CHIEF COMPLAINT: fever, chills

PRESENT ILLNESS: Mr. [**Known firstname 487**] [**Initial (NamePattern1) **]. [**Known lastname **] is a very nice 52 year-old gentleman with
history of bicuspid aortic valve and ascending aortic aneurysm
s/p mechanical [**Hospital3 **] AVR on coumadin, h/o CHB s/p PPM who
comes with malaise, HA and fever up to 102 with peripheral
vision loss. He underwent surgery succesfuly in [**1-21**], which was
complicated by recurrent pericardial effusion that was treated
with a pericardial window. He was discharged home on [**2105-2-21**]
and was doing well, able to play golf and purposely losing some
weight. Six days ago he started noticing fever up to 102,
chills, rigors, loss of apetite and night sweats. He almost had
no symptoms during the day. He went and saw his PCP 3 days ago
who did blood work and sent him home. His PCP labs included gluc
11, BUN 8, Creat 0.68, Na 136, K 4.1, Cl 102, CO2 26, Ca 8.8,
Prot 6.4, Alb 3.4, AP 87, AST 38, ALT 34, Bil 0.7.  UA negative
for UTI, but with mild proteinuria and keytones. He got blood
cultures drawn that came back positive 1/2 bottles (anaerobic)
with GPCs in chains and was called to go to the ER.
.
At [**Hospital **] Hospital his VS were stable. He received in Vancomycin 1
gm IV once morphine and zofran. WBC 9.7, HCT 25, PLT 191, no
bands. He was transfered to our ER for further work up.
.
In our ER his initial VS were T 103.1 F, BP 124/70 BPM, HR 90
BPM, RR 18 X', SpO2 96% on RA. His initial exam showed normal
JVP, clear lungs, no edema. He received gentamycin 120 mg IV,
tylenol PO at 6 AM, 8 mg of morphine IV, 4 mg of zofran and 5 mg
of IV Vit K. During his ED stay he reports loss of vision in the
left upper visual field in his left eye. Stroke service was
consulted. Repeat CT scan showed 15 mm lesion without any new
lesions. Minimal perihemorrhagic edema. Reconstruction is
pending to eval for mycotic aneurysm. Ophtalmology evaluated
patient and saw no abnormalities after dilation. The
differential includes TIA, compromised circulation to occipital
area, embolic event is also possible. He is admitted to the CCU
service. Her received 2 FFPs. His VS prior to transfer were VS:
HR 85, RR 12, BP 109/68, 96% 2L.
.
Of note, he denies any recent dental procedures, skin
infections, URI-symptoms, sick contacts, IVDU, changes in his
medications (other than stopping Toprol XL and ranitidine). No
recent travel.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: - Diabetes, - Dyslipidemia, -
Hypertension
2. CARDIAC HISTORY:
-CABG: None.
-PERCUTANEOUS CORONARY INTERVENTIONS: None.
-PACING/ICD: PPM, 2 leads in place.

MEDICATION ON ADMISSION: Aspirin 81 mg Daily
Colace 100 mg PO BID
Coumadin 10 mg 3 days per week and 11 mg 4 days per week
Simvastain 40 mg, PCP switching to [**Name9 (PRE) **]

ALLERGIES: Penicillins

PHYSICAL EXAM: VITAL SIGNS - Temp 97.8 F, BP 123/67 mmHg, HR 77 BPM, RR 26 X',
O2-sat 98% 2 L NC

FAMILY HISTORY: No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory. Father had
first MI in his 60s and died of emphysema. Mother died of a
blood clot (unknown location).

SOCIAL HISTORY: He lives with his wife, daughter, son and son in law in [**Name (NI) 1727**].
He works in a shipyard, but denies any exposure to asbestos. He
quit smoking 2 years ago and has history of 30-40 pack-year. He
denies any current or past alcohol intake or illegal substance
use. He plays golf as excercise.
Acute and subacute bacterial endocarditis,Septic pulmonary embolism,Cerebral embolism with cerebral infarction,Atrioventricular block, complete,Congenital insufficiency of aortic valve,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group B,Other and unspecified hyperlipidemia,Anemia, unspecified,Pain in limb,Cardiac pacemaker in situ,Personal history of venous thrombosis and embolism,Heart valve replaced by other means,Aortocoronary bypass status,Long-term (current) use of anticoagulants
Ac/subac bact endocard,Septic pulmonary embolsm,Crbl emblsm w infrct,Atriovent block complete,Cong aorta valv insuffic,Streptococcus group b,Hyperlipidemia NEC/NOS,Anemia NOS,Pain in limb,Status cardiac pacemaker,Hx-ven thrombosis/embols,Heart valve replac NEC,Aortocoronary bypass,Long-term use anticoagul
Admission Date:  [**2105-7-22**]              Discharge Date:   [**2105-8-9**]

Date of Birth:  [**2052-9-21**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins

Attending:[**First Name3 (LF) 106**]
Chief Complaint:
fever, chills

Major Surgical or Invasive Procedure:
Pacemaker explant
Insertion of temporary external pacemaker
PICC line placement R


History of Present Illness:
Mr. [**Known firstname 487**] [**Initial (NamePattern1) **]. [**Known lastname **] is a very nice 52 year-old gentleman with
history of bicuspid aortic valve and ascending aortic aneurysm
s/p mechanical [**Hospital3 **] AVR on coumadin, h/o CHB s/p PPM who
comes with malaise, HA and fever up to 102 with peripheral
vision loss. He underwent surgery succesfuly in [**1-21**], which was
complicated by recurrent pericardial effusion that was treated
with a pericardial window. He was discharged home on [**2105-2-21**]
and was doing well, able to play golf and purposely losing some
weight. Six days ago he started noticing fever up to 102,
chills, rigors, loss of apetite and night sweats. He almost had
no symptoms during the day. He went and saw his PCP 3 days ago
who did blood work and sent him home. His PCP labs included gluc
11, BUN 8, Creat 0.68, Na 136, K 4.1, Cl 102, CO2 26, Ca 8.8,
Prot 6.4, Alb 3.4, AP 87, AST 38, ALT 34, Bil 0.7.  UA negative
for UTI, but with mild proteinuria and keytones. He got blood
cultures drawn that came back positive 1/2 bottles (anaerobic)
with GPCs in chains and was called to go to the ER.
.
At [**Hospital **] Hospital his VS were stable. He received in Vancomycin 1
gm IV once morphine and zofran. WBC 9.7, HCT 25, PLT 191, no
bands. He was transfered to our ER for further work up.
.
In our ER his initial VS were T 103.1 F, BP 124/70 BPM, HR 90
BPM, RR 18 X', SpO2 96% on RA. His initial exam showed normal
JVP, clear lungs, no edema. He received gentamycin 120 mg IV,
tylenol PO at 6 AM, 8 mg of morphine IV, 4 mg of zofran and 5 mg
of IV Vit K. During his ED stay he reports loss of vision in the
left upper visual field in his left eye. Stroke service was
consulted. Repeat CT scan showed 15 mm lesion without any new
lesions. Minimal perihemorrhagic edema. Reconstruction is
pending to eval for mycotic aneurysm. Ophtalmology evaluated
patient and saw no abnormalities after dilation. The
differential includes TIA, compromised circulation to occipital
area, embolic event is also possible. He is admitted to the CCU
service. Her received 2 FFPs. His VS prior to transfer were VS:
HR 85, RR 12, BP 109/68, 96% 2L.
.
Of note, he denies any recent dental procedures, skin
infections, URI-symptoms, sick contacts, IVDU, changes in his
medications (other than stopping Toprol XL and ranitidine). No
recent travel.

<br>
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
<br>
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.

Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, - Dyslipidemia, -
Hypertension
2. CARDIAC HISTORY:
-CABG: None.
-PERCUTANEOUS CORONARY INTERVENTIONS: None.
-PACING/ICD: PPM, 2 leads in place.

<br><b>PAST MEDICAL HISTORY: </b>
Complete Heart Block(PPM)
Postop DVT in LUE [**2104-3-12**] following lead extraction
Hyperlipidemia
s/p Dual chamber pacemaker placement in [**2087**]
s/p replacement of PM generator [**2096**]
s/p Lead extraction and reimplantation of PPM [**3-/2104**]
Hernia repair as child
s/p AVR(mechcanical)Ascending Aortic arch  replacment on [**2105-2-3**]
with 25-mm St. [**Hospital 923**] Medical Regent mechanical valve secondarily
to bicuspid aortic valve diagnosed in 7th grade and progressing
ascending aortic aneurysm of  5.4cm at time of surgery. Surgery
was complicated by tamponade and required Subxiphoid pericardial
window on [**2105-2-18**].
s/p CABG LIMA-LAD in [**2105-2-3**]
h/o DVT

Social History:
He lives with his wife, daughter, son and son in law in [**Name (NI) 1727**].
He works in a shipyard, but denies any exposure to asbestos. He
quit smoking 2 years ago and has history of 30-40 pack-year. He
denies any current or past alcohol intake or illegal substance
use. He plays golf as excercise.

Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory. Father had
first MI in his 60s and died of emphysema. Mother died of a
blood clot (unknown location).

Physical Exam:
VITAL SIGNS - Temp 97.8 F, BP 123/67 mmHg, HR 77 BPM, RR 26 X',
O2-sat 98% 2 L NC


GENERAL - well-appearing man in NAD, Oriented x3, comfortable,
Mood, affect appropriate.
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear,
Conjunctiva were pink, no pallor or cyanosis of the oral mucosa.
No xanthalesma.
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI located in 5th intercostal space, midclavicular
line. RRR, normal S1, mechanical S2. Mild SEM [**1-17**] RUSB radiating
towards both carotids. No r/g. No thrills, lifts. No S3 or S4.
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding. Abd aorta not enlarged by palpation. No
abdominial bruits.
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs), No c/c/e. No femoral bruits.
SKIN - no rashes or lesions. No stasis dermatitis, ulcers,
scars, or xanthomas. No osler nodes or signs of embili.
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-15**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, gait not evaluated, normal
eye exam on confrontation and 20/20 bilateraly.


Pertinent Results:
[**2105-7-22**] 10:38AM BLOOD WBC-7.6 RBC-3.63* Hgb-10.1* Hct-29.9*
MCV-82 MCH-27.7 MCHC-33.7 RDW-15.0 Plt Ct-166
[**2105-7-23**] 04:30AM BLOOD WBC-9.1 RBC-3.62* Hgb-9.9* Hct-30.7*
MCV-85 MCH-27.2 MCHC-32.1 RDW-14.5 Plt Ct-173
[**2105-7-24**] 07:00AM BLOOD WBC-8.4 RBC-4.17* Hgb-11.6* Hct-35.0*
MCV-84 MCH-27.8 MCHC-33.1 RDW-15.0 Plt Ct-251
[**2105-8-4**] 06:00AM BLOOD WBC-12.5* RBC-3.43* Hgb-9.4* Hct-28.3*
MCV-83 MCH-27.4 MCHC-33.2 RDW-14.7 Plt Ct-374
[**2105-8-5**] 06:02AM BLOOD WBC-11.1* RBC-3.32* Hgb-9.3* Hct-27.0*
MCV-81* MCH-28.2 MCHC-34.6 RDW-14.3 Plt Ct-356
[**2105-7-22**] 06:00AM BLOOD PT-46.6* PTT-38.9* INR(PT)-5.0*
[**2105-7-22**] 10:38AM BLOOD PT-24.6* PTT-33.5 INR(PT)-2.4*
[**2105-7-22**] 09:07PM BLOOD PT-14.9* PTT-27.3 INR(PT)-1.3*
[**2105-7-22**] 10:38AM BLOOD ESR-45*
[**2105-7-22**] 10:38AM BLOOD Ret Aut-0.9*
[**2105-7-22**] 06:00AM BLOOD Glucose-109* UreaN-8 Creat-0.7 Na-136
K-4.4 Cl-102 HCO3-23 AnGap-15
[**2105-7-23**] 04:30AM BLOOD Glucose-113* UreaN-6 Creat-0.7 Na-133
K-4.2 Cl-100 HCO3-25 AnGap-12
[**2105-7-24**] 07:00AM BLOOD Glucose-101* UreaN-6 Creat-0.6 Na-136
K-4.3 Cl-97 HCO3-31 AnGap-12
[**2105-8-4**] 06:00AM BLOOD Glucose-113* UreaN-9 Creat-1.0 Na-129*
K-4.4 Cl-96 HCO3-27 AnGap-10
[**2105-8-5**] 06:02AM BLOOD Glucose-121* UreaN-10 Creat-1.1 Na-131*
K-4.1 Cl-96 HCO3-28 AnGap-11
[**2105-7-22**] 10:38AM BLOOD ALT-29 AST-36 LD(LDH)-364* AlkPhos-56
TotBili-0.4
[**2105-7-27**] 06:30AM BLOOD ALT-94* AST-60* LD(LDH)-406* AlkPhos-73
TotBili-0.3
[**2105-7-28**] 06:35AM BLOOD ALT-94* AST-57* LD(LDH)-414* AlkPhos-72
TotBili-0.3
[**2105-8-5**] 06:02AM BLOOD ALT-33 AST-18 LD(LDH)-329* CK(CPK)-28*
AlkPhos-70 TotBili-0.3
[**2105-7-22**] 06:00AM BLOOD cTropnT-<0.01
[**2105-7-22**] 10:38AM BLOOD Albumin-3.2* Calcium-7.9* Phos-2.6*
Mg-1.7
[**2105-7-23**] 04:30AM BLOOD Calcium-8.0* Phos-2.0* Mg-1.9
[**2105-8-5**] 06:02AM BLOOD Albumin-3.0* Calcium-8.8 Phos-4.5 Mg-2.1
[**2105-7-24**] 09:20AM BLOOD Iron-22*
[**2105-7-24**] 09:20AM BLOOD calTIBC-225* VitB12-1376* Folate-14.9
Ferritn-388 TRF-173*
[**2105-7-22**] 10:38AM BLOOD RheuFac-13 CRP-215.5*

[**2-11**] blood cultures drawn on the day of admission showed the same
culture results.
Blood Culture, Routine (Final [**2105-7-24**]):
      BETA STREPTOCOCCUS GROUP B.    FINAL SENSITIVITIES.
         This isolate is presumed to be resistant to clindamycin
based on
         the detection of inducible resistance .
         Sensitivity testing performed by Sensititre.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             BETA STREPTOCOCCUS GROUP B
                             |
CLINDAMYCIN-----------       R
ERYTHROMYCIN----------   =>4 R
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------   <=1 S

   Anaerobic Bottle Gram Stain (Final [**2105-7-22**]):
      GRAM POSITIVE COCCI IN CHAINS.
      REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] AT 1715 ON [**2105-7-22**].

   Aerobic Bottle Gram Stain (Final [**2105-7-23**]):
      GRAM POSITIVE COCCI IN CHAINS.

EKG [**7-22**]: Sinus rhythm with atrial sensed and ventricular paced
rhythm. Since the previous tracing of [**2105-2-18**] there is no
significant change.

CTA Head: IMPRESSION:
1. Stable 15 mm right frontal parenchymal hematoma with slight
increase of
peripheral zone of edema; a small underlying mass cannot be
entirely excluded.

2. No CT angiographic "spot sign" to suggest impending
enlargement of
hemorrhage.
3. No evidence of cerebral venous thrombosis.
4. No new focus of hemorrhage.
5. Patent anterior and posterior circulation vasculature without
evidence of
vascular malformation or aneurysm larger than 2 mm.

TEE [**7-23**]: No spontaneous echo contrast or thrombus is seen in
the body of the left atrium/left atrial appendage or the body of
the right atrium/right atrial appendage. No atrial septal defect
is seen by 2D or color Doppler. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There are simple
atheroma in the descending thoracic aorta. A bileaflet aortic
valve prosthesis is present. No masses or vegetations are seen
on the aortic valve. Trace aortic regurgitation is seen. [The
amount of regurgitation present is normal for this prosthetic
aortic valve.] The mitral valve leaflets are mildly thickened.
Trivial mitral regurgitation is seen. No vegetation/mass is seen
on the pulmonic valve. There is a trivial/physiologic
pericardial effusion.

IMPRESSION: No vegetations seen on mitral valve, tricuspid
valve, pulmonic valve. There is small (3mm) relatively fixed
echodensisty adjacent to the aortic root side of the mechanical
aortic valve near the non-coronary cusp which was present in the
immediate post operative TEE on [**2105-2-3**] and is likely a
suture.
Compared with the prior TEE study (images reviewed) of [**2105-2-3**]
there are no significant changes.
.
TEE [**7-30**]: The left atrium is markedly dilated. The left atrium
is elongated. No spontaneous echo contrast is seen in the body
of the left atrium or left atrial appendage.There is moderate
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. There is inferolateral and inferior wall
hypokinesis but overall left ventricular systolic function is
normal (LVEF>55%).
Right ventricular systolic function is normal with good free
wall contractility.The aortic root is moderately dilated at the
sinus level. A mechanical aortic valve prosthesis is present.
The valve appears to be well-seated without perivalvular leaks,
however, the individual prosthetic leaflets cannot be adequately
assessed due to artifact. There is mild aortic valve stenosis
(valve area 1.2-1.9cm2). Peak/mean gradients are 64/36 mmHg.
Mild-moderate aortic regurgitation is seen.
There is a mobile 7mm x 6 mm mass on the upstream surface of the
aortic valve, most likely on the right cusp. This is also the
area which shows the AI. It is consistent with a vegetation.
The mitral valve leaflets are mildly thickened. No mass or
vegetation is seen on the mitral valve.
Trivial mitral regurgitation is seen.
There is no pericardial effusion.
.
TTE [**7-29**]: The left atrium is elongated. There is mild symmetric
left ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Tissue Doppler
imaging suggests a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic root is moderately dilated at the
sinus level. A bileaflet aortic valve prosthesis is present. The
aortic valve prosthesis appears well seated, with normal disc
motion and transvalvular gradients. Trace aortic regurgitation
is seen. [The amount of regurgitation present is normal for this
prosthetic aortic valve.] The mitral valve appears structurally
normal with trivial mitral regurgitation. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion. Compared with the prior focused study (images
reviewed) of [**2105-2-20**], the pericardial effusion has resolved.
The absence of endocarditis on a transthoracic echo does not
exclude the diagnosis if clinically suggested. If clinically
suggested, a TEE may be more sensitive for identifying
vegetations.
.
Cerbral angiography: IMPRESSION:
No evidence of aneurysm, arteriovenous malformation, or active
extravasation. In particular, no abnormality identified in the
region of the right frontal parenchymal hemorrhage.
.
LENI [**8-3**]: [**Doctor Last Name **]-scale and Doppler son[**Name (NI) **] of bilateral common
femoral, superficial femoral, and popliteal veins were
performed. There is appropriate compressibility, flow, and
augmentation.
IMPRESSION: No evidence of DVT.
.
PICC: IMPRESSION: Uncomplicated ultrasound and fluoroscopically
guided double lumen PICC line placement via the right brachial
venous approach. Final internal length is 37 cm, with the tip
positioned in SVC. The line is ready to use.
.
LLE U/S: STUDY: Left lower extremity soft tissue ultrasound.
FINDINGS: Multiple grayscale images of the left groin, left
thigh and left
calf demonstrate no fluid collection.
IMPRESSION: No evidence for fluid collection.
.
CXR [**8-5**]: Lung volumes are normal. Lungs are clear without focal
consolidations. Heart size is normal. Hilar and mediastinal
silhouettes appear stable. No pulmonary edema, pleural effusions
or pneumothoraces are identified.  Pacemaker lead projects over
right ventricle. Two radiopaque densities are seen projecting
over right ventricle, which may represent fragmented leads, and
are unchanged since [**2105-1-23**] study. Right PICC line tip
is obscured by pacemaker lead, it is visible at upper to mid
SVC.
IMPRESSION: No acute cardiopulmonary process.
.
CT L-Spine
1. No evidence of epidural or paraspinal abscess in the
lumbosacral spine.

2. Mild degenerative changes of the lumbar spine, worse at L4-L5
level, with
discogenic disease and osteophytes causing thecal sac indentment
and neural
foraminal narrowing bilaterally.

ATTENDING NOTE: Although CT without contrast is not sensitive to
detect
epidural disease, no obvious deformity of thecal sac seen to
suggest abscess.
Bilateral moderate foraminal narrowing seen at L4-5.


Brief Hospital Course:
Mr. [**Known firstname 487**] [**Initial (NamePattern1) **]. [**Known lastname **] is a very nice 52 year-old gentleman with
history of bicuspid aortic valve and ascending aortic aneurysm
s/p mechanical [**Hospital3 **] AVR on coumadin, h/o CHB s/p PPM who
comes with malaise, HA and fever up to 102 with peripheral
vision loss and positive blood cultures for GPCs.

# Endocarditis: The patient came from an outside hospital with
positive blood cultures.  He was immediately started on
vancomycin and gentamicin.  The vancomycin was then switched to
ceftriaxone and he was continued on the gent.  He had an initial
TEE that showed no evidence of a thrombus or vegetation in the
[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] leads.  CT surgery did not want to intervene at this time
as he was stable.  His first 3 blood cultures all returned
positive for group B streptococcus that was sensitive to
ceftriaxone.  The patient had a CT head at an OSH that showed a
frontal lobe hemorrhage, this was followed by CT and showed
small interval change after the first.  A cerebral angiogram was
also obtained per neurology which showed no evidence of mycotic
aneurysm, or other irregularities.  Neurology recommended
re-imaging only if there was change on physical exam, which
there was not.  The patient had repeated fevers spikes so a TTE
was done which showed no evidence of vegetation.  A repeat TEE
was done which showed a 7mm x 6 mm vegetation on the aortic
valve.  CT surgery was reconsulted and again deferred
intervention until he had a longer treatment with abx.  The
patient had his pacer and leads explanted with EP and a
temporary external pacemaker was placed.  CT A/P was obtained
which showed no focus of infection in the abdomen.  He developed
intermittent back and left leg pain which ID was concerned for
abscess/phlegmon.  A CT L-spine showed no evidence of abscess,
discitis, or osteomyelitis.  U/S of the left thigh and DVT
studies were obtained which showed no evidence of fluid
collection or DVT.  It was thought this pain was MSK and was
managed with pain control and hot packs.  The patient had a PICC
line inserted under IR with no complications.  His gentamicin
was stopped in house after a 2 week course and he was to
continue ceftriaxone for a total of 6 weeks.  Follow-up was
scheduled with Dr. [**Last Name (STitle) **] on [**8-27**].

# Embolic Stroke - The patient had a head CT at an OSH that
showed a frontal lobe hemorrhage.  The patient's coumadin was
held and he had a repeat CT head and CTA which showed a small
interval increase in hemorrhage from previous.  A cerebral
angiogram showed no irregularities as above. Neurology
recommendations were to hold his coumadin for 1 week and then
start a heparin drip to bridge to a therapeutic INR.  He was
also started on aspirin 81mg daily. INR therapeutic at 2.3 on
Coumadin 12mg daily on [**8-9**]. Pt discharged.
.
#  Follow up: Pt requires CT abdomen for evaluation of abscesses
[**1-13**] septic emboli from endocarditis as outpatient.
Cardiology Device Clinic at [**Hospital **] Hospital for evaluation of
device within 1 week following discharge.
ID f/u per appts.
INR checks with f/u with PCP, [**Name10 (NameIs) **] home INR machine and titrate
medication based on PCP [**Name Initial (PRE) 2742**].
Cardiology f/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] per appt.
CT surgery f/u [**Doctor Last Name **] per appt.

Medications on Admission:
Aspirin 81 mg Daily
Colace 100 mg PO BID
Coumadin 10 mg 3 days per week and 11 mg 4 days per week
Simvastain 40 mg, PCP switching to [**Name9 (PRE) **]


Discharge Medications:
1. Ceftriaxone 2 gram Recon Soln Sig: Two (2) gram Intravenous
every twenty-four(24) hours for 27 days.
Disp:*qs 27 doses* Refills:*0*
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
5. Warfarin 10 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*2*
6. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.


Discharge Disposition:
Home With Service

Facility:
[**Hospital6 486**] of Southern [**State 1727**]

Discharge Diagnosis:
Endocarditis - AV vegetation


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


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

It was a pleasure taking care of you during your
hospitalization. You were admitted for infection of your aortic
valve and blood stream. You were started on antibiotics to treat
the infection and it was decided by the cardiology and
electrophysiology teams to remove your pacemaker as well since
it was a potential focus of infection. A temporary pacemaker was
placed in your neck until you finish your course of antibiotics
and can have a new pacemaker replaced. You were also started on
blood thinning medications called warfarin and IV heparin. You
became therapeutic on wafarin on [**8-9**].
Dr. [**Last Name (STitle) **] advised you to go rehab with your temporary
pacemaker until surgical replacement of your pacer could occur
after you finished the course of IV antibiotics. The reason for
this is your heart rhythm is pacer dependent and if your pacer
is disrupted, it could result in lifethreatening consequences.
You declined discharge to long-term acute care and stated
preference to be discharged to home.
.
We recommend that you get an abdominal CT scan to evaluate for
possible abscess formation as an outpatient. Please schedule
this through your PCP [**Name Initial (PRE) 3726**].
.
The following changes were made to your medications:
STARTED CeftriaXONE 2 gm IV Q24H Day 1 [**2105-7-23**]
INCREASED Coumadin 12mg daily
.
Please follow up with your physicians at the appts states below:

Followup Instructions:
Department: CARDIAC SURGERY
When: THURSDAY [**2105-8-27**] at 1:45 PM
With: [**Name6 (MD) **] [**Name8 (MD) 6144**], MD [**Telephone/Fax (1) 170**]
Building: LM [**Hospital Unit Name **] [**Location (un) 551**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: CARDIAC SERVICES
When: TUESDAY [**2105-9-22**] at 3:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
.
Dr. [**Last Name (STitle) **] wants pt to see device clinic 2 weeks post op
according to [**Doctor First Name **]( Dr.[**Initials (NamePattern4) 1565**] [**Last Name (NamePattern4) **]) when she spoke to
him.

Department: INFECTIOUS DISEASE
When: TUESDAY [**2105-8-25**] at 9:00 AM
With: [**Name6 (MD) 9462**] FLASH, MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: INFECTIOUS DISEASE
When: TUESDAY [**2105-9-8**] at 10:30 AM
With: [**Name6 (MD) 9462**] FLASH, MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage
.
Please follow up with your Cardiology Device Clini At [**Hospital **]
Hospital, call for appointment within 1 week of discharge. Call
for appt: [**Telephone/Fax (1) 83782**]
.
INR checks on your warfarin medication: please check levels
using your home INR machine. Follow up with your PCP who will
titrate your medication appropriately.
{'Acute and subacute bacterial endocarditis,Septic pulmonary embolism,Cerebral embolism with cerebral infarction,Atrioventricular block, complete,Congenital insufficiency of aortic valve,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group B,Other and unspecified hyperlipidemia,Anemia, unspecified,Pain in limb,Cardiac pacemaker in situ,Personal history of venous thrombosis and embolism,Heart valve replaced by other means,Aortocoronary bypass status,Long-term (current) use of anticoagulants'}


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, chills

PRESENT ILLNESS: Mr. [**Known firstname 487**] [**Initial (NamePattern1) **]. [**Known lastname **] is a very nice 52 year-old gentleman with
history of bicuspid aortic valve and ascending aortic aneurysm
s/p mechanical [**Hospital3 **] AVR on coumadin, h/o CHB s/p PPM who
comes with malaise, HA and fever up to 102 with peripheral
vision loss. He underwent surgery succesfuly in [**1-21**], which was
complicated by recurrent pericardial effusion that was treated
with a pericardial window. He was discharged home on [**2105-2-21**]
and was doing well, able to play golf and purposely losing some
weight. Six days ago he started noticing fever up to 102,
chills, rigors, loss of apetite and night sweats. He almost had
no symptoms during the day. He went and saw his PCP 3 days ago
who did blood work and sent him home. His PCP labs included gluc
11, BUN 8, Creat 0.68, Na 136, K 4.1, Cl 102, CO2 26, Ca 8.8,
Prot 6.4, Alb 3.4, AP 87, AST 38, ALT 34, Bil 0.7.  UA negative
for UTI, but with mild proteinuria and keytones. He got blood
cultures drawn that came back positive 1/2 bottles (anaerobic)
with GPCs in chains and was called to go to the ER.
.
At [**Hospital **] Hospital his VS were stable. He received in Vancomycin 1
gm IV once morphine and zofran. WBC 9.7, HCT 25, PLT 191, no
bands. He was transfered to our ER for further work up.
.
In our ER his initial VS were T 103.1 F, BP 124/70 BPM, HR 90
BPM, RR 18 X', SpO2 96% on RA. His initial exam showed normal
JVP, clear lungs, no edema. He received gentamycin 120 mg IV,
tylenol PO at 6 AM, 8 mg of morphine IV, 4 mg of zofran and 5 mg
of IV Vit K. During his ED stay he reports loss of vision in the
left upper visual field in his left eye. Stroke service was
consulted. Repeat CT scan showed 15 mm lesion without any new
lesions. Minimal perihemorrhagic edema. Reconstruction is
pending to eval for mycotic aneurysm. Ophtalmology evaluated
patient and saw no abnormalities after dilation. The
differential includes TIA, compromised circulation to occipital
area, embolic event is also possible. He is admitted to the CCU
service. Her received 2 FFPs. His VS prior to transfer were VS:
HR 85, RR 12, BP 109/68, 96% 2L.
.
Of note, he denies any recent dental procedures, skin
infections, URI-symptoms, sick contacts, IVDU, changes in his
medications (other than stopping Toprol XL and ranitidine). No
recent travel.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: - Diabetes, - Dyslipidemia, -
Hypertension
2. CARDIAC HISTORY:
-CABG: None.
-PERCUTANEOUS CORONARY INTERVENTIONS: None.
-PACING/ICD: PPM, 2 leads in place.

MEDICATION ON ADMISSION: Aspirin 81 mg Daily
Colace 100 mg PO BID
Coumadin 10 mg 3 days per week and 11 mg 4 days per week
Simvastain 40 mg, PCP switching to [**Name9 (PRE) **]

ALLERGIES: Penicillins

PHYSICAL EXAM: VITAL SIGNS - Temp 97.8 F, BP 123/67 mmHg, HR 77 BPM, RR 26 X',
O2-sat 98% 2 L NC

FAMILY HISTORY: No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory. Father had
first MI in his 60s and died of emphysema. Mother died of a
blood clot (unknown location).

SOCIAL HISTORY: He lives with his wife, daughter, son and son in law in [**Name (NI) 1727**].
He works in a shipyard, but denies any exposure to asbestos. He
quit smoking 2 years ago and has history of 30-40 pack-year. He
denies any current or past alcohol intake or illegal substance
use. He plays golf as excercise. 

### Response:
{'Acute and subacute bacterial endocarditis,Septic pulmonary embolism,Cerebral embolism with cerebral infarction,Atrioventricular block, complete,Congenital insufficiency of aortic valve,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group B,Other and unspecified hyperlipidemia,Anemia, unspecified,Pain in limb,Cardiac pacemaker in situ,Personal history of venous thrombosis and embolism,Heart valve replaced by other means,Aortocoronary bypass status,Long-term (current) use of anticoagulants'}
