrome, recent sepsis
while at [**Hospital6 1708**] secondary to bilateral
lymphoceles, atrial fibrillation with rapid ventricular
response, cerebrovascular accident, and endometrial cancer,
who presents from [**Hospital3 2558**] with a fever to 104 and a
systolic blood pressure of 70.

The [**Hospital 228**] medical issues, again, in [**2196-1-25**] when
the patient developed and endocarditis resulting in a Bovine
aortic valve replacement and mitral and tricuspid repair at
an outside hospital (presumably [**Hospital6 15291**]).  Her postoperative course was complicated by a
left-sided cerebrovascular accident which left her with mild
aphagia and right hemiparesis.  Somewhere along this course
it is the time it is felt that the patient developed atrial
fibrillation with a rapid ventricular response which was
controlled on beta blockers.  The patient was rehabilitating
at home when she developed lymphoceles in her groin in [**2196-8-24**] resulting in sepsis and requiring a 1-month
hospitalization at [**Hospital6 1708**].  The
lymphoceles were felt to be secondary to groin catheter
placements during her cardiac surgery in [**Month (only) 404**] of this year
plus related to history of groin radiation from the
endometrial in her past.  The patient was being rehabilitated
at [**Hospital3 2558**] since the end of [**Month (only) **] with long-term
antibiotics when she developed this current episode of
sepsis.

On the evening of [**11-4**], the patient notes feeling quite
well after having dinner with her son; although, she does
admit to feeling a little bit "flushed."  She went to sleep
but woke up with extreme/severe nausea and uncontrollable
emesis.  The patient was diverted to [**Hospital1 190**] as there were no beds available at [**Hospital6 8866**] or [**Hospital 882**] Hospital.  She was found to have
a temperature of 104 and be hypotensive with a systolic blood
pressure in the 70s in the Emergency Department.  She
received 3 liters of normal saline with an increase in her
systolic blood pressure to the 90s and was given stress-dose
steroids and a dose of levofloxacin and Flagyl.  She was
admitted to the Medical Intensive Care Unit for management of
her sepsis.  The patient was also noted to have heme-positive
emesis and a guaiac-positive rectal examination in the
Emergency Department, as well as decreased platelets, and
this was to be managed in the Medical Intensive Care Unit.

PAST MEDICAL HISTORY:
1.  Evans' syndrome which is autoimmune hemolytic anemia and
thrombocytopenia associated with rheumatoid arthritis.
2.  Atrial fibrillation, rate controlled with Lopressor.
3.  Hypertension.
4.  Bovine aortic valve replacement with mitral and tricuspid
repair in [**2196-1-25**].
5.  Endocarditis in [**2196-1-25**] resulting in aortic valve
replacement.
6.  Left-sided cerebrovascular accident in [**2196-1-25**].
7.  Endometrial cancer; status post total abdominal
hysterectomy, chemotherapy, and radiation.
8.  Lymphocele infection with methicillin-resistant
Staphylococcus aureus, Proteus, carinii bacterium at [**Hospital6 4193**]; hospitalized from [**Month (only) 216**] through
[**10-2**].  Status post splenic infarct at [**Hospital6 15291**] during past hospitalization in [**2196-9-24**].

MEDICATIONS ON ADMISSION:
 1.  Compazine 10 mg p.o. q.d.
 2.  Plavix 75 mg p.o. q.d.
 3.  Celexa 10 mg p.o. q.d.
 4.  MS Contin 15 mg p.o. b.i.d.
 5.  Lasix 80 mg p.o. q.d.
 6.  Ativan p.r.n.
 7.  Trazodone 25 mg p.o. q.d.
 8.  Prednisone 20 mg p.o. q.d.
 9.  Prilosec 40 mg p.o. q.d.
10.  Milk of Magnesia.
11.  Dulcolax p.r.n.
12.  Folate 1 mg p.o. q.d.
13.  Atenolol 37.5 mg p.o. q.d.
14.  Danazol 400 mg p.o. b.i.d.
15.  Atrovent.
16.  Multivitamin.

ALLERGIES:  PENICILLIN causes anaphylaxis, SULFA, AZTREONAM.

PHYSICAL EXAMINATION ON ADMISSION:  Physical examination in
the Emergency Department revealed temperature 100.3,
pulse 110, blood pressure 90/40, respiratory rate 30, pulse
oximetry 96% on room air.  In general, this was a chronically
ill-appearing, appearing diaphoretic, pale female in no acute
respiratory distress.  Pupils were equally, round, and
reactive to light.  Extraocular muscles were intact.  Sclerae
were anicteric, and there were some ecchymoses noted over her
right eye.  The oropharynx was clear, and the patient had dry
mucous membranes.  Neck was supple.  No lymphadenopathy or
carotid bruits noted.  Chest was with decreased breath sounds
on the right side greater than left.  Chest was clear to
auscultation bilaterally.  Cardiovascular revealed
tachycardic, irregularly irregular with plus S1 and S2, and a
2/6 systolic ejection murmur at the left upper sternal
border.  The abdomen was soft and nontender with mild right
upper quadrant tenderness.  No rebound.  Rectal was
heme-positive.  Extremities with 1+ dorsalis pedis pulses
bilaterally with a right inguinal lymphocele with dressing,
and left inguinal lymphadenopathy noted.  Neurologic
examination revealed the patient was alert and oriented times
three.  Cranial nerves II through XII were grossly intact,
but the patient with some slurred speech.  Strength revealed
right upper extremity was [**4-28**] and left upper extremity was
4+/5.  Sensation was intact bilaterally, and gait was not
assessed.

LABORATORY DATA ON ADMISSION:   White blood cell count 14.2,
hematocrit 29, platelets 75.  Sodium 140, potassium 2.9,
chloride 99, bicarbonate 28, BUN 24, creatinine 0.9, and
glucose of 97.  Albumin 3.3, calcium 8.4, phosphate 3,
magnesium 1.1.  ALT was 74, AST 32, amylase 50, lipase 16,
alkaline phosphatase 85, total bilirubin 1.4.  PT was 15.6
and INR was 1.6.  Urinalysis was  notable for a large amount
of blood, 236 red blood cells, 22 white blood cells, and
positive nitrites.

RADIOLOGY/IMAGING:   Electrocardiogram demonstrated atrial
fibrillation with a right bundle-branch block and left axis
deviation, left anterior fascicular block, rate of 112, with
T wave inversions in V2 and aVL.

Chest x-ray demonstrated a right-sided pleural effusion and a
question of a right-sided infiltrate.

Abdominal CT was notable for small to moderate right-sided
pleural effusion with adjacent atelectasis and a right
paraspinal hematoma that measured 7.6 cm X 3.6 cm, a small
amount of free fluid in the pelvis and the abdomen, and a
lymphocele with some surrounding fatty stranding consistent
with recent processes as noted above, but no intra-abdominal
abscesses.

Studies from [**Hospital6 1708**] that were obtained
by our staff here demonstrated blood cultures from [**9-19**]
that were methicillin-resistant Staphylococcus aureus
positive; and a lymphocele drainage from [**9-21**] growing
out methicillin-resistant Staphylococcus aureus, Proteus, and
carinii bacterium.

A transesophageal echocardiogram and transthoracic
echocardiogram done at [**Hospital6 1708**] during
that month were negative for vegetations, and the patient had
a thoracentesis for her chronic right-sided pleural effusion
at [**Hospital6 1708**] which was consistent with a
transudative process.

The patient had a peripherally inserted central catheter line
placed on [**2196-9-30**], and had been receiving long-term
antibiotics at [**Hospital3 2558**] through this peripherally
inserted central catheter line.

Other records indicated that a cardiac catheterization from
[**2196-1-25**] demonstrated only 10% left main disease.

HOSPITAL COURSE:

 1.  INFECTIOUS DISEASE:  On the first date of admission the
patient grew out 2/2 bottles of methicillin-resistant
Staphylococcus aureus and was begun, even before these
cultures were back, with vancomycin and gentamicin.  The
patient's peripherally inserted central catheter line was
removed, and the patient responded well to the antibiotics
with a drop in her white blood cell count to 6.4 on
[**11-6**], and her systolic blood pressure remained stable
at the 140s to 150s without the use of pressors.

Possible sources of this bacteremia/sepsis were thought to be
secondary to a possible pneumonia with her chronic right
pleural effusion, a peripherally inserted central catheter
line infection, or perhaps an endocarditis, or a urinary
tract infection.  Cultures from the catheter tip from her
peripherally inserted central catheter line were negative.

Urine cultures were negative, and sputum culture demonstrated
only sparse growth of gram-negative rods.  This was a good
sputum culture with less than 10 epithelial cells per high
powered field.

Although the patient was afebrile on vancomycin and
gentamicin, to guide our antibiotic therapy the patient went
for a transesophageal echocardiogram on [**11-9**] which
demonstrated no spontaneous echocontrast/mass/thrombus seen
in the left atrium or left atrial appendage, good left
ventricular and right ventricular function, and normal aortic
valve leaflets.  The patient was noted to have
mild-to-moderate 1 to 2+ mitral regurgitation with 2 jets,
one which was central and one which appeared to be through
the posterior leaflet, and 2+ tricuspid regurgitation.  The
mitral regurgitation was felt to be odd and perhaps
suggestive of a degenerative process of the valve, a/k/a an
endocarditis.  Attempts were made to obtain a transesophageal
echocardiogram from [**Hospital6 1708**] to compare
in order to guide antibiotic therapy.  The patient was
continued on vancomycin and gentamicin for this time with
resolution of her fevers, leukocytosis, and hypotension.

 2.  CARDIOVASCULAR:  The patient with a history of atrial
fibrillation, mitral and tricuspid valve repair, and
endocarditis.

(A)  CORONARY ARTERY DISEASE/ISCHEMIA:  The patient had a low
creatine kinase in the Emergency Department with no
complaints of chest pain; although, she was diaphoretic with
some nausea and vomiting.  For this reason, the patient's
creatine kinases were cycled, and she ruled out for
myocardial infarction by enzymes.

(B)  PUMP:  The patient with a history of mild congestive
heart failure with chronic right-sided pleural effusions
while at [**Hospital6 1708**], and for this reason
was maintained on her daily Lasix dose of 80 mg p.o. q.d.
The patient was noted to have an increase in size in her
right pleural effusion and some mild congestive heart failure
on follow-up chest x-rays; however, her oxygen saturations
remained stable on room air, and the patient did not complain
of orthopnea or shortness of breath.

(C)  RATE AND RHYTHM:  Atrial fibrillation with rate in the
100s on admission.  The patient was held on beta blockers
when she was hypotensive but was restarted soon afterwards
with resolution of her rapid ventricular response to the
atrial fibrillation.  The patient maintained her blood
pressure throughout her hospitalization, and her heart rate.
The patient apparently had been on Coumadin in the past and
had her strokes while on Coumadin in the past.  The patient
then was on Lovenox for her atrial fibrillation after that,
but while at [**Hospital6 1708**] had a paraspinous
muscle hematoma, and at that time the Lovenox was
discontinued.  The patient had been on Plavix since that
hospitalization which was discontinued upon hospitalization
here, but then restarted on [**11-9**] with good toleration
of this medication.  Repeat electrocardiograms demonstrated
no changes other than more rate controlled.

 3.  PULMONARY:  The patient with a chronic right pleural
effusion that had been tapped at [**Hospital6 1708**]
and was found to be transudative.  The patient's follow-up
x-rays demonstrated an increase in the size of the right
pleural effusion with some possible loculation, but the
patient was asymptomatic, and Lasix was continued for
management of her right pleural effusion and mild congestive
heart failure.  The patient remained with good oxygen
saturations on room air throughout the rest of her
hospitalization.

 4.  ENDOCRINE/RHEUMATOLOGY:  The patient with a history of
Evans' syndrome which autoimmune hemolytic anemia and
thrombocytopenia associated with rheumatoid arthritis.  We
have contact[**Name (NI) **] Dr. [**Last Name (STitle) 6358**] of [**Hospital6 1708**]
who is the patient's rheumatologist, and the patient has been
controlled in the past with 10 mg to 20 mg of prednisone
q.d., requiring very few transfusions; however, earlier in
the year when the patient had multiple infections including
endocarditis and lymphoceles, the prednisone was tapered down
and the patient subsequently was requiring more frequent
transfusions.  Prednisone 20 mg p.o. q.d. had been started in
the past few weeks, and the patient presented with a
hematocrit of 29, which dropped down to below 24, which has
been her threshold in the past for transfusion.  The patient
received 2 units of packed red blood cells which were
difficult to obtain secondary to the patient's numerous
antibodies and had to be specially ordered through Red Cross.
The patient was administered stress-dose hydrocortisone on
admission and was tapered back to her normal dose of
prednisone 20 mg p.o. q.d.  The patient did not require any
other transfusions throughout the course of this
hospitalization and maintained her hematocrit at
approximately 28.

 5.  HEMATOLOGY:  Upon admission, the patient received 2
units of fresh frozen plasma and 1 units of platelets for her
low platelet count of 71, to which she did not significantly
respond and maintained a platelet count of approximately 71
throughout the course of this hospitalization.  According to
the patient's rheumatologist, the patient tends to maintain a
steady hematocrit and platelet count on prednisone doses but
does not respond extremely well to IVIG or other therapies.
The patient is also on Danazol for her autoimmune hemolytic
anemia which acts to decrease the immune response against her
red blood cells.  The patient's iron studies and hemolysis
studies were all within normal limits at this time.

 6.  GASTROINTESTINAL:  The patient with nausea and vomiting
with heme-positive stools and heme-positive emesis on
admission into the Emergency Department.  The patient was
lavaged in the Emergency Department and was without bright
red blood or coffee-grounds.  The patient was subsequently
transfused 2 units of packed red blood cells, and her
hematocrit remained stable throughout the rest of the course
of her hospitalization.  The patient received Protonix 40 mg
b.i.d., and no other interventions were necessary.

 7.  FLUIDS/ELECTROLYTES/NUTRITION:  The patient received 3
liters of normal saline in the Emergency Department and
multiple transfusions including 2 units of packed red blood
cells, 1 units of platelets, 2 units of fresh frozen plasma,
and was maintained on a cardiac diet throughout this
admission, taking good p.o.  The patient had some nausea on
the morning of [**11-10**], but no emesis.  The patient was
noted to have hypokalemia multiple times during this
admission and was continuously repleted with good response.

 8.  ACCESS:  The patient received her antibiotics through
peripheral IV during this hospitalization.  Surveillance
blood cultures from [**11-5**] and [**11-7**] were without
any growth, and the patient received a peripherally inserted
central catheter line to receive long-term antibiotics on
[**11-10**].

 9.  PROPHYLAXIS:  The patient was with Pneumo boots and
Protonix throughout her hospitalization.

10.  CODE STATUS:  The patient expressed her desire to be do
not resuscitate/do not intubate during this hospitalization,
and per discussion with the patient and her family the
patient was made do not resuscitate/do not intubate.  The
patient states that they have a living will and they will
bring this to the hospital at their earliest convenience.

DISCHARGE STATUS:   To rehabilitation for long-term
intravenous antibiotics and physical therapy with vancomycin
and gentamicin when medically stable.

MEDICATIONS ON DISCHARGE:
 1.  Colace 100 mg p.o. b.i.d.
 2.  Protonix 40 mg p.o. q.d.
 3.  Folate 1 mg p.o. q.d.
 4.  Celexa 10 mg p.o. q.d.
 5.  Vitamin D 400 IU p.o. q.d.
 6.  Tums 3 tablets p.o. q.d.
 7.  Danazol 400 mg p.o. b.i.d.
 8.  Iron sulfate 325 mg p.o. t.i.d.
 9.  Lasix 80 mg p.o. q.d.
10.  Atenolol 37.5 mg p.o. q.d.
11.  Prednisone 20 mg p.o. q.d.
12.  Ativan 1 mg to 2 mg p.o. p.r.n. for nausea or anxiety.
13.  Trazodone 25 mg p.o. q.h.s. p.r.n. for insomnia.
14.  Senna 1 tablet p.o. q.d. p.r.n. for constipation.
15.  MSO4 1 mg to 2 mg intravenously q.4-6h. p.r.n. for pain.
16.  Tylenol 650 mg p.o. q.4h. p.r.n. for fever and pain.
17.  Vancomycin 1 g intravenously q.12h. (given over two
hours secondary to the patient's flushing response upon
receiving this medication).
18.  Gentamicin 100 mg intravenously q.8h.
19.  Plavix 75 mg p.o. q.d.

CONDITION AT DISCHARGE:  Condition on discharge was fair.

DISCHARGE DIAGNOSES:
1.  Methicillin-resistant Staphylococcus aureus sepsis.
2.  ? Endocarditis.
3.  Autoimmune hemolytic anemia.
4.  Gastrointestinal bleed.





                          [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D.  [**MD Number(1) 4561**]

Dictated By:[**Last Name (NamePattern1) 19212**]

MEDQUIST36

D:  [**2196-11-10**]  12:20
T:  [**2196-11-10**]  13:40
JOB#:  [**Job Number 35992**]


Admission Date:  [**2196-11-4**]     Discharge Date:  [**2196-11-13**]

Date of Birth:   [**2132-5-15**]     Sex:  F

Service:

CHIEF COMPLAINT:  Fever and hypotension.

HISTORY OF PRESENT ILLNESS:  This is a 64-year-old woman with
a past medical history of rheumatoid arthritis, Evans'
syndrome, endocarditis, status post aortic valve replacement,
mitral valve and tricuspid repair, and a recent history of
methicillin-resistant Staphylococcus aureus infection after
lymphocele drainage who presents from [**Hospital3 2558**] with a
fever of 104 and hypotension.

The patient has a history of endocarditis in [**2196-1-25**],
status post aortic valve replacement and repair of her mitral
and tricuspid valves with an echocardiogram with an ejection
fraction of 55%, and 4+ tricuspid regurgitation.  Her
recovery from this endocarditis and surgery was complicated
by a left-sided cerebrovascular accident in [**2196-1-25**].
She has a history of chronic atrial fibrillation, but had
been off of warfarin.  The patient was home for a period of
one month or two after rehabilitation from this surgery when
she returned to [**Hospital6 1708**] where she
received all of her care for drainage of bilateral groin
lymphoceles which were found to be infected with
methicillin-resistant Staphylococcus aureus, Proteus, and
corynebacterium.  She began a prolonged course of vancomycin,
levofloxacin, and Flagyl and was discharged to [**Hospital3 2558**]
on [**2196-10-17**] on a course of linezolid and
vancomycin.  During this hospitalization at [**Hospital6 8866**] she also was noted to have bilateral pleural
effusions (right greater than left) which were drained, and
were culture negative, and found to be transudative.  This
hospital course was also complicated by a splenic infarct and
a paraspinous hematoma.

Today, the patient was noted to have a temperature of 101.
She had developed nausea and vomiting that was
guaiac-positive last night at [**Hospital3 2558**].  She was sent
to the [**Hospital1 69**] Emergency
Department because [**Hospital6 1708**] was on
diversion.  She was noted to be hypotensive with a blood
pressure in the 70s in the Emergency Department and received
3 liters of normal saline with an increase in her systolic
blood pressure to the 90s.  She was given levofloxacin and
Flagyl and stress dose steroids.  She was admitted to the
Intensive Care Unit for management of sepsis as well as
monitoring for gastrointestinal bleed and was noted to have a
heme-positive rectal examination and decreased platelet count
in the Emergency Department.  An OG was placed.

PAST MEDICAL HISTORY:
1.  Evans' syndrome, chronically on steroids (prednisone 20
mg p.o. q.d.) and transfused with a hematocrit of less than
24.
2.  Rheumatoid arthritis.
3.  Atrial fibrillation.
4.  Hypertension.
5.  Aortic valve replacement, mitral and tricuspid repair.
6.  Endocarditis in [**2196-1-25**].
7.  Cerebrovascular accident in [**2196-1-25**].
8.  History of endometrial cancer, status post total
abdominal hysterectomy.
9.  Status post lymphocele drainage and sclerosis with
methicillin-resistant Staphylococcus aureus and Proteus
cultures positive.

MEDICATIONS ON ADMISSION:  Compazine 10 mg p.o. q.d.,
Prilosec 40 mg p.o. q.d., Plavix 75 mg p.o. q.d., Milk of
Magnesia, Celexa 10 mg p.o. q.d., Dulcolax, MS Contin 15 mg
p.o. q.d., folate 1 mg p.o. q.d., Lasix 80 mg p.o. q.d.,
atenolol 37.5 mg p.o. q.d., Ativan p.r.n., danazol 400 mg
p.o. b.i.d., trazodone 25 mg p.o. q.d., Atrovent,
prednisone 20 mg p.o. q.d., multivitamin.

ALLERGIES:  PENICILLIN, SULFA, and AZTREONAM.

PHYSICAL EXAMINATION ON PRESENTATION:  Physical examination
on admission revealed temperature of 103, pulse 110, blood
pressure 90/40, respiratory rate 30, pulse oximetry 96% on
room air.  In general, this was a chronically ill-appearing,
diaphoretic, pale female.  Pupils were equally round and
reactive to light and accommodation.  Sclerae were anicteric.
Ecchymoses over the right eye.  The oropharynx was clear.
Dry mucous membranes.  The neck was supple.  Lungs were clear
to auscultation bilaterally.  Cardiovascular was tachycardic,
irregularly irregular, with first heart sound and second
heart sound.  A 2/6 systolic ejection murmur at the left
upper sternal border.  Abdomen was soft and nondistended,
mild right upper quadrant tenderness.  No rebound or
guarding.  Rectal was heme-positive.  Extremities revealed 1+
dorsalis pedis pulses bilaterally.  Right inguinal lymphocele
with dressing, left inguinal lymphocele with dressing.  Alert
and oriented times three.  Neurologically, the patient had
slurred speech.  Strength revealed right upper extremity was
[**4-28**], left upper extremity 4+/5.  Sensation was intact to
light touch.  Gait not assessed.

PERTINENT LABORATORY DATA ON PRESENTATION:  Laboratories on
admission revealed white blood cell count 14.2 (with
75 neutrophils, 15 bands, 7 lymphocytes), hematocrit 29,
platelets of 75.  Urinalysis was notable for a large amount
of blood, positive nitrites, 30 protein, 236 red blood cells,
22 white blood cells.  Chem-7 notable for a potassium of 2.9,
bicarbonate of 28.  ALT 74, alkaline phosphatase 85, total
bilirubin 1.4, CK of 7.  PT 15.6, PTT 33.9.

RADIOLOGY/IMAGING:  Electrocardiogram revealed atrial
fibrillation, a right bundle-branch block, left axis
deviation, rate 112, T wave inversions in leads II and aVL.

Chest x-ray with pleural effusion on the right with a
question of a right infiltrate.

HOSPITAL COURSE:

1.  INFECTIOUS DISEASE:  The patient had blood cultures grow
4/4 bottles positive for methicillin-resistant Staphylococcus
aureus and was treated from the date of admission with
vancomycin and gentamicin for one week.  She continued to
have low-grade fevers throughout the course of her admission
until the day of discharge.

A transesophageal echocardiogram was performed which
demonstrated no overt vegetations and was compared with prior
transesophageal echocardiogram [**Hospital6 1708**].
No changes were noted.  Stool culture and urine cultures were
all negative as well as surveillance cultures on this
patient.  However, given the patient's history of valve
repair and recent treatment times one month for
methicillin-resistant Staphylococcus aureus after lymphocele
drainage with recurrence of bacteremia and sepsis, the
patient will continue on a long-term course of antibiotics
for at least six weeks.  Infectious Disease was consulted and
recommended vancomycin 1 g q.12h. intravenously,
rifampin 300 mg p.o. q.8h. (both times six weeks), plus
gentamicin 80 mg intravenously q.8h. times one additional
week after the week she received in house.  The patient was
to follow up with her outpatient physicians at [**Hospital6 8866**] for further workup of infection and
endocarditis.  The patient maintained her blood pressure and
her oxygen saturations throughout the course of her admission
after initial presentation.

2.  PULMONARY:  The patient was noted to have a right pleural
effusion with loculation.  Her pleural effusion had received
thoracentesis at [**Hospital6 1708**] and was found
to be transudative.  Given her good oxygen saturations on
room air, the decision was made to not intervene at this
point.

DISCHARGE DISPOSITION/INSTRUCTIONS:  The patient was to
return to [**Hospital3 2558**] and was to follow up with her
[**Hospital6 1708**] physicians as an outpatient with
the antibiotic course as listed above.  No change was made in
the rest of her medications.  From a rheumatologic and
cardiovascular standpoint, the patient was stable throughout
the rest of this admission.

DISCHARGE DIAGNOSES:
1.  Methicillin-resistant Staphylococcus aureus sepsis.
2.  Hypotension.

CONDITION AT DISCHARGE:  Condition on discharge was fair.




                          [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D.  [**MD Number(1) 4561**]

Dictated By:[**Last Name (NamePattern1) 19212**]

MEDQUIST36

D:  [**2197-2-15**]  17:07
T:  [**2197-2-16**]  08:27
JOB#:  [**Job Number 35993**]
{'Methicillin susceptible Staphylococcus aureus septicemia,Endocarditis, valve unspecified, unspecified cause,Congestive heart failure, unspecified,Unspecified pleural effusion,Hemorrhage of gastrointestinal tract, unspecified,Atrial fibrillation,Rheumatoid arthritis,Heart valve replaced by transplant'}


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: Fever and emesis.

PRESENT ILLNESS: This is a 64-year-old woman with
a past medical history notable for endocarditis resulting in
aortic valve replacement and mitral repair and tricuspid
repair in [**2196-1-25**], Evans' syndrome, recent sepsis
while at [**Hospital6 1708**] secondary to bilateral
lymphoceles, atrial fibrillation with rapid ventricular
response, cerebrovascular accident, and endometrial cancer,
who presents from [**Hospital3 2558**] with a fever to 104 and a
systolic blood pressure of 70.

MEDICAL HISTORY: 1.  Evans' syndrome which is autoimmune hemolytic anemia and
thrombocytopenia associated with rheumatoid arthritis.
2.  Atrial fibrillation, rate controlled with Lopressor.
3.  Hypertension.
4.  Bovine aortic valve replacement with mitral and tricuspid
repair in [**2196-1-25**].
5.  Endocarditis in [**2196-1-25**] resulting in aortic valve
replacement.
6.  Left-sided cerebrovascular accident in [**2196-1-25**].
7.  Endometrial cancer; status post total abdominal
hysterectomy, chemotherapy, and radiation.
8.  Lymphocele infection with methicillin-resistant
Staphylococcus aureus, Proteus, carinii bacterium at [**Hospital6 4193**]; hospitalized from [**Month (only) 216**] through
[**10-2**].  Status post splenic infarct at [**Hospital6 15291**] during past hospitalization in [**2196-9-24**].

MEDICATION ON ADMISSION: 1.  Compazine 10 mg p.o. q.d.
 2.  Plavix 75 mg p.o. q.d.
 3.  Celexa 10 mg p.o. q.d.
 4.  MS Contin 15 mg p.o. b.i.d.
 5.  Lasix 80 mg p.o. q.d.
 6.  Ativan p.r.n.
 7.  Trazodone 25 mg p.o. q.d.
 8.  Prednisone 20 mg p.o. q.d.
 9.  Prilosec 40 mg p.o. q.d.
10.  Milk of Magnesia.
11.  Dulcolax p.r.n.
12.  Folate 1 mg p.o. q.d.
13.  Atenolol 37.5 mg p.o. q.d.
14.  Danazol 400 mg p.o. b.i.d.
15.  Atrovent.
16.  Multivitamin.

ALLERGIES: PENICILLIN causes anaphylaxis, SULFA, AZTREONAM.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Methicillin susceptible Staphylococcus aureus septicemia,Endocarditis, valve unspecified, unspecified cause,Congestive heart failure, unspecified,Unspecified pleural effusion,Hemorrhage of gastrointestinal tract, unspecified,Atrial fibrillation,Rheumatoid arthritis,Heart valve replaced by transplant'}
