CHIEF COMPLAINT: Endocarditis septic shock [**3-18**] MRSA bactermia, transfer for ICD
lead removal

PRESENT ILLNESS: 65 yo M with Hx of CAD with inferior MI (95) c/b post-infarction
VSD urgently repaired at same time of single vessel bypass (SVG
to RCA), recurrent VSD s/p repair, then out-of-hospital V Fib
arrest (successfully resucitated) s/p additional single vessel
bypass surgery (LIMA to LAD), additional VSD repair with
residual shunting, and implantation of ICD. Additionally,
patient has a hx of paroxysmal AFib/Flutter and is s/p
successful electrical cardioversion on [**2161-3-18**] performed [**3-18**]
worsening heart failure symptoms.
.
He presented to [**Hospital 732**] [**Hospital 107**] Hospital in [**Location (un) 90158**], NY on
[**2161-3-29**] with complaints of fever, chills, and cough X 3 days. He
was found to have a leukocytosis (16) with impressive bandemia
(27), anion-gap metabolic acidosis, hypotension, possible PNA
and AOCKI.
.
Ultimately the patient developed septic shock secondary to MRSA
bacteremia with subsequent multi-organ failure requiring
hemodialysis. He was treated with Vancomycin and Rifampin
without clearance of blood cultures, and continued to experience
rigors. TEE revealed a vegetation attached to the lead closest
to the interatrial septum (within the RA) and a second
vegetation as the lead crosses the tricuspid valve. He initially
required dopamine and levophed for hypotension, and intermittent
BiPAP ventilation. Per report, he was shocked inappropriately
multiple times for runs of SVT and rapid A Fib, so he was
started on IV Amiodarone (now transitioned to oral).
The patient was transferred to our facility for ICD lead
extraction and management of his MRSA endocarditis.
.
Currently the patient reports he feels alright. He is without
chest pain, and his dyspnea is improving. He is having
persistent hiccups.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery. He denies exertional buttock or calf pain. All
of the other review of systems were negative.
.
Cardiac review of systems is notable for + dyspnea on exertion,
paroxysmal nocturnal dyspnea, LE edema, and intermittent
palpitations. Also absence of chest pain, orthopnea, syncope or
presyncope.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: +Diabetes II, +Dyslipidemia,
+Hypertension
2. CARDIAC HISTORY:
-CABG: X 2
-VSD s/p repair X 2 with reported residual leaking
-PERCUTANEOUS CORONARY INTERVENTIONS: BMS to LCx and LAD
-PACING/ICD: ICD placement in 90s, replacement in [**2160**]
3. OTHER PAST MEDICAL HISTORY:
-Obesity
-Chronic Kindey Injury (baseline 2.2-2.6)
-Gout

MEDICATION ON ADMISSION: HOME MEDICATIONS:
-Pepcid 20 daily
-Coumadin 1 daily
-Aspirin 81 daily
-Metoprolol 50 [**Hospital1 **]
-Lasix 40 PO daily
-Allopurinol 300 daily
-Levsin 0.125 daily PRN
-Glipizide XL 5 daily
-Levitra 20 daily
.
TRANSFER MEDICATIONS:
-Miconazole powder
-Lactobacillus 10 [**Hospital1 **]
-ASA 325 daily
-Protonix 40 daily
-Mupirocin 2% [**Hospital1 **] to nares
-Vancomycin 200 IV after HD
-Rifampin 300 [**Hospital1 **]
-Coumadin (no dose today)
-Heparin gtt
-Nystatin S&S
-Doxycycline 100 [**Hospital1 **]
-Insulin aspart SQ
-Amiodarone 400 daily
-Albuterol 2.5 inh q6h
-Atrovent 0.5 mg inh q6
-Acetaminophen
-Zofran

ALLERGIES: Gentamicin / clindamycin / Iodine

PHYSICAL EXAM: ADMISSION PHYSICAL:
VS: T=97.4  BP=102/62  HR=89  RR=22  O2 sat= 96%
GENERAL: obese male, mildly tachypneic, but NAD, Oriented x3,
Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: -Father died of MI at age of 69.

SOCIAL HISTORY: -Lives alone in apartment, has 3 children all healthy
-Tobacco history: non-smoker
-ETOH: occasional use of ETOH ([**4-17**] drinks on weekends)
-Illicit drugs: none
Infection and inflammatory reaction due to cardiac device, implant, and graft,Methicillin resistant Staphylococcus aureus septicemia,Severe sepsis,Septic shock,Acute kidney failure with lesion of tubular necrosis,Acute on chronic systolic heart failure,Endocarditis in diseases classified elsewhere,Chronic kidney disease, Stage IV (severe),Jaundice, unspecified, not of newborn,Hyposmolality and/or hyponatremia,Acquired cardiac septal defect,Atrial flutter,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Automatic implantable cardiac defibrillator in situ,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Obesity, unspecified,Gout, unspecified,Obstructive sleep apnea (adult)(pediatric),Old myocardial infarction,Diarrhea,Cephalosporin group causing adverse effects in therapeutic use,Accidents occurring in residential institution,Epistaxis,Abnormal coagulation profile
React-cardiac dev/graft,MRSA septicemia,Severe sepsis,Septic shock,Ac kidny fail, tubr necr,Ac on chr syst hrt fail,Endocarditis in oth dis,Chr kidney dis stage IV,Jaundice NOS,Hyposmolality,Acq cardiac septl defect,Atrial flutter,Abn react-artif implant,Hy kid NOS w cr kid I-IV,Cor ath unsp vsl ntv/gft,Aortocoronary bypass,Status autm crd dfbrltr,DMII wo cmp nt st uncntr,Obesity NOS,Gout NOS,Obstructive sleep apnea,Old myocardial infarct,Diarrhea,Adv eff cephalosporin,Accid in resident instit,Epistaxis,Abnrml coagultion prfile
Admission Date:  [**2161-4-8**]              Discharge Date:   [**2161-4-15**]

Date of Birth:  [**2095-7-23**]             Sex:   M

Service: MEDICINE

Allergies:
Gentamicin / clindamycin / Iodine

Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Endocarditis septic shock [**3-18**] MRSA bactermia, transfer for ICD
lead removal

Major Surgical or Invasive Procedure:
Removal of Implantable Cardioverter Difibrillator


History of Present Illness:
65 yo M with Hx of CAD with inferior MI (95) c/b post-infarction
VSD urgently repaired at same time of single vessel bypass (SVG
to RCA), recurrent VSD s/p repair, then out-of-hospital V Fib
arrest (successfully resucitated) s/p additional single vessel
bypass surgery (LIMA to LAD), additional VSD repair with
residual shunting, and implantation of ICD. Additionally,
patient has a hx of paroxysmal AFib/Flutter and is s/p
successful electrical cardioversion on [**2161-3-18**] performed [**3-18**]
worsening heart failure symptoms.
.
He presented to [**Hospital 732**] [**Hospital 107**] Hospital in [**Location (un) 90158**], NY on
[**2161-3-29**] with complaints of fever, chills, and cough X 3 days. He
was found to have a leukocytosis (16) with impressive bandemia
(27), anion-gap metabolic acidosis, hypotension, possible PNA
and AOCKI.
.
Ultimately the patient developed septic shock secondary to MRSA
bacteremia with subsequent multi-organ failure requiring
hemodialysis. He was treated with Vancomycin and Rifampin
without clearance of blood cultures, and continued to experience
rigors. TEE revealed a vegetation attached to the lead closest
to the interatrial septum (within the RA) and a second
vegetation as the lead crosses the tricuspid valve. He initially
required dopamine and levophed for hypotension, and intermittent
BiPAP ventilation. Per report, he was shocked inappropriately
multiple times for runs of SVT and rapid A Fib, so he was
started on IV Amiodarone (now transitioned to oral).
The patient was transferred to our facility for ICD lead
extraction and management of his MRSA endocarditis.
.
Currently the patient reports he feels alright. He is without
chest pain, and his dyspnea is improving. He is having
persistent hiccups.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery. He denies exertional buttock or calf pain. All
of the other review of systems were negative.
.
Cardiac review of systems is notable for + dyspnea on exertion,
paroxysmal nocturnal dyspnea, LE edema, and intermittent
palpitations. Also absence of chest pain, orthopnea, syncope or
presyncope.


Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes II, +Dyslipidemia,
+Hypertension
2. CARDIAC HISTORY:
-CABG: X 2
-VSD s/p repair X 2 with reported residual leaking
-PERCUTANEOUS CORONARY INTERVENTIONS: BMS to LCx and LAD
-PACING/ICD: ICD placement in 90s, replacement in [**2160**]
3. OTHER PAST MEDICAL HISTORY:
-Obesity
-Chronic Kindey Injury (baseline 2.2-2.6)
-Gout

Social History:
-Lives alone in apartment, has 3 children all healthy
-Tobacco history: non-smoker
-ETOH: occasional use of ETOH ([**4-17**] drinks on weekends)
-Illicit drugs: none

Family History:
-Father died of MI at age of 69.

Physical Exam:
ADMISSION PHYSICAL:
VS: T=97.4  BP=102/62  HR=89  RR=22  O2 sat= 96%
GENERAL: obese male, mildly tachypneic, but NAD, Oriented x3,
Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

NECK: Supple, difficult to appreciate JVP given obesity and RIJ
CARDIAC: + SEM across precordium, loudest at LLSB and apex.
S1/S2, increased rate
LUNGS: No chest wall deformities, scoliosis or kyphosis.
Inspiratory bibasilar coarse crackles bilaterally
ABDOMEN: soft, distended, non-tender. Abd aorta not enlarged by
palpation. No abdominal bruits.
EXTREMITIES: + pitting edema to thighs b/l, warm and
well-perfused
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
.
DISCHARGE PHYSICAL:
Tc 37.1, P: 65, BP: 120/51, RR: 21. 97% on 3L, wt 105 kg
GENERAL: obese male, NAD, Oriented x3, Mood, affect appropriate.

HEENT: sclera anicteric, moist mucous membranes
NECK: Supple, difficult to appreciate JVP given obesity, HD line
in place L neck
CARDIAC: + SEM across precordium, loudest at LLSB and apex.
S1/S2, normal rate
LUNGS: No chest wall deformities, scoliosis or kyphosis. CTAB
ABDOMEN: soft, distended, non-tender, BS+
EXTREMITIES: [**3-19**]+ pitting edema of all extremities (UE, LE),
warm and well-perfused, L picc ok


Pertinent Results:
ADMISSION LABS ([**2161-4-8**]):
Chem:
GLUCOSE-102* UREA N-32* CREAT-3.9* SODIUM-131* POTASSIUM-3.8
CHLORIDE-98 TOTAL CO2-26 ANION GAP-11 CALCIUM-7.3* PHOSPHATE-3.5
MAGNESIUM-1.7
LFTs:
ALT(SGPT)-17 AST(SGOT)-25 LD(LDH)-176 ALK PHOS-62 TOT BILI-2.6*
DIR BILI-2.2* INDIR BIL-0.4 ALBUMIN-2.3*
Iron Studies:
IRON-21* calTIBC-185* HAPTOGLOB-169 FERRITIN-361 TRF-142* RET
AUT-2.0
CBC:
WBC-11.8* RBC-2.77* HGB-8.2* HCT-24.9* MCV-90 MCH-29.5 MCHC-32.7
RDW-17.5*
NEUTS-88.3* LYMPHS-7.7* MONOS-3.3 EOS-0.5 BASOS-0.2 PLT
COUNT-156
Coags:
PT-38.2* PTT-37.5* INR(PT)-4.0*
.
DISCHARGE LABS ([**2161-4-15**]):
[**2161-4-15**] 03:53AM BLOOD WBC-7.7 RBC-2.68* Hgb-8.0* Hct-23.9*
MCV-89 MCH-29.7 MCHC-33.3 RDW-18.9* Plt Ct-137*
[**2161-4-15**] 03:53AM BLOOD Glucose-101* UreaN-50* Creat-6.2*# Na-134
K-4.1 Cl-98 HCO3-23 AnGap-17
[**2161-4-15**] 03:53AM BLOOD Calcium-8.0* Phos-6.9*# Mg-2.2
[**2161-4-15**] 03:53AM BLOOD Vanco-19.3
[**2161-4-10**] 03:45AM BLOOD HBsAg-NEGATIVE
[**2161-4-9**] 06:15AM BLOOD HBsAb-NEGATIVE HBcAb-NEGATIVE
[**2161-4-13**] 03:28AM BLOOD ALT-12 AST-22 AlkPhos-63 TotBili-0.9
.
STUDIES:
MICRO:
- BCx ([**4-12**]): 1/6 bottles positive for GPCs
- Bcx ([**4-10**]): 1/4 bottles (anaerobic bottle) with GPC in
clusters
- Bcx ([**2074-4-7**] and [**2077-4-10**]): NGTD
- Stool C diff tox ([**4-9**] and 26): negative
- IDC lead ([**4-9**]): negative
.
Radiology:
CXR [**2161-4-8**]:
REASON FOR EXAMINATION: Heart failure in a patient with infected
ICD leads.

Portable AP chest radiograph was reviewed with no prior studies
available for comparison.

Pacemaker leads terminate in right ventricle with the second
lead not clearly seen on the current study. The right internal
jugular line tip is at the level of low SVC. Cardiomediastinal
silhouettes demonstrate prior sternotomy and mild cardiomegaly.
The evaluation of the lung parenchyma demonstrates nodular
opacities projecting over the right lung that might represent
unusual appearance of pulmonary edema, but infectious process
would be a consideration. Evaluation of the patient after
diuresis is suggested and if findings persist, further
evaluation with chest CT would be highly recommended. Small
amount of bilateral pleural effusion cannot be excluded, in
particular on the left given the relatively significant distance
between the gastric bubble and the low cardiac border that might
suggest subpulmonic effusion on the left.
.
TTE [**2161-4-9**]:
Conclusions
The left atrium is dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
moderately dilated. There is moderate global left ventricular
hypokinesis (LVEF = 30-35%). A left ventricular mass/thrombus
cannot be excluded. There is no ventricular septal defect. The
right ventricular cavity is dilated with depressed free wall
contractility. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No masses or
vegetations are seen on the aortic valve. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No masses or vegetations are seen on the mitral
valve, but cannot be fully excluded due to suboptimal image
quality. Moderate (2+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Moderate to
severe [3+] tricuspid regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. [In the setting of
at least moderate to severe tricuspid regurgitation, the
estimated pulmonary artery systolic pressure may be
underestimated due to a very high right atrial pressure.] There
is no pericardial effusion.

IMPRESSION: Moderately dilated left ventricle with moderate
global LV hypokinesis. There is likely significant dyssynchrony
present. Prior VSD repair is seen in the basal septum which is
thinned and akinetic. Dilated and hypokinetic right ventricle.
Mild aortic, moderate mitral and moderate to severe tricuspid
regurgitation. No evidence of endocarditis (cannot exclude). The
LV apex is heavily trabeculated, a LV thrombus cannot be
excluded (unlikely as the apex has normal systolic function).
.
RUQ U/S [**2161-4-9**]:
IMPRESSION:

1. Non-visualization of the gallbladder. The patient will be
called back for further imaging at no additional charge by the
radiology department.
2. Normal appearance of the liver without focal liver lesions.
2. Splenomegaly.
3. Simple cysts within the right kidney.

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

Brief Hospital Course:
Mr. [**Known lastname **] is an 82 yo M with Hx of CAD complicated by inferior
myocardial infarction, VSD s/p repair X 3, s/p 1V CABG X 2,
multiple PCIs, V Fib arrest s/p ICD placement, as well as A
Fib/Flutter s/p recent electrical cardioversion, and chronic
kidney injury who was transferred from an outside hospital with
septic shock secondary to MRSA endocarditis for planned ICD
removal by Dr. [**Last Name (STitle) **].
.
# MRSA ENDOCARDITIS/SEPTIC SHOCK: Per report, the patient
presented to the OSH with multi-organ failure requiring pressure
support and intermittent BiPAP. He was started on hemodialysis
for oliguric renal failure. Blood cultures grew
methicillin-resistant staphylococcus aureus for which he was
started on Vancomycin and Rifampin. TTE revealed vegetations on
ICD hardware (RA lead and lead crossing tricuspid valve) so the
patient was transferred to our facility for ICD extraction. He
underwent this procedure on [**4-9**], which went well. He was
extubated quickly and only required small amounts of Levophed
transiently for pressure support. TEE did not reveal clear
infection of the VSD patch. Infectious Disease provided
recommendations throughout his admission. He was continued on
Vancomycin (dosed at hemodialysis). Rifampin was not started
secondary to documented resistance at the outside hospital.
Blood cultures remained negative until evening prior to
discharge back to OSH ([**2161-4-10**] one set of blood cultures grew
GPC in clusters, sensitivites and speciations pending). He will
likely need suppressive antibiosis with Doxycycline or Bactrim
for 6-12 months after 6 weeks of IV Vancomycin. Infectious
Disease here at [**Hospital1 18**] did update Dr. [**Last Name (STitle) **] regarding the
patient.
.
# ACUTE ON CHRONIC KIDNEY INJURY: Etiology most likely ATN
secondary to hypoperfusion from septic shock. Additional work-up
was negative (Renal U/S without gross abnormalities, C3/C4
normal). Patient was started on hemodialysis at the outside
hospital and continued at our facility. His temporary HD line
was re-sited to the left internal jugular vein. Given his
clinical evidence of heart failure, his volume status was
optimized by fluid removal at HD. We renally-dosed appropriate
medications and avoided nephrotoxins. Prior to discharge, we
placed a PPD which was negative and obtained hepatitis
serologies in order for screening for outpatient dialysis center
placement given his likely future need to continue treatment.
Hepatitis B and C serologies were negative and PPD read was
negative. Additionally, he was started on nephrocaps and calcium
acetate with meals. Patient should be monitored for signs of
renal recovery to determine if he can stop dialysis in the
future. Last HD session at [**Hospital1 18**] was [**2161-4-14**]. He will likely need
HD tomorrow ([**2161-4-16**]) and should have a nephrology consult to
help facilitate this process. Vancomycin should be dosed with
HD.
.
# HYPOXIA: Likely etiology is pulmonary edema; however, patient
has nodular opacities on chest xray, which may be evidence of
septic emboli. The patient's gross volume overload was managed
at hemodialysis. He remained on 6L of oxygen supplementation via
nasal cannula during the day, and BiPAP for suspected
Obstructive Sleep Apnea at night.
.
# ACUTE ON CHRONIC SYSTOLIC CONGESTIVE HEART FAILURE: The
patient has a history of ischemic cardiomyopathy. Echo obtained
during this admission revealed a moderately dilated left
ventricle with moderate global LV hypokinesis, likely
significant dyssynchrony present, prior VSD repair seen in the
basal septum which is thinned and akinetic, dilated and
hypokinetic right ventricle, mild aortic, moderate mitral, and
moderate to severe tricuspid regurgitation. He appeared grossly
volume overloaded with rales and significant pitting anasarca.
We attempted to initiate beta-blocker therapy for better rate
control (see below); however, the patient began to have episodes
of asymptomatic bradycardia to the 30s. We did not initiate an
ace-inhibitor given his current renal function and unclear
future course. The patient had volume removed during
hemodialysis.
.
# CORONARY ARTERY DISEASE: The patient has a Hx of inferior
myocardial infarction complicated by ventricular septal defect
status post three repairs, as well as 2 single-vessel bypass
grafts (SVG to RCA, and LIMA to LAD), as well as multiple PCIs.
There was no evidence to suspect acute coronary syndrome during
this admission. We continued him on Aspirin 325 daily and
Atorvastatin 80 daily.
.
# ATRIAL FIB/FLUTTER: The patient presented with a history of
Atrial Fibrillation for which he had a successful electrical
cardioversion performed on [**2161-3-18**]. Per report, the patient had
been receiving inappropriate shocks by his ICD for runs of SVT
and AF with RVR. He was started on Amiodarone, which we
continued. During this admission he remained in coarse atrial
fibrillation and atrial tachycardia intermittently. He was also
started on a heparin drip for anticoagulation. He will receive
replacement ICD 6-8 weeks, because planned treatment course of
antibiotics is currently set for 6 weeks.
.
# COAGULOPATHY: Patient presented with prolonged PT and PTT.
Unclear if he had been receiving Coumadin at the outside
hospital. Coagulopathy possibly secondary to poor nutrition,
current antibiotics use, or prior liver injury. He received IV
vit K to reverse his INR prior to ICD removal. Resumed on
heparin gtt at end of [**Hospital1 18**] hospitalization with need for
resumption of coumadin at OSH when appropriate.
.
# ANEMIA: Iron studies reflected anemia of chronic inflammation
and iron depletion. The patient's stools were guaiac positive;
however, he demonstrated no signs or symptoms of acute bleeding.
He was started on pantoprazole daily. He may benefit from EPO
with hemodialysis; current plan is to hold off and consider iron
with hemodialysis. Additionally, given his cardiac history, he
was transfused one unit of packed red blood cells at dialysis.
.
# HYPONATREMIA: Based on clinical exam, likely hypervolemic
hyponatremia in etiology. Unable to obtain urine electrolytes.
Hyponatremia was mild and improved with volume removal. He never
demonstrated any mental status changes.
.
# ISOLATED DIRECT HYPERBILIRUBINEMIA: Present on admission and
resolved within two days. Other transaminases were within normal
limits and RUQ ultrasound was unrevealing; however, gallbladder
was not visualized. Likely secondary to cholestasis from
resolving sepsis. The patient had no RUQ abdominal pain to
suggest infection such as cholangitis. As gallbladder was not
visualized, a repeat abdominal ultrasound may be considered for
further evaluation.
.
# UNCLEAN URINALYSIS: Urinalysis appeared infected with pyuria
and hematuria; however, patient was making very little urine
volume. Was given two doses of ceftriaxone, which was
discontinued once culture returned negative for growth.
.
# DIARRHEA: Likely secondary to ceftriaxone, which was
discontinued. Clostridium difficile toxin assay negative.
.
FEN: Patient remained on cardiac, low Na, diabetic diet
ACCESS: Left IJ HD line, 2 PIVs, A-line for BP monitoring
PROPHYLAXIS:
-DVT ppx with pneumoboots
-Pain management with tylenol as needed
-Bowel regimen with senna and colace
CODE: Full code
COMM: patient, daughter ([**Name (NI) 402**]) @ [**Telephone/Fax (1) 90159**]

Medications on Admission:
HOME MEDICATIONS:
-Pepcid 20 daily
-Coumadin 1 daily
-Aspirin 81 daily
-Metoprolol 50 [**Hospital1 **]
-Lasix 40 PO daily
-Allopurinol 300 daily
-Levsin 0.125 daily PRN
-Glipizide XL 5 daily
-Levitra 20 daily
.
TRANSFER MEDICATIONS:
-Miconazole powder
-Lactobacillus 10 [**Hospital1 **]
-ASA 325 daily
-Protonix 40 daily
-Mupirocin 2% [**Hospital1 **] to nares
-Vancomycin 200 IV after HD
-Rifampin 300 [**Hospital1 **]
-Coumadin (no dose today)
-Heparin gtt
-Nystatin S&S
-Doxycycline 100 [**Hospital1 **]
-Insulin aspart SQ
-Amiodarone 400 daily
-Albuterol 2.5 inh q6h
-Atrovent 0.5 mg inh q6
-Acetaminophen
-Zofran

Discharge Medications:
1. insulin lispro 100 unit/mL Solution Sig: According to Scale
Subcutaneous ASDIR (AS DIRECTED).
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for itching, rash.
6. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily): Continue while on Dialysis.
7. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS): Continue while on dialysis.

8. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1)
Intravenous HD PROTOCOL (HD Protochol): Adjust according to
Vancomycin Trough and HD.
10. heparin, porcine (PF)  Intravenous
11. Levsin 0.125 mg Tablet Sig: One (1) Tablet PO once a day as
needed for abdominal pain .


Discharge Disposition:
Extended Care

Discharge Diagnosis:
MRSA Endocarditis with infection of defibrillator


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

Discharge Instructions:
Mr. [**Known lastname **],

You were transfered to [**Hospital1 69**] for
an infection in you heart. You were evaluated and treated by the
cardiology service. You received removal of you Implantable
Cardioverter Defibrillator and tolerated its removal well. You
also received antibiotics for the infection of your
defibrillator and dialysis for your kidney difficulties. You
remained comfortable and stable throughout your admission. You
are being transfered to [**Hospital **] Hospital - [**Location (un) 732**] where you will
continue to recieve care for your heart infection.

The following changes were made to your medications:
-STOPPED Coumadin- this may be restarted at the transfer
hospital
-STOPPED Pepcid
-STOPPED Furosemide (lasix)
-STOPPED Allopurinol
-STOPPED Glipizide
-STOPPED Metoprolol
-STARTED Amiodarone 400 mg by mouth daily
-STARTED Heparin drip
-STARTED Pantoprazole 40 mg daily
-STARTED Insulin Sliding Scale
-INCREASED Aspirin from 81 to 325 mg daily

Followup Instructions:
Department: RADIOLOGY
When: MONDAY [**2161-4-20**] at 2:30 PM
With:  ULTRASOUND [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST     Best Parking: [**Doctor First Name **]. GARAGE
{'Infection and inflammatory reaction due to cardiac device, implant, and graft,Methicillin resistant Staphylococcus aureus septicemia,Severe sepsis,Septic shock,Acute kidney failure with lesion of tubular necrosis,Acute on chronic systolic heart failure,Endocarditis in diseases classified elsewhere,Chronic kidney disease, Stage IV (severe),Jaundice, unspecified, not of newborn,Hyposmolality and/or hyponatremia,Acquired cardiac septal defect,Atrial flutter,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Automatic implantable cardiac defibrillator in situ,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Obesity, unspecified,Gout, unspecified,Obstructive sleep apnea (adult)(pediatric),Old myocardial infarction,Diarrhea,Cephalosporin group causing adverse effects in therapeutic use,Accidents occurring in residential institution,Epistaxis,Abnormal coagulation profile'}


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: Endocarditis septic shock [**3-18**] MRSA bactermia, transfer for ICD
lead removal

PRESENT ILLNESS: 65 yo M with Hx of CAD with inferior MI (95) c/b post-infarction
VSD urgently repaired at same time of single vessel bypass (SVG
to RCA), recurrent VSD s/p repair, then out-of-hospital V Fib
arrest (successfully resucitated) s/p additional single vessel
bypass surgery (LIMA to LAD), additional VSD repair with
residual shunting, and implantation of ICD. Additionally,
patient has a hx of paroxysmal AFib/Flutter and is s/p
successful electrical cardioversion on [**2161-3-18**] performed [**3-18**]
worsening heart failure symptoms.
.
He presented to [**Hospital 732**] [**Hospital 107**] Hospital in [**Location (un) 90158**], NY on
[**2161-3-29**] with complaints of fever, chills, and cough X 3 days. He
was found to have a leukocytosis (16) with impressive bandemia
(27), anion-gap metabolic acidosis, hypotension, possible PNA
and AOCKI.
.
Ultimately the patient developed septic shock secondary to MRSA
bacteremia with subsequent multi-organ failure requiring
hemodialysis. He was treated with Vancomycin and Rifampin
without clearance of blood cultures, and continued to experience
rigors. TEE revealed a vegetation attached to the lead closest
to the interatrial septum (within the RA) and a second
vegetation as the lead crosses the tricuspid valve. He initially
required dopamine and levophed for hypotension, and intermittent
BiPAP ventilation. Per report, he was shocked inappropriately
multiple times for runs of SVT and rapid A Fib, so he was
started on IV Amiodarone (now transitioned to oral).
The patient was transferred to our facility for ICD lead
extraction and management of his MRSA endocarditis.
.
Currently the patient reports he feels alright. He is without
chest pain, and his dyspnea is improving. He is having
persistent hiccups.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery. He denies exertional buttock or calf pain. All
of the other review of systems were negative.
.
Cardiac review of systems is notable for + dyspnea on exertion,
paroxysmal nocturnal dyspnea, LE edema, and intermittent
palpitations. Also absence of chest pain, orthopnea, syncope or
presyncope.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: +Diabetes II, +Dyslipidemia,
+Hypertension
2. CARDIAC HISTORY:
-CABG: X 2
-VSD s/p repair X 2 with reported residual leaking
-PERCUTANEOUS CORONARY INTERVENTIONS: BMS to LCx and LAD
-PACING/ICD: ICD placement in 90s, replacement in [**2160**]
3. OTHER PAST MEDICAL HISTORY:
-Obesity
-Chronic Kindey Injury (baseline 2.2-2.6)
-Gout

MEDICATION ON ADMISSION: HOME MEDICATIONS:
-Pepcid 20 daily
-Coumadin 1 daily
-Aspirin 81 daily
-Metoprolol 50 [**Hospital1 **]
-Lasix 40 PO daily
-Allopurinol 300 daily
-Levsin 0.125 daily PRN
-Glipizide XL 5 daily
-Levitra 20 daily
.
TRANSFER MEDICATIONS:
-Miconazole powder
-Lactobacillus 10 [**Hospital1 **]
-ASA 325 daily
-Protonix 40 daily
-Mupirocin 2% [**Hospital1 **] to nares
-Vancomycin 200 IV after HD
-Rifampin 300 [**Hospital1 **]
-Coumadin (no dose today)
-Heparin gtt
-Nystatin S&S
-Doxycycline 100 [**Hospital1 **]
-Insulin aspart SQ
-Amiodarone 400 daily
-Albuterol 2.5 inh q6h
-Atrovent 0.5 mg inh q6
-Acetaminophen
-Zofran

ALLERGIES: Gentamicin / clindamycin / Iodine

PHYSICAL EXAM: ADMISSION PHYSICAL:
VS: T=97.4  BP=102/62  HR=89  RR=22  O2 sat= 96%
GENERAL: obese male, mildly tachypneic, but NAD, Oriented x3,
Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: -Father died of MI at age of 69.

SOCIAL HISTORY: -Lives alone in apartment, has 3 children all healthy
-Tobacco history: non-smoker
-ETOH: occasional use of ETOH ([**4-17**] drinks on weekends)
-Illicit drugs: none 

### Response:
{'Infection and inflammatory reaction due to cardiac device, implant, and graft,Methicillin resistant Staphylococcus aureus septicemia,Severe sepsis,Septic shock,Acute kidney failure with lesion of tubular necrosis,Acute on chronic systolic heart failure,Endocarditis in diseases classified elsewhere,Chronic kidney disease, Stage IV (severe),Jaundice, unspecified, not of newborn,Hyposmolality and/or hyponatremia,Acquired cardiac septal defect,Atrial flutter,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Automatic implantable cardiac defibrillator in situ,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Obesity, unspecified,Gout, unspecified,Obstructive sleep apnea (adult)(pediatric),Old myocardial infarction,Diarrhea,Cephalosporin group causing adverse effects in therapeutic use,Accidents occurring in residential institution,Epistaxis,Abnormal coagulation profile'}
