CHIEF COMPLAINT: Endocarditis

PRESENT ILLNESS: 28 yo male with h/o bicuspid valve with aortic valvuloplasty at
age 15, MSSA endocarditis in [**2137**] (age 24) s/p AVR with a
homograft, and subsequent endocarditis in [**2140**] with AVR with a
mechanical valve, and h/o IVDU; p/w prosthetic valve
enterococcal IE.

MEDICAL HISTORY: 1. Bicuspid Aortic Valve- s/p Aortic Valvuolplasty at age 15
2. MSSA Recurrent Aortic Valve Endocarditis, ([**2137**], [**2139**])
----[**12/2137**]: MSSA endocarditis: with a 6 week course of
nafcillin and ultimately [**Year (4 digits) 1834**] a Bentall procedure utilizing
homograft along with VSD closure and debridement of aortic root
abscess.
----[**3-/2140**]: MSSA? Endocarditis: Redo aortic valve replacement
with a size 27 mm Onyx mechanical valve and ascending aortic
interposition graft with a size 24 mm Dacron graft
3. History of Septic Emboli to Spleen, Kidney and Cerebrum;
hepatic pseudoaneurysm embolization in [**2137**]
4. Intravenous Drug Abuser; patient states last time used IVDs
was prior to his last surgery in [**2139**].
5. History encephalomalacia of the right parietal lobe from a
prior infarct, and minimal chronic microvascular ischemic
changes.
6. Chronic systolic heart failure

MEDICATION ON ADMISSION: CURRENT MEDICATIONS: HOME
Carvedilol 25 mg [**Hospital1 **]
Lisinopril 10 mg Daily
Aspirin 81 mg Daily
Coumadin 10 mg Daily
Suboxone
.
Medications in OSH:
Ampicillin 2 grams IV q 4 hours
Gentamicin 70 mg IV q 12 hours
Vancomycin 1.25 mg
Ambien
Lasix 40 IV BID
Cefipime: 1 gram IV x 1
Ceftazidime IV 2 grams
Fentanyl
Versed
Morphine
Benedryl
Solumedrol 125 mg IV x 1
Vitamin K 10 mg IV (INR 6.6 on presentation)
.

ALLERGIES: Dilaudid

PHYSICAL EXAM: 72"  90 kg
Blood pressure was 95/62 mm Hg while seated. Pulse was 70
beats/min and regular, respiratory rate was 26 breaths/min.
Generally the patient was well developed, well nourished and
well groomed. The patient was oriented to person, place and
time. The patient's mood and affect were appropriate.
.
There was no xanthalesma and conjunctiva were pink with no
pallor or cyanosis of the oral mucosa. There is a 2x2mm scleral
hemorrage in the L eye. The neck was supple with JVP at
clavicle. The carotid waveform was normal. There was no
thyromegaly. The were no chest wall deformities, scoliosis or
kyphosis. The respirations were not labored and there were no
use of accessory muscles. The lungs were clear to ascultation
bilaterally with normal breath sounds and no adventitial sounds
or rubs.
.
Palpation of the heart revealed the PMI to be located in the 5th
intercostal space, mid clavicular line. There were no thrills or
palpable S3 or S4. Mild lift was noted. The heart sounds
revealed a normal S1 and the S2 was normal. There were no rubs
or gallops. Harsh [**5-14**] crescendo/decresendo systolic murmur heard
best at the left sternal border on the clavicle; radiating to
carotids, apex, and back.
.
There was no hepatosplenomegaly or tenderness. The abdomen was
soft nontender and nondistended. The extremities had no pallor,
cyanosis, clubbing or edema. Inspection and/or palpation of skin
and subcutaneous tissue showed no stasis dermatitis, ulcers,
scars, or xanthomas.
.
Pulses:
Right: DP 2+ PT 2+
Left: DP 1+ PT 1+

FAMILY HISTORY: Patient adopted and does not know family history.

SOCIAL HISTORY: Quit tobacco just prior to admission h/o [**2-9**] ppd for 12 years.
Denies ETOH over the last year. He currently lives with his
parents. Several years of IVDU but denies since last AVR.
Infection and inflammatory reaction due to cardiac device, implant, and graft,Acute and subacute bacterial endocarditis,Streptococcal septicemia,Acute on chronic systolic heart failure,Acute kidney failure, unspecified,Other non-autoimmune hemolytic anemias,Ventricular fibrillation,Septic arterial embolism,Arterial embolism and thrombosis of lower extremity,Sepsis,Cardiac tamponade,Hemorrhage complicating a procedure,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Tobacco use disorder,Anxiety state, unspecified,Other specified forms of chronic ischemic heart disease
React-cardiac dev/graft,Ac/subac bact endocard,Streptococcal septicemia,Ac on chr syst hrt fail,Acute kidney failure NOS,Oth nonauto hem anemia,Ventricular fibrillation,Septic arterial embolism,Lower extremity embolism,Sepsis,Cardiac tamponade,Hemorrhage complic proc,Abn react-anastom/graft,Hx TIA/stroke w/o resid,Tobacco use disorder,Anxiety state NOS,Chr ischemic hrt dis NEC
Admission Date:  [**2142-9-3**]              Discharge Date:   [**2142-10-2**]

Date of Birth:  [**2114-4-25**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
Dilaudid

Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Endocarditis

Major Surgical or Invasive Procedure:
[**2142-9-9**] Redo Bentall procedure ([**Street Address(2) 17009**]. [**Male First Name (un) 923**] mechanical
AV/graft composite)/Hemi Arch aortic replace.(26 mm Gelweave)/
LVOT reconstruction ( pericardial patch)


History of Present Illness:
28 yo male with h/o bicuspid valve with aortic valvuloplasty at
age 15, MSSA endocarditis in [**2137**] (age 24) s/p AVR with a
homograft, and subsequent endocarditis in [**2140**] with AVR with a
mechanical valve, and h/o IVDU; p/w prosthetic valve
enterococcal IE.

The patient was slowly becoming more dyspnic over the past
several weeks. He usually is quite active at baseline, but has
noticed in the past week he has had difficulty walking to class
that has forced him to stop. On Thursday, the patient
experienced acute shortness of breath while sitting at home. He
called 911 and was taken to the emergency room in [**Location (un) **]. On
presentation in the ED, he had profound anemia with a Hct of
11.5. He was found to be in acute pulmonary edema as well. He
had a mild troponin I elevation of 0.37 with a BUN and Creatine
37/1.9 (BUN/Cr baseline 10-18/0.8-1.0). His white count was 8.1.

.
He was electively intubated secondary to respiratory instability
and respiratory acidosis. TEE on [**8-31**] revealed a large
obstructive mass in the ascending aorta, with prosthetic valve
AI, as well as aneurysm and dehiscence in the aorta. After the
TEE, blood cultures were sent, which eventually grew
enterococcus. He was started on Amp/Gent, diuresed and received
10 units of PRBCs. Patient's respiratory status improved and was
extubated [**9-2**]. He was transferred to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1675**] for further
management and evaluation by CT surgery of repeat AVR.
.
Of note, he had a tooth filling in [**Month (only) 404**] and a re-do filling
in [**Month (only) 958**], of which he took antibiotics both times. He states
after [**Month (only) 958**], he started feeling ill. He c/o muscle cramps in his
thighs and increased palpipations. He denied shortness of breath
until the episode last week.
.
Upon arrival to the CCU, vitals were T: 99.5 HR: 73 BP: 95/62
RR: 26 SpO2: 99% on 4L. He denied complaints, notably, denied
CP, SOB, dizziness, and palpitations.
.
On review of symptoms, he complains of left lower extremity
numbness and decreased pulses in DP/PT. He was followed by
vascular surgery in the OSH and no intervention was done.
.
He denies any prior history of deep venous thrombosis, pulmonary
embolism, bleeding at the time of surgery, myalgias, cough,
black stools or red stools. He denies exertional buttock or calf
pain. All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
pnd, orthopnea, ankle edema, syncope or presyncope.


Past Medical History:
1. Bicuspid Aortic Valve- s/p Aortic Valvuolplasty at age 15
2. MSSA Recurrent Aortic Valve Endocarditis, ([**2137**], [**2139**])
----[**12/2137**]: MSSA endocarditis: with a 6 week course of
nafcillin and ultimately [**Year (4 digits) 1834**] a Bentall procedure utilizing
homograft along with VSD closure and debridement of aortic root
abscess.
----[**3-/2140**]: MSSA? Endocarditis: Redo aortic valve replacement
with a size 27 mm Onyx mechanical valve and ascending aortic
interposition graft with a size 24 mm Dacron graft
3. History of Septic Emboli to Spleen, Kidney and Cerebrum;
hepatic pseudoaneurysm embolization in [**2137**]
4. Intravenous Drug Abuser; patient states last time used IVDs
was prior to his last surgery in [**2139**].
5. History encephalomalacia of the right parietal lobe from a
prior infarct, and minimal chronic microvascular ischemic
changes.
6. Chronic systolic heart failure

Social History:
Quit tobacco just prior to admission h/o [**2-9**] ppd for 12 years.
Denies ETOH over the last year. He currently lives with his
parents. Several years of IVDU but denies since last AVR.

Family History:
Patient adopted and does not know family history.

Physical Exam:
72"  90 kg
Blood pressure was 95/62 mm Hg while seated. Pulse was 70
beats/min and regular, respiratory rate was 26 breaths/min.
Generally the patient was well developed, well nourished and
well groomed. The patient was oriented to person, place and
time. The patient's mood and affect were appropriate.
.
There was no xanthalesma and conjunctiva were pink with no
pallor or cyanosis of the oral mucosa. There is a 2x2mm scleral
hemorrage in the L eye. The neck was supple with JVP at
clavicle. The carotid waveform was normal. There was no
thyromegaly. The were no chest wall deformities, scoliosis or
kyphosis. The respirations were not labored and there were no
use of accessory muscles. The lungs were clear to ascultation
bilaterally with normal breath sounds and no adventitial sounds
or rubs.
.
Palpation of the heart revealed the PMI to be located in the 5th
intercostal space, mid clavicular line. There were no thrills or
palpable S3 or S4. Mild lift was noted. The heart sounds
revealed a normal S1 and the S2 was normal. There were no rubs
or gallops. Harsh [**5-14**] crescendo/decresendo systolic murmur heard
best at the left sternal border on the clavicle; radiating to
carotids, apex, and back.
.
There was no hepatosplenomegaly or tenderness. The abdomen was
soft nontender and nondistended. The extremities had no pallor,
cyanosis, clubbing or edema. Inspection and/or palpation of skin
and subcutaneous tissue showed no stasis dermatitis, ulcers,
scars, or xanthomas.
.
Pulses:
Right: DP 2+ PT 2+
Left: DP 1+ PT 1+


Pertinent Results:
Admission Labs:

[**2142-9-3**] 07:32PM   PTT-58.3*
[**2142-9-3**] 02:30PM   GLUCOSE-103 UREA N-32* CREAT-1.2 SODIUM-139
POTASSIUM-3.4 CHLORIDE-103 TOTAL CO2-28 ANION GAP-11
[**2142-9-3**] 02:30PM   CALCIUM-8.9 PHOSPHATE-3.3 MAGNESIUM-1.9
[**2142-9-3**] 02:30PM   WBC-8.8 RBC-3.75* HGB-10.3* HCT-29.9* MCV-80*
MCH-27.4 MCHC-34.4 RDW-18.3*
[**2142-9-3**] 02:30PM   NEUTS-85.1* LYMPHS-11.6* MONOS-2.0 EOS-1.1
BASOS-0.2
[**2142-9-3**] 02:30PM   PT-25.5* PTT-60.3* INR(PT)-2.5*

ECG Study Date of [**2142-9-3**]:
Sinus rhythm. Rightward axis. Deep T wave inversions in leads
V1-V6 raise the possibility of ischemia, metabolic effect or
left ventricular hypertrophy. Compared to the previous tracing
of [**2140-3-19**] anterior and lateral T wave abnormalities are more
pronounced.

ART EXT (REST ONLY) Study Date of [**2142-9-4**]
IMPRESSION:
1. Severe left tibial disease, greater in the dorsalis pedis
than in the
posterior tibial artery.
2. Right ABI of 1.25 and the left ABI of 0.68 at rest.
3. Normal right lower extremity hemodynamics at rest.

MRI Head W/ and W/O Contrast ([**2142-9-4**]):
IMPRESSION:
1. Interval development of small contrast-enhancing and
hemorrhagic lesions along the cerebral hemispheres and left
cerebellum, which may be cortical or leptomeningeal. Given the
clinical setting, they are consistent with septic emboli.
2. Interval increase in chronic infacts and chronic
microhemorrhages, likely due to recurrent emboli in the setting
of AVR.

Chest/Abdomen/Pelvis CT w/ and w/o contrast ([**2142-9-5**]):
IMPRESSION:
1. Post-surgical changes with aortic graft and aortic valve
prosthesis.
2. Dilated ascending aorta measures up to 5.9 cm in diameter.
3. Cardiomegaly.
4. Small left pleural effusion.
5. Left basilar consolidation/atelectasis.
6. Splenomegaly.
7. Small amount of free fluid in the pelvis.
8. No CT evidence for aortoenteric fistula.
9. Air in the non-dependent portion of the urinary bladder may
be related to instrumentation. Please correlate clinically.

MRA Lower extremities ([**2142-9-5**]):
1. Aortoiliac station: The aortoiliac system is widely patent.
2. Left lower extremity: Embolic occlusion of the distal
tibioperoneal trunk, long segment of proximal posterior tibialis
artery, peroneal artery, distal anterior tibialis artery,
plantar arch and proximal dorsalis pedis.
3. Right lower extremity: Abrupt cut off of enhancement of the
distal right posterior tibialis artery, which reconstitutes
retrograde without a gap in enhancement identified on delayed
images is of uncertain significance. The findings would be
unlikely to be a very small focal embolus alternatively
congenital variant. The remainder of the arteries of the right
lower extremity are widely patent.

TEE ([**2142-9-8**]):
No atrial septal defect is seen by 2D or color Doppler. LV
systolic function appears depressed. A mechanical aortic valve
prosthesis is present. A paravalvular aortic valve leak is
present. An aortic annular abscess is seen with turbulent flow
measuring 1.5x3.2cm2 in the anterior portion. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. Mild (1+) mitral regurgitation is seen. No
aortomitral continuity disruption is identified. Proximal
pulmonary artery is not well visualized. The tricuspid valve
leaflets are mildly thickened. There is no pericardial effusion.


Conclusions
Prebypass

No atrial septal defect is seen by 2D or color Doppler. There is
severe regional left ventricular systolic dysfunction with
hypokinesia of the anterior wall, anteroseptal wall, septal and
inferoseptal wall . Overall left ventricular systolic function
is severely depressed (LVEF= 25 %). with moderate global RV free
wall hypokinesis. A mechanical aortic valve prosthesis is
present. A paravalvular aortic valve leak is present. The aortic
valve prosthesis cannot be adequately assessed. An aortic
annular abscess is seen. Significant aortic regurgitation is
present, but cannot be quantified. Mild (1+) mitral
regurgitation is seen. Dr. [**Last Name (STitle) **] was notified in person
of the results on [**2142-9-9**] at 945am. Dr [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] present for
the perioperative study and felt the aortic root abscess was
bigger in size compared to yesterday.

Post Bypass

The patient is in sinus rhythm receiving an infusion of
Norepinephrine, milrinone and vasopressin. Biventricular
systolic function is slightly improved. Mechanical valve seen in
the aortic position. Appears well seated and the leaflets move
well. Peak gradient across the arotic valve is 28 mm Hg.
Findings discussed with Dr [**Last Name (STitle) **].
  I certify that I was present for this procedure in compliance
with HCFA regulations.

Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2142-9-9**] 20:38



Brief Hospital Course:
28 year old with h/o recurrent aortic valve endocarditis, AVR x
2 presenting with enterococcal bacteremia causing dehiscence of
aortic valve replacement ring/right fibrous trigone, and s/p
profound hemolytic anemia secondary to valvular damage.

# Endocarditis:  Patient was transferred to our hospital for
enterococcal mechanical valve endocarditis in OSH. He was
continued on ampicillin and changed from gentamycin to
ceftriaxone per ID recommendations, as he has had ototoxicity to
gentamycin in the past.  During his workup, he was found to have
embolic phenomena to his left eye ([**Doctor Last Name **] spot),left foot, and
brain (of note, MRA of the head ruled out mycotic aneurysm prior
to surgery).  He had new wall motion abnormalities on TTE that
were concerning for emboli to the coronary arteries.  He had a
dental filling replacement in [**Month (only) 958**], even though patient took
antibiotics, he started to feel increasingly tired some time
after this procedure.  Since patient denies IVDU, it is likely
the dental procedure is the source of his enterococcus
bacteremia.

Approximately 5 days after admission (on [**2142-9-8**]), patient had a
TTE and TEE that showed increased size of his aortic valve
abscess.  In addition, his hematocrit dropped signifying
worsening hemolytic anemia and he had worsening signs of heart
failure requiring aggressive diuresis with Lasix.  He was
restarted on gentamicin as this is the best treatment for
enterococcal endocarditis, despite the risk of ototoxicity.  Per
ID recs and cardiology recs, CT surgery decided to take the
patient for AVR the next morning ([**2142-9-9**]).

# Aortic Valve Replacement: Patient with dehiscent aortic valve
in the right fibrous trigone. Patient was hemodynamicaly stable
in the CCU, but obviously he was clinically worsening and aortic
valve integrity was worsening on echo.  Patient on a heparin
drip for anticoagulation prior to the surgery (coumadin stopped
[**2142-9-6**])

# Pump: EF on TTE in [**2141-11-27**] (after AVR) was > 55% with normal
filling pressures PCWP < 12.  Patient with symptoms of heart
failure intermittently throughout admission that acutely
worsened with decreased hematocrit and aortic valve destruction.
 He was treated with Lasix, which he responded to well with less
shortness of breath and peripheral edema.  Afterload reduction
was aggressively pursued in this patient with metoprolol
titrated up during his stay.

# Anemia: Patient anemic throughout admission, most likely due
to anemia.  There was some concern for GI bleed, as patient was
guaiac positive, but CT aorta showed no aortoenteric fistula.
Metoprolol was continued to reduce shear stress.  He was
transfused 10 units of blood at the outside hospital, and 2
units prior to his surgery here.

# Suspected L foot embolic disease - Patient initially had pain
in left lower extremity with diminished pulses.  The feet were
warm and well-perfused.  MRA of the lower extremities showed
multiple occlusions but also significant collateral flow.
Clinically, his pain decreased throughout his stay and pulses
became louder on doppler.

# CORONARIES: Cardiac Cath [**3-17**] showed clean coronaries. Patient
did have a troponin leak of 0.37. This is likely secondary to
demand ischemia secondary to profound anemia.

# History of IVDU: Patient states he has not used IV drugs since
prior to his second surgery in [**2139**]. He is Hep C negative.  He
is maintained on suboxone as an outpatient.  His suboxone was
decreased on admission due to concerns about pain control after
his CT surgery.  The addiction team was consulted who managed
his suboxone weaning.

# RHYTHM: Patient remained in normal sinus rhythm throughout his
admission.  He was monitored with daily ECG's for signs of new
AV block.

Patient was FULL CODE throughout this admission.

Mr. [**Known lastname 57041**] [**Last Name (Titles) 1834**] a redo sternotomy, redo bental (25mm st.
[**Male First Name (un) **] mechanical aortic valve graft), hemi-arch replacement, and
left ventricular outflow tract reconstruction with pericardial
patch with Dr. [**First Name (STitle) **] on [**9-9**]. He tolerated the procedure well
and was transferred to the CVICU in stable condition on
levophed, milrinone, vasopressin and propofol drips.  His
antibiotics were continued per the infectious disease service.
He was weaned from his pressors and extubated.  Pain control
quickly became an issue so the acute pain service was consulted.
 His chest tubes and epicardial wires were removed.  Coumadin
and heparin were started for his mechanical aortic valve.  Dr.
[**First Name (STitle) 437**] of the heart failure service followed Mr. [**Known lastname 57047**] course
as he did pre-operatively.  He was transferred to the surgical
step down floor on post-operative day four. He was seen in
consultation by infectious disease for vegetation obtained
during OR  which was positive for pan sensitive enterococus. He
was treated with ampicillin 2 gms IV q4hrs and gentamycin 90mg
IV q24hrs for enterococcal endocarditis which he will continue
on until [**2142-10-21**].  The pain service was aslo consulted regarding
pain management- he was treated w/ MS contin and Morphine IR
successfully. He was being weaned from his MS contin and has
been on suboxone in the past and will discuss this with his PCP
upon return to home. His current dose of MS contin is 15mg tid
w/ 15 mg of IR morphine for breakthru.
 He was doing well until POD#11 when he had vague c/o "not
feeling well". An Echo was done revealing pericardial effusion
with tamponade physiology. Mr. [**Known lastname 57041**] was taken emergently back
to the OR and a moderate amount of clot was evacuated. See
operative note for details. Post operatively he was admitted to
the CVICU intubated and sedated. he was weaned and extubated on
POD#2. he was transferred to the step down unit on POD#3. He
continued to be followed by infectious disease and chronic pain
service. He was restarted on coumadin for mech AVR (goal
2.5-3.5)without heparin bridge d/t risk of bleeding. he was
folowed by daily echo to eval for recurrent pleural effusion-
all echo's were without recurrent effusion.
He was discharged to home on IV ampi and gent thru [**2142-10-21**] with
infectious disease follow up. He will be on 10mg of coumadin to
maintain goal INR 2.5-3.5.

Medications on Admission:
CURRENT MEDICATIONS: HOME
Carvedilol 25 mg [**Hospital1 **]
Lisinopril 10 mg Daily
Aspirin 81 mg Daily
Coumadin 10 mg Daily
Suboxone
.
Medications in OSH:
Ampicillin 2 grams IV q 4 hours
Gentamicin 70 mg IV q 12 hours
Vancomycin 1.25 mg
Ambien
Lasix 40 IV BID
Cefipime: 1 gram IV x 1
Ceftazidime IV 2 grams
Fentanyl
Versed
Morphine
Benedryl
Solumedrol 125 mg IV x 1
Vitamin K 10 mg IV (INR 6.6 on presentation)
.


Discharge Medications:
1. Outpatient [**Hospital1 **] Work
Needs CBC, Panel 7, LFTs, coags, gentamicin level drawn every
Monday and gent level and BUN/Cre every Friday with results sent
to the infectious disease clinic attn: infectious disease nurses
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*2*
4. Outpatient [**Hospital1 **] Work
INR will be drawn on Monday [**2142-10-5**] with results sent to the
coumadin clinic at the office of Dr. [**Last Name (STitle) 57048**] (cardiologist)
phone ([**2142**], fax ([**Telephone/Fax (1) 57049**].  Plan confirmed with [**Doctor First Name **]
on [**2142-9-27**].  INR goal for mechanical AVR is 2.5 to 3.5.
5. Gentamicin 40 mg/mL Solution Sig: Ninety (90) mg Injection
Q24H (every 24 hours): last dose on [**10-21**].
Disp:*19 doses* Refills:*0*
6. Ampicillin Sodium 2 gram Recon Soln Sig: Two (2) gms
Injection Q4H (every 4 hours) for 19 days: last dose 9/13.
Disp:*76 doses* Refills:*0*
7. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
Disp:*180 Capsule(s)* Refills:*0*
8. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q8H (every 8 hours).
Disp:*42 Tablet Sustained Release(s)* Refills:*0*
10. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for severe pain.
Disp:*40 Tablet(s)* Refills:*0*
11. Warfarin 5 mg Tablet Sig: Two (2) Tablet PO ONCE (Once) for
1 doses: Take as directed by the office of Dr. [**Last Name (STitle) 57048**].
Disp:*60 Tablet(s)* Refills:*0*
12. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
13. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QWED (every Wednesday).
Disp:*4 Patch Weekly(s)* Refills:*2*
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
Albony VNA

Discharge Diagnosis:
enterococal prosthetic valve endocarditis
CHF, chronic systolic heart failure
s/p redo(X4) Bentall procedure/repl. hemiarch aorta/ LVOT
reconstruct.
prior MSSA endocarditis
prior MRSA endocarditis
prior encephalomalacia ( infarct in past)
[**2137**] septic emboli to spleen, kidney, cerebrum)
prior IVDU
deafness one ear ( gentamicin ototoxicity)


Discharge Condition:
good


Discharge Instructions:
no lotions, creams, ointments, or powders on any incision
shower daily and pat incisions dry
call for fever greater than 100, redness, drainage, or weight
gain of 2 pounds in 2 days or 5 pounds in one week
no driving for one month AND off all narcotics
no lifting greater than 10 pounds for 10 weeks

Followup Instructions:
Please see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (PCP) ([**Telephone/Fax (1) 57050**] in [**2-9**] weeks.
Please see Dr. [**Last Name (STitle) 57048**] (cardiologist in NY) in [**3-13**] weeks.
Please see Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] (cardiologist in MA) in [**3-13**] weeks.
Please see Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] (Cardiac surgeon) in [**3-13**] weeks
[**Telephone/Fax (1) 170**]
Please see Dr. [**Last Name (STitle) **] (Infectious disease) in [**3-13**] weeks.
Needs CBC, Panel 7, LFTs, coags drawn every Monday and a BUN/Cre
every Friday with results sent to the infectious disease clinic
attn: infectious disease nurses
INR will be drawn on Monday [**2142-10-1**] with results sent to the
coumadin clinic at the office of Dr. [**Last Name (STitle) 57048**] (cardiologist)
phone ([**2142**], fax ([**Telephone/Fax (1) 57049**].  Plan confirmed with [**Doctor First Name **]
on [**2142-9-27**].  INR goal for mechanical AVR is 2.5 to 3.5.
If pain continues to be [**Name (NI) 2480**], can follow-up in pain
clinic.
Please obtain a audiology exam within 1-2 weeks.
Please call for all appts.


                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]

Completed by:[**2142-10-2**]
{'Infection and inflammatory reaction due to cardiac device, implant, and graft,Acute and subacute bacterial endocarditis,Streptococcal septicemia,Acute on chronic systolic heart failure,Acute kidney failure, unspecified,Other non-autoimmune hemolytic anemias,Ventricular fibrillation,Septic arterial embolism,Arterial embolism and thrombosis of lower extremity,Sepsis,Cardiac tamponade,Hemorrhage complicating a procedure,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Tobacco use disorder,Anxiety state, unspecified,Other specified forms of chronic ischemic heart disease'}


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

PRESENT ILLNESS: 28 yo male with h/o bicuspid valve with aortic valvuloplasty at
age 15, MSSA endocarditis in [**2137**] (age 24) s/p AVR with a
homograft, and subsequent endocarditis in [**2140**] with AVR with a
mechanical valve, and h/o IVDU; p/w prosthetic valve
enterococcal IE.

MEDICAL HISTORY: 1. Bicuspid Aortic Valve- s/p Aortic Valvuolplasty at age 15
2. MSSA Recurrent Aortic Valve Endocarditis, ([**2137**], [**2139**])
----[**12/2137**]: MSSA endocarditis: with a 6 week course of
nafcillin and ultimately [**Year (4 digits) 1834**] a Bentall procedure utilizing
homograft along with VSD closure and debridement of aortic root
abscess.
----[**3-/2140**]: MSSA? Endocarditis: Redo aortic valve replacement
with a size 27 mm Onyx mechanical valve and ascending aortic
interposition graft with a size 24 mm Dacron graft
3. History of Septic Emboli to Spleen, Kidney and Cerebrum;
hepatic pseudoaneurysm embolization in [**2137**]
4. Intravenous Drug Abuser; patient states last time used IVDs
was prior to his last surgery in [**2139**].
5. History encephalomalacia of the right parietal lobe from a
prior infarct, and minimal chronic microvascular ischemic
changes.
6. Chronic systolic heart failure

MEDICATION ON ADMISSION: CURRENT MEDICATIONS: HOME
Carvedilol 25 mg [**Hospital1 **]
Lisinopril 10 mg Daily
Aspirin 81 mg Daily
Coumadin 10 mg Daily
Suboxone
.
Medications in OSH:
Ampicillin 2 grams IV q 4 hours
Gentamicin 70 mg IV q 12 hours
Vancomycin 1.25 mg
Ambien
Lasix 40 IV BID
Cefipime: 1 gram IV x 1
Ceftazidime IV 2 grams
Fentanyl
Versed
Morphine
Benedryl
Solumedrol 125 mg IV x 1
Vitamin K 10 mg IV (INR 6.6 on presentation)
.

ALLERGIES: Dilaudid

PHYSICAL EXAM: 72"  90 kg
Blood pressure was 95/62 mm Hg while seated. Pulse was 70
beats/min and regular, respiratory rate was 26 breaths/min.
Generally the patient was well developed, well nourished and
well groomed. The patient was oriented to person, place and
time. The patient's mood and affect were appropriate.
.
There was no xanthalesma and conjunctiva were pink with no
pallor or cyanosis of the oral mucosa. There is a 2x2mm scleral
hemorrage in the L eye. The neck was supple with JVP at
clavicle. The carotid waveform was normal. There was no
thyromegaly. The were no chest wall deformities, scoliosis or
kyphosis. The respirations were not labored and there were no
use of accessory muscles. The lungs were clear to ascultation
bilaterally with normal breath sounds and no adventitial sounds
or rubs.
.
Palpation of the heart revealed the PMI to be located in the 5th
intercostal space, mid clavicular line. There were no thrills or
palpable S3 or S4. Mild lift was noted. The heart sounds
revealed a normal S1 and the S2 was normal. There were no rubs
or gallops. Harsh [**5-14**] crescendo/decresendo systolic murmur heard
best at the left sternal border on the clavicle; radiating to
carotids, apex, and back.
.
There was no hepatosplenomegaly or tenderness. The abdomen was
soft nontender and nondistended. The extremities had no pallor,
cyanosis, clubbing or edema. Inspection and/or palpation of skin
and subcutaneous tissue showed no stasis dermatitis, ulcers,
scars, or xanthomas.
.
Pulses:
Right: DP 2+ PT 2+
Left: DP 1+ PT 1+

FAMILY HISTORY: Patient adopted and does not know family history.

SOCIAL HISTORY: Quit tobacco just prior to admission h/o [**2-9**] ppd for 12 years.
Denies ETOH over the last year. He currently lives with his
parents. Several years of IVDU but denies since last AVR. 

### Response:
{'Infection and inflammatory reaction due to cardiac device, implant, and graft,Acute and subacute bacterial endocarditis,Streptococcal septicemia,Acute on chronic systolic heart failure,Acute kidney failure, unspecified,Other non-autoimmune hemolytic anemias,Ventricular fibrillation,Septic arterial embolism,Arterial embolism and thrombosis of lower extremity,Sepsis,Cardiac tamponade,Hemorrhage complicating a procedure,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Tobacco use disorder,Anxiety state, unspecified,Other specified forms of chronic ischemic heart disease'}
