CHIEF COMPLAINT: Transfer from OSH for management of endocarditis.

PRESENT ILLNESS: Mr. [**Known lastname 65453**] is a 22 year old male with a PMH significant for WPW
and bicuspid aortic valve. He has a history of cardiac arrest
and is status post ablation at age 17. He is an intravenous drug
abuser. He presented to OSH yesterday for bilateral lower
extremity pain and rash. The pain started about 2 weeks prior to
admission, is in his hamstrings, calves, and feet. Pain was so
severe he was unable to stand on his feet. Described as "achy"
quality. No back pain. No numbness, tingling, or weakness. Was
sent home with Percocets and Amoxicillin. Called back to OSH
today for [**4-9**] blood cultures growing GPC in pairs & chains. An
echocardiogram showed a bicuspid aortic valve with large
vegetation. He was subsequently started on Ceftriaxone and
Vancomycin, and transferred to the [**Hospital1 18**] further management and
evaluation. On admission, he denied SOB, CP, lightheadedness,
DOE, PND, and orthopnea. He reports loss of appetite, 20 lb
weight loss and night sweats over several weeks prior to
admission

MEDICAL HISTORY: Aortic Valve Endocarditis, Aortic Valve Insufficiency, Bicsupid
Aortic Valve, History of IVDA, Left forearm Abscess, WPW -
history of cardiac arrest and status post ablation at age 17,
Anemia

MEDICATION ON ADMISSION: Percocet, Amoxicillin

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS - T 97.9, BP 124/59, HR 51, RR 18, O2 sat 100% RA
gen - well-appearing, NAD
HEENT - PERRL, EOMI, OP clr, MM dry
CV - RRR, 2/6 systolic RSB 2ICS; no JVD
chest - CTAB
abd - NABS, soft, NT
skin -  no splinter hemorrhages, no Osler or [**Last Name (un) 1003**] lesions
ext - no edema
neuro - CN II-XII intact, strength 5/5 throughout, [**Last Name (un) 36**] grossly
intact to lt touch

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Last IVDU was 3.5 months ago. Denies ETOH. Admits to tobacco,
approximately [**1-8**] pack per day. Lives with his parents.
Acute and subacute bacterial endocarditis,Streptococcal septicemia,Congenital insufficiency of aortic valve,Arterial embolism and thrombosis of lower extremity,Phlebitis and thrombophlebitis of deep veins of lower extremities, other,Infective myositis,Anomalous atrioventricular excitation,Unspecified viral hepatitis C without hepatic coma,Opioid type dependence, unspecified,Severe sepsis,Cerebral embolism without mention of cerebral infarction,Tobacco use disorder,Dental caries, unspecified,Pain in limb
Ac/subac bact endocard,Streptococcal septicemia,Cong aorta valv insuffic,Lower extremity embolism,Deep phlebitis-leg NEC,Infective myositis,Anomalous av excitation,Hpt C w/o hepat coma NOS,Opioid dependence-unspec,Severe sepsis,Crbl emblsm wo infrct,Tobacco use disorder,Dental caries NOS,Pain in limb
Admission Date:  [**2171-1-10**]              Discharge Date:   [**2171-3-12**]

Date of Birth:  [**2148-1-28**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Transfer from OSH for management of endocarditis.

Major Surgical or Invasive Procedure:
[**2171-2-11**] Aortic Valve Replacement utilizing a 23 millimeter OnX
ConformX mechanical valve
[**2171-1-28**] Placement of PICC Line
[**2171-1-14**], [**2171-1-18**] Transesophogeal Echocardiogram


History of Present Illness:
Mr. [**Known lastname 65453**] is a 22 year old male with a PMH significant for WPW
and bicuspid aortic valve. He has a history of cardiac arrest
and is status post ablation at age 17. He is an intravenous drug
abuser. He presented to OSH yesterday for bilateral lower
extremity pain and rash. The pain started about 2 weeks prior to
admission, is in his hamstrings, calves, and feet. Pain was so
severe he was unable to stand on his feet. Described as "achy"
quality. No back pain. No numbness, tingling, or weakness. Was
sent home with Percocets and Amoxicillin. Called back to OSH
today for [**4-9**] blood cultures growing GPC in pairs & chains. An
echocardiogram showed a bicuspid aortic valve with large
vegetation. He was subsequently started on Ceftriaxone and
Vancomycin, and transferred to the [**Hospital1 18**] further management and
evaluation. On admission, he denied SOB, CP, lightheadedness,
DOE, PND, and orthopnea. He reports loss of appetite, 20 lb
weight loss and night sweats over several weeks prior to
admission

Past Medical History:
Aortic Valve Endocarditis, Aortic Valve Insufficiency, Bicsupid
Aortic Valve, History of IVDA, Left forearm Abscess, WPW -
history of cardiac arrest and status post ablation at age 17,
Anemia


Social History:
Last IVDU was 3.5 months ago. Denies ETOH. Admits to tobacco,
approximately [**1-8**] pack per day. Lives with his parents.

Family History:
Non-contributory

Physical Exam:
VS - T 97.9, BP 124/59, HR 51, RR 18, O2 sat 100% RA
gen - well-appearing, NAD
HEENT - PERRL, EOMI, OP clr, MM dry
CV - RRR, 2/6 systolic RSB 2ICS; no JVD
chest - CTAB
abd - NABS, soft, NT
skin -  no splinter hemorrhages, no Osler or [**Last Name (un) 1003**] lesions
ext - no edema
neuro - CN II-XII intact, strength 5/5 throughout, [**Last Name (un) 36**] grossly
intact to lt touch


Pertinent Results:
[**2171-3-6**] 02:46PM BLOOD WBC-7.5 RBC-3.09* Hgb-9.0* Hct-25.7*
MCV-83 MCH-29.1 MCHC-34.9 RDW-13.9 Plt Ct-408
[**2171-2-11**] 01:56PM BLOOD Fibrino-162#
[**2171-3-5**] 06:45AM BLOOD ESR-43*
[**2171-3-5**] 06:45AM BLOOD ESR-43*
[**2171-3-3**] 09:20AM BLOOD UreaN-10 Creat-1.4* Na-140 K-4.6 Cl-104
HCO3-27 AnGap-14
[**2171-3-1**] 08:00AM BLOOD ALT-14 AST-16 LD(LDH)-214 AlkPhos-92
Amylase-28 TotBili-0.3
[**2171-2-27**] 06:30AM BLOOD VitB12-927* Folate-5.6
[**2171-2-27**] 06:30AM BLOOD TSH-2.7
[**2171-1-16**] 07:00AM BLOOD HIV Ab-NEGATIVE

[**2171-1-16**] 07:00AM
HEPATITIS C VIRUS RNA BY PCR, QUALITATIVE
  Test                          Result              Reference
Range/Units
HCV RNA, QUAL, PCR            NOT DETECTED

REFERENCE RANGE:  NOT DETECTED


THE DETECTION OF HEPATITIS C VIRAL RNA IS BY
REVERSE TRANSCRIPTION OF GENOMIC RNA FOLLOWED
BY PCR AMPLIFICATION.

THIS TEST WAS PERFORMED USING THE COBAS AMPLICOR
(TM) HEPATITIS C VIRUS TEST, VERSION 2.0 ([**Doctor Last Name 8721**]
DIAGNOSTICS).

TEST PERFORMED AT:
[**Company **] [**Doctor Last Name **] INSTITUTE
[**Numeric Identifier 14272**] P.0. BOX [**Numeric Identifier 19430**]
CHANTILLY, [**Numeric Identifier 19431**]

   RADIOLOGY  Final Report

IN-111 WHITE BLOOD CELL STUDY  [**2171-3-6**]

IN-111 WHITE BLOOD CELL STUDY

Reason: PT WITH S/P AVR (MECHANICAL) W/ PERSISTANT POST OP
FEVERS, A ASSESS FOR INFECTIOUS SOURCE

History: 23 year old with mechanical AVR. Persistent post-op
fevers.

DECISION: SPECT views of the chest and upper abdomen were
obtained.

INTERPRETATION: Following the injection of autologous white
blood cells labeled
with In-111, images of the whole body were obtained at 24 hours.

These images show no abnormal areas of increased uptake.

IMPRESSION: Normal white blood cell scan.

Cardiology Report ECHO Study Date of [**2171-2-28**]



PATIENT/TEST INFORMATION:
Indication: Aortic valve disease. Evaluation for abscess. H/O
cardiac surgery. Prosthetic valve function.
Height: (in) 67
Weight (lb): 120
BSA (m2): 1.63 m2
BP (mm Hg): 123/46
HR (bpm): 64
Status: Inpatient
Date/Time: [**2171-2-28**] at 21:57
Test: Portable TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006W001-0:00
Test Location: West SICU/CTIC/VICU
Technical Quality: Adequate




REFERRING DOCTOR: DR. [**First Name (STitle) 412**] [**Last Name (Prefixes) 413**]

INTERPRETATION:

Findings:

LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
LA/LAA or the
RA/RAA.

RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.


LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
systolic function
(LVEF>55%).

RIGHT VENTRICLE: Normal RV chamber size and free wall motion.

AORTA: Normal ascending, transverse and descending thoracic
aorta with no
atherosclerotic plaque.

AORTIC VALVE: Bileaflet aortic valve prosthesis (AVR). AVR
leaflets move
normally. Paravalvular leak. No masses or vegetations on aortic
valve.

MITRAL VALVE: Normal mitral valve leaflets. No mass or
vegetation on mitral
valve. Mild (1+) MR.

TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. No mass or
vegetation on tricuspid valve.

PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
No
vegetation/mass on pulmonic valve.

GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. The patient
was monitored
by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**] throughout the procedure. The patient
was sedated for
the TEE. Medications and dosages are listed above (see Test
Information
section). Local anesthesia was provided by benzocaine topical
spray. No TEE
related complications. Echocardiographic results were reviewed
with the
houseofficer caring for the patient.

Conclusions:
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. Left
ventricular wall thickness, cavity size, and systolic function
are normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal.
The ascending, transverse and descending thoracic aorta are
normal in diameter
and free of atherosclerotic plaque. Prominent coronary artery
flow is present.
A bileaflet aortic valve prosthesis is present. The aortic
prosthesis leaflets
appear to move normally. A small paravalvular aortic valve leak
is present. No
masses or vegetations are seen on the aortic valve. There is an
echodense
space posterior to the aortic valve prosthesis which likely
represents
postoperative change. The mitral valve leaflets are structurally
normal. No
mass or vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation
is seen.

IMPRESSION: Normal functioning aortic valve prosthesis with a
small
paravalvular leak. No aortic root abcess seen. No valvular
vegetations seen.

Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD on [**2171-3-4**] 17:35.

[**Location (un) **] PHYSICIAN:


Cardiology Report ECHO Study Date of [**2171-2-28**]



PATIENT/TEST INFORMATION:
Indication: S/p recent mechanical AVR for SBE. ?evidence of
recurrent endocarditis.
Height: (in) 67
Weight (lb): 120
BSA (m2): 1.63 m2
BP (mm Hg): 94/50
HR (bpm): 66
Status: Inpatient
Date/Time: [**2171-2-28**] at 17:03
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006W000-0:00
Test Location: West [**Hospital Ward Name 121**] [**2-8**]
Technical Quality: Adequate




REFERRING DOCTOR: DR. [**First Name (STitle) 412**] [**Last Name (Prefixes) 413**]

MEASUREMENTS:
Left Ventricle - Septal Wall Thickness: *1.4 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.4 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.5 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 3.5 cm
Left Ventricle - Fractional Shortening: *0.22 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 45% (nl >=55%)
Aorta - Valve Level: *4.0 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.1 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: *2.4 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Peak Gradient: 24 mm Hg
Aortic Valve - Mean Gradient: 16 mm Hg
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 0.4 m/sec
Mitral Valve - E/A Ratio: 2.00
Mitral Valve - E Wave Deceleration Time: 320 msec
TR Gradient (+ RA = PASP): 15 mm Hg (nl <= 25 mm Hg)

INTERPRETATION:

Findings:

This study was compared to the prior study of [**2171-2-6**].


LEFT VENTRICLE: Mildly depressed LVEF.

RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
Paradoxic septal
motion consistent with prior cardiac surgery. Abnormal septal
motion/position
consistent with RV pressure/volume overload.

AORTA: Moderately dilated aortic root. Normal ascending aorta
diameter.

AORTIC VALVE: Bileaflet aortic valve prosthesis (AVR). Trace AR.


MITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR.

TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.

PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.

PERICARDIUM: No pericardial effusion.

Conclusions:
There is mild global left ventricular hypokinesis. Overall left
ventricular
systolic function is mildly depressed with akinesis/hypokinesis
of the
inferolateral wall (with a (with an echodense focus in the basal
inferolateral
wall) . Right ventricular chamber size and free wall motion are
normal. There
is abnormal septal motion/position consistent with right
ventricular
pressure/volume overload. The aortic root is moderately dilated.
A bileaflet
aortic valve prosthesis is present. There is an echolucent space
around the
lateral aspect of the prosthetic ring which may represent
post-operative
change but an abscess cannot be exclude. Trace aortic
regurgitation is seen.
The mitral valve leaflets are structurally normal. Mild (1+)
mitral
regurgitation is seen. There is no pericardial effusion.

Compared with the prior study (images reviewed) of [**2171-2-6**], a
bileaflet
aortic prosthesis is now in place and left ventricular systolic
function is
now mildly impaired.

No definite vegetation seen but cannot exclude.

Electronically signed by [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) **], MD on [**2171-2-28**] 17:31.
[**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].


RADIOLOGY  Final Report

CHEST (PA & LAT)  [**2171-2-28**] 12:59 AM

CHEST (PA & LAT)

Reason: Please evaluate for pneumonia

[**Hospital 93**] MEDICAL CONDITION:
23 y/o M w/ aortic valve endocarditis s/p AVR now w/ temp to
101.6
REASON FOR THIS EXAMINATION:
Please evaluate for pneumonia
REASON FOR EXAMINATION: High temperature in a patient with
prosthetic aortic valve endocarditis.

Upright PA and lateral chest x-ray were compared to the previous
study from [**2171-2-25**].

The patient is status post median sternotomy and aortic valve
replacement. The right PICC line catheter is inserted with its
tip in distal SVC. The cardiac silhouette is within normal
limits in size, but demonstrates left ventricular configuration.
The pulmonary vasculature is normal. No evidence of congestive
heart failure or focal infiltrate is present. No pneumothorax or
pleural fluid is seen.

The previously reported small air collection in the retrosternal
region is unchanged in comparison to the previous chest x-ray.

IMPRESSION: No evidence of active cardiopulmonary process in a
patient after recent aortic valve replacement.

The study and the report were reviewed by the staff radiologist.
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
DR. [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1508**]Approved: [**Doctor First Name **] [**2171-2-28**] 4:51 PM

[**Hospital1 69**]
[**Location (un) 86**], [**Telephone/Fax (1) 15701**]

Pathology Examination

Name Birthdate    Age     Sex Pathology #     [**Hospital1 18**] [**Known lastname 65454**],[**Known firstname 1730**] P       [**2148-1-28**]    23 Male      [**Numeric Identifier 65455**]
[**Numeric Identifier 65456**]
Report to:   DR. [**Last Name (STitle) **] [**Last Name (Prefixes) 413**]
Gross Description by:   DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 60868**]/dif



SPECIMEN SUBMITTED:  THYMUS, AORTIC VALVE LEAFLET.

Procedure date     Tissue received     Report Date    Diagnosed
by
[**2171-2-11**] [**2171-2-11**] [**2171-2-14**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/cma??????
Previous biopsies:    [**Numeric Identifier 65457**]  EXTRACTED TEETH 2 LOWER MOLARS.


DIAGNOSIS

1.  Thymus (6 grams, A-B):

Focal calcifications; no diagnostic abnormalities recognized.

2.  Aortic valve leaflets (C-D):

Bacterial endocarditis, see note.

Note:  Sections show cardiac valve leaflet with organizing
fibrin "vegetations", acute and chronic inflammation,
calcifications, and focal necrosis.  Brown-Brenn stained
sections are positive for Gram positive cocci, present singly.
Correlation with microbiologic culture results is recommended
for increased specificity and sensitivity; if indicated
clinically.  GMS-stained sections are negative for fungi.

Clinical:  Infected aortic valve.

Gross:  The specimen is received in formalin labeled with
"[**Known lastname 65453**], [**Known firstname **]" and the medical record number.



Part 1 is additionally labeled "thymus" and consists of a thymus
which weighs 6 grams and measures 1.5 x 4.6 x 1.3 cm.  The
specimen sectioned to reveal unremarkable tan and yellow lobular
cut surface with no nodules or other masses noted.  The specimen
is represented in A-B.



Part 2 is additionally labeled "aortic valve leaflets" and
consists of two valve leaflets with several detached fragments
of white tissue that measure up to 3.3 x 1.5 x 1.0 cm.  The
specimen is sectioned and entirely submitted in C-D.

Cardiology Report ECHO Study Date of [**2171-1-25**]



PATIENT/TEST INFORMATION:
Indication: Endocarditis. Evaluate AOV vegetation
Height: (in) 67
Weight (lb): 130
BSA (m2): 1.69 m2
BP (mm Hg): 118/54
HR (bpm): 82
Status: Inpatient
Date/Time: [**2171-1-25**] at 15:56
Test: Portable TTE (Congenital, focused views)
Doppler: Limited Doppler and color Doppler
Contrast: None
Tape Number: 2006W006-0:16
Test Location: [**Location 11648**]/[**Hospital Ward Name 121**] 6
Technical Quality: Adequate




REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
  DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]

MEASUREMENTS:
Left Atrium - Long Axis Dimension: 3.8 cm (nl <= 4.0 cm)
Left Ventricle - Septal Wall Thickness: 0.9 cm (nl 0.6 - 1.1 cm)

Left Ventricle - Inferolateral Thickness: 1.0 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: *6.3 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 3.3 cm
Left Ventricle - Fractional Shortening: 0.48 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 55% (nl >=55%)
Aorta - Valve Level: 2.8 cm (nl <= 3.6 cm)
Aorta - Ascending: *3.7 cm (nl <= 3.4 cm)
Aorta - Arch: 2.3 cm (nl <= 3.0 cm)
Aortic Valve - Peak Velocity: *2.3 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Peak Gradient: 21 mm Hg
Aortic Valve - Mean Gradient: 11 mm Hg

INTERPRETATION:

Findings:

LEFT ATRIUM: Normal LA size.

RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.

LEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV
cavity.
Overall normal LVEF (>55%). [Intrinsic LV systolic function
likely depressed
given the severity of valvular regurgitation.]

RIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber
size. Normal RV
systolic function.

AORTA: Normal aortic root diameter. Mildly dilated ascending
aorta. Normal
aortic arch diameter.

AORTIC VALVE: Bicuspid aortic valve. Moderate-sized vegetation
on aortic
valve. Aortic root abscess. Moderate to severe (3+) AR.

MITRAL VALVE: Normal mitral valve leaflets. No MR.

PERICARDIUM: No pericardial effusion.

Conclusions:
1. The left atrium is normal in size.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity
is moderately dilated. Overall left ventricular systolic
function is normal
(LVEF=55%). [Intrinsic left ventricular systolic function is
likely more
depressed given the severity of valvular regurgitation.]
3. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The ascending aorta is mildly dilated.
5.The aortic valve is bicuspid. There is a moderate-sized
vegetation on the
aortic valve of (0.6 x 1.1) cm. An aortic annular abscess is
seen adjacent to
the right sided bicuspic valve leaflet, in the anterior aspect
of the aortic
root and a smaller one posteriorly. Moderate to severe (3+)
aortic
regurgitation is seen.
6.The mitral valve leaflets are structurally normal. No mitral
regurgitation
is seen.
7.There is no pericardial effusion.

Compared with the findings of the prior study (images reviewed)
of [**2171-1-11**], the
LV function may have decreased while the size of the vegetation
is less. No MR
is seen on the present study but this may be in part due to the
fact that the
previous study was a TEE.

Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD on [**2171-1-25**]
17:31.
[**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].

RADIOLOGY  Final Report

CT CHEST W/CONTRAST  [**2171-1-23**] 10:05 AM

CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST

Reason: eval for evid of septic emboli
Field of view: 36 Contrast: OPTIRAY

[**Hospital 93**] MEDICAL CONDITION:
22 year old man with aortic valve endocarditis, w/ suspected
septic emboli to brain, w/ ? embolic pulmonary focus in RLL.
REASON FOR THIS EXAMINATION:
eval for evid of septic emboli
CONTRAINDICATIONS for IV CONTRAST: None.

CT OF THE CHEST, ABDOMEN, AND PELVIS.

There is a chest radiograph from [**2171-1-20**] as comparison.

CLINICAL HISTORY: Endocarditis. Question of right lower lobe
pulmonary embolism. Evaluate for evidence of septic emboli.

TECHNIQUE: Axial MDCT images of the chest, abdomen, and pelvis
were obtained post-IV contrast enhancement. Oral contrast was
also administered. Coronal and sagittal images were generated
which were essential in evaluation of the torso.

CT CHEST FINDINGS: There is no thoracic lymphadenopathy. There
is no pericardial or pleural effusion. The heart size is normal.
The aorta and great vessels appear normal.

Lung windows demonstrate a wedge-shaped focus of consolidation
in the right lower lobe which corresponds to the abnormality
seen on the recent chest radiograph. The remainder of the lungs
are clear.

Images of the abdomen demonstrate normal appearance of the
liver, pancreas, adrenal glands, and kidneys. There is no
lymphadenopathy. There are no dilated bowel loops. The portal
vein and splenic vein are patent. The gallbladder is present.
There is no biliary dilatation.

There is a 3.6 x 4.4 x 3.4 cm low-density lesion with an
irregular contour in the posterior aspect of the spleen which
corresponds to the abnormality seen on the recent chest
radiograph. It is mildly hyperdense relative to simple fluid
measuring 20-24 Hounsfield units. The aorta, celiac axis,
proximal hepatic artery, and splenic artery are patent. The
renal arteries are patent. The [**Female First Name (un) 899**] is patent.

There is no free fluid or lymphadenopathy present in the pelvis.
There are no dilated bowel loops in the pelvis.

Bone windows demonstrate no lytic or blastic lesions in the
chest, abdomen, or pelvis.

IMPRESSION:
1. Low-density lesion in the spleen is nonspecific. While this
most likely represents a cyst or perhaps a hemangioma, an
infarct could appear in this fashion as well. There is no other
evidence in the abdomen of embolism.
2. Focal consolidation at the right lung base is also
nonspecific. This could represent a focal septic embolism or
simply focal atelectasis. A followup chest radiograph could be
performed to determine resolution or to evaluate for new
lesions.

The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 3688**] [**Last Name (NamePattern1) 65458**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7832**]
Approved: MON [**2171-1-28**] 3:37 PM

RADIOLOGY  Final Report

CT ABDOMEN W/CONTRAST  [**2171-1-23**] 10:05 AM

CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST

Reason: eval for evid of septic emboli
Field of view: 36 Contrast: OPTIRAY

[**Hospital 93**] MEDICAL CONDITION:
22 year old man with aortic valve endocarditis, w/ suspected
septic emboli to brain, w/ ? embolic pulmonary focus in RLL.
REASON FOR THIS EXAMINATION:
eval for evid of septic emboli
CONTRAINDICATIONS for IV CONTRAST: None.

CT OF THE CHEST, ABDOMEN, AND PELVIS.

There is a chest radiograph from [**2171-1-20**] as comparison.

CLINICAL HISTORY: Endocarditis. Question of right lower lobe
pulmonary embolism. Evaluate for evidence of septic emboli.

TECHNIQUE: Axial MDCT images of the chest, abdomen, and pelvis
were obtained post-IV contrast enhancement. Oral contrast was
also administered. Coronal and sagittal images were generated
which were essential in evaluation of the torso.

CT CHEST FINDINGS: There is no thoracic lymphadenopathy. There
is no pericardial or pleural effusion. The heart size is normal.
The aorta and great vessels appear normal.

Lung windows demonstrate a wedge-shaped focus of consolidation
in the right lower lobe which corresponds to the abnormality
seen on the recent chest radiograph. The remainder of the lungs
are clear.

Images of the abdomen demonstrate normal appearance of the
liver, pancreas, adrenal glands, and kidneys. There is no
lymphadenopathy. There are no dilated bowel loops. The portal
vein and splenic vein are patent. The gallbladder is present.
There is no biliary dilatation.

There is a 3.6 x 4.4 x 3.4 cm low-density lesion with an
irregular contour in the posterior aspect of the spleen which
corresponds to the abnormality seen on the recent chest
radiograph. It is mildly hyperdense relative to simple fluid
measuring 20-24 Hounsfield units. The aorta, celiac axis,
proximal hepatic artery, and splenic artery are patent. The
renal arteries are patent. The [**Female First Name (un) 899**] is patent.

There is no free fluid or lymphadenopathy present in the pelvis.
There are no dilated bowel loops in the pelvis.

Bone windows demonstrate no lytic or blastic lesions in the
chest, abdomen, or pelvis.

IMPRESSION:
1. Low-density lesion in the spleen is nonspecific. While this
most likely represents a cyst or perhaps a hemangioma, an
infarct could appear in this fashion as well. There is no other
evidence in the abdomen of embolism.
2. Focal consolidation at the right lung base is also
nonspecific. This could represent a focal septic embolism or
simply focal atelectasis. A followup chest radiograph could be
performed to determine resolution or to evaluate for new
lesions.

   RADIOLOGY  Final Report

MRA BRAIN W/O CONTRAST  [**2171-1-21**] 5:29 PM

MRA BRAIN W/O CONTRAST

Reason: evaluate for mycotic aneurysm

[**Hospital 93**] MEDICAL CONDITION:
22 year old man with aortic valve endocarditis, on IV abx, with
persistent fever, intermittent throbbing h/a.
REASON FOR THIS EXAMINATION:
evaluate for mycotic aneurysm
MR ANGIOGRAPHY OF THE CIRCLE OF [**Location (un) **] AND ITS TRIBUTARIES.

HISTORY: Aortic valve endocarditis. On IV antibiotics.
Intermittent throbbing headaches and fever. Assess for mycotic
aneurysm.

TECHNIQUE: 3D time of flight imaging with multiplanar
reconstructions.

FINDINGS: The major tributaries of the circle of [**Location (un) 431**] appear
to be of normal architecture. There is no sign for the presence
of an area of hemodynamically significant stenosis, aneurysm or
vascular malformation.

However, it is to be emphasized that mycotic aneurysms are
frequently located in the peripheral vasculature, and therefore
not necessarily imaged by MR angiography. Also, the standard MR
angiographic sequence does not encompass the entire brain or its
associated vasculature.

CONCLUSION: No definite abnormality seen. However, it is to be
emphasized that if there is serious consideration for mycotic
aneurysm, conventional angiography must be entertained, as it is
a definitive diagnostic modality in that regard.

COMMENT: Though not optimized for soft tissue imaging, there is
demonstration of a moderate sized left maxillary antral mucous
retention cyst. This abnormality was shown quite clearly on the
preceding MR study of [**1-16**].

DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9987**]
Approved: [**First Name8 (NamePattern2) **] [**2171-1-22**] 12:38 PM




Brief Hospital Course:
On admission, additional blood cultures were taken. The
cardiology and ID services were consulted. He was empirically
started on intravenous antibiotics while awaiting speciation and
sensitivities of gram positive cocci. He was maintained on
telemetry, and no conduction abnormalities were noted. He
continued to complain of lower extremity pain which required
narcotics for adequate pain control. Blood cultures eventually
grew out Enterococcus faecalis for which antibiotics were
adjusted accordingly. He was maintained on Ampicillin and
Gentamicin. Despite antibiotics, he was intermittently febrile.
Hepatitis B surface antibody and Hepatitis C virus antibody came
back positive while HIV serology and RPR returned negative. HCV
viral load was negative. A transesophogeal echocardiogram on
[**1-14**] was notable for a bicuspid aortic valve with a large
mobile vegetation on the left ventricular outflow tract side of
the anterior cusp. There was a small (~1.0 x 0.5 cm) echolucent
space posterior to the aortic root (and a smaller space anterior
to the aortic root). An abscess could not be ruled out. At least
mild to moderate ([**1-7**]+) aortic regurgitation was seen. The
neurology service was also consulted for new onset headaches and
persistent lower extremity pain. A head CT scan on [**1-15**]
was unremarkable. Lower extremity ultrasound found no evidence
of deep vein thrombosis. A brain MRI on [**1-16**] was notable
for multiple bilateral foci of lobulated enhancement with
negligible adjacent increased T2 signal. Given the history,
there was concern for septic emboli. A repeat TEE on [**1-18**] confirmed a bicuspid aortic valve with echodensity
consistent with vegetation. There was moderate-severe aortic
regurgitation. Compared with the prior study, the aortic valve
vegetation was slightly larger. In addition, there were two
small (2-4mm) echolucent spaces in the anterior and posterior
aortic root consistent with small abscesses. Given the echo
findings of continued growth of vegetation with abscesses and
persistent fevers despite antibiotics, cardiac surgery was
consulted as his clinical picture suggested poor prognosis for
success of medical management alone. Prior to surgical
intervention, several additional weeks of intravenous
antibiotics was recommended to minimize the risk of intracranial
bleed while on cardiopulmonary bypass. For the next several
weeks, he remained on intravenous antibiotics. Additional
studies included MRI imaging which found no evidence of mycotic
aneurysm. Lower extremity MRI showed lack of intraluminal
opacification in portions of the proximal peroneal and posterior
tibial arteries, suspicious for septic emboli with
thrombophlebitis. MRI also showed nonspecific findings
consistent with infectious myositis of the right thigh. There
was no MRI evidence for abscess or osteomyelitis. CT imaging
showed a nonspecific low-density lesion in the spleen with no
other evidence of embolism in the abdomen. There was also
nonspecific focal consolidation at the right lung base. Physical
examination revealed new [**Last Name (un) 1003**] lesions on his left hand.

PICC line placed on [**1-28**] for continued ampicillin and
gentamicin. Repeat TEE on [**1-29**] showed 3+ AI, 2 AV vegetations.
Dental consult done on [**1-31**]. extractions were recommended prior
to surgery. These were done on [**2-4**]. The patient had no CNS
events for 2 weeks at this point. Another TEE done [**2-6**] showed
vegetations present with small pericardial effusion, but no
tamponade and 4+ AI.  Clinical nutrition and social work teams
continued to additional support. Blood cultures continued to be
negative.

AVR done [**2-11**] with 23 mm OnX ConformX mechanical valve.
Transferred to the CSRU in stable condition on epinephrine,
vasopressin and phenylephrine drips. Extubated later that
evening. On POD #1, remained on insulin and nitroglycerin drips.
Beta blockade and coumadin were started. On POD #2, nitro drip
weaned and Cordis removed. He was transferred to the floor to
begin ambulating and med adjustment. Chest tubes and pacing
wires were removed over the next 2 days. He was on a heparin
drip until his INR was therapeutic. The pain management team was
consulted on [**2-15**]. INR rose rapidly to 3.2 and coumadin was held
on [**2-15**]. He will require ampicillin until [**2-25**] and follow up
with ID then. He had fever and night sweats on [**2-16**], but no
fever the following day.  On [**2171-2-28**] he had a febrile episode
for which he was restarted on Vancomycin and Zosyn.  His PICC
line was discontinued.  Surveilliance blood cultures were
negative and there was no elevation in his white count.  A
tagged WBC study did not reveal any focal area of inflammation
or infection.  Repeat TEE did not reveal any vegetations or
abscess.  His PICC catheter tip culture was also negative.  His
coumadin was continued for a target INR of 2.5-3.0 for a
mechanical AVR.  He is presently being discharged on heparin for
a subtherapuetic INR.  He will continue Ampicillin 2gm IV q4 hrs
until [**2171-3-28**].

Medications on Admission:
Percocet, Amoxicillin

Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
[**Year (4 digits) **]:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
[**Year (4 digits) **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Multivitamin     Capsule Sig: One (1) Cap PO DAILY (Daily).
[**Year (4 digits) **]:*30 capsule* Refills:*2*
4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
[**Year (4 digits) **]:*30 Tablet(s)* Refills:*0*
5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
[**Year (4 digits) **]:*60 Tablet(s)* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
[**Year (4 digits) **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
[**Year (4 digits) **]:*60 Tablet(s)* Refills:*2*
8. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Year (4 digits) **]:*30 Tablet(s)* Refills:*2*
9. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO every [**4-11**]
hours as needed.
[**Month/Day (3) **]:*50 Tablet(s)* Refills:*0*
10. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day: Take
as directed by PCP.
[**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*2*
11. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution
Sig: 1100 units/hr  Intravenous  ASDIR (AS DIRECTED).
[**Name Initial (NameIs) **]:*qs qs* Refills:*2*
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
[**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*0*
13. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous  DAILY (Daily) as needed.
[**Name Initial (NameIs) **]:*qs ML(s)* Refills:*0*
14. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*2*
15. Ampicillin Sodium 2 g Recon Soln Sig: One (1) Recon Soln
Injection Q4H (every 4 hours).
[**Name Initial (NameIs) **]:*180 Recon Soln(s)* Refills:*2*
16. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
[**Name Initial (NameIs) **]:*120 Tablet(s)* Refills:*2*
17. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
[**Name Initial (NameIs) **]:*40 Tablet(s)* Refills:*0*
18. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO ONCE (once)
for 1 doses.
[**Name Initial (NameIs) **]:*3 Tablet(s)* Refills:*0*
19. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous  DAILY (Daily) as needed.
[**Name Initial (NameIs) **]:*qs ML(s)* Refills:*0*


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 2222**] - [**Location (un) 538**]

Discharge Diagnosis:
Enterococcal Aortic Valve Endocarditis, Septic Emboli, Aortic
Valve Insufficiency, Bicsupid Aortic Valve, Aortic Root Abscess,
History of IVDA, Left forearm Abscess, WPW - history of cardiac
arrest and status post ablation at age 17, Anemia


Discharge Condition:
Good


Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.


Followup Instructions:
[**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2171-3-21**] 11:30

Schedule coumadin follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 10166**] [**Hospital3 65459**] [**Telephone/Fax (1) 31979**]

Follow up with [**Location (un) 22870**] outpatient addiction treatment



Completed by:[**2171-3-12**]
{'Acute and subacute bacterial endocarditis,Streptococcal septicemia,Congenital insufficiency of aortic valve,Arterial embolism and thrombosis of lower extremity,Phlebitis and thrombophlebitis of deep veins of lower extremities, other,Infective myositis,Anomalous atrioventricular excitation,Unspecified viral hepatitis C without hepatic coma,Opioid type dependence, unspecified,Severe sepsis,Cerebral embolism without mention of cerebral infarction,Tobacco use disorder,Dental caries, unspecified,Pain in limb'}


You are an AI assistant analyzing clinical admission notes from the MIMIC III dataset. Your task is to map symptoms mentioned in the notes to a list of provided ICD-9 LONG_TEXT.



### Clinical text :
CHIEF COMPLAINT: Transfer from OSH for management of endocarditis.

PRESENT ILLNESS: Mr. [**Known lastname 65453**] is a 22 year old male with a PMH significant for WPW
and bicuspid aortic valve. He has a history of cardiac arrest
and is status post ablation at age 17. He is an intravenous drug
abuser. He presented to OSH yesterday for bilateral lower
extremity pain and rash. The pain started about 2 weeks prior to
admission, is in his hamstrings, calves, and feet. Pain was so
severe he was unable to stand on his feet. Described as "achy"
quality. No back pain. No numbness, tingling, or weakness. Was
sent home with Percocets and Amoxicillin. Called back to OSH
today for [**4-9**] blood cultures growing GPC in pairs & chains. An
echocardiogram showed a bicuspid aortic valve with large
vegetation. He was subsequently started on Ceftriaxone and
Vancomycin, and transferred to the [**Hospital1 18**] further management and
evaluation. On admission, he denied SOB, CP, lightheadedness,
DOE, PND, and orthopnea. He reports loss of appetite, 20 lb
weight loss and night sweats over several weeks prior to
admission

MEDICAL HISTORY: Aortic Valve Endocarditis, Aortic Valve Insufficiency, Bicsupid
Aortic Valve, History of IVDA, Left forearm Abscess, WPW -
history of cardiac arrest and status post ablation at age 17,
Anemia

MEDICATION ON ADMISSION: Percocet, Amoxicillin

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS - T 97.9, BP 124/59, HR 51, RR 18, O2 sat 100% RA
gen - well-appearing, NAD
HEENT - PERRL, EOMI, OP clr, MM dry
CV - RRR, 2/6 systolic RSB 2ICS; no JVD
chest - CTAB
abd - NABS, soft, NT
skin -  no splinter hemorrhages, no Osler or [**Last Name (un) 1003**] lesions
ext - no edema
neuro - CN II-XII intact, strength 5/5 throughout, [**Last Name (un) 36**] grossly
intact to lt touch

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Last IVDU was 3.5 months ago. Denies ETOH. Admits to tobacco,
approximately [**1-8**] pack per day. Lives with his parents. 

### Response:
{'Acute and subacute bacterial endocarditis,Streptococcal septicemia,Congenital insufficiency of aortic valve,Arterial embolism and thrombosis of lower extremity,Phlebitis and thrombophlebitis of deep veins of lower extremities, other,Infective myositis,Anomalous atrioventricular excitation,Unspecified viral hepatitis C without hepatic coma,Opioid type dependence, unspecified,Severe sepsis,Cerebral embolism without mention of cerebral infarction,Tobacco use disorder,Dental caries, unspecified,Pain in limb'}
