CHIEF COMPLAINT: fever and altered mental status

PRESENT ILLNESS: 73 year old male with CAD, CHF (EF 20%), v-tach s/p ICD
placement, AFib on warfarin, s/p whipple, chronic dyspnea with
2.5L NC at baseline, presenting with fever (100.2 at home),
rigors, and altered mental status. Patient has a history of
aspiration pneumonia, with admission in [**2142-4-22**] requiring an
ICU stay and ventilation.

MEDICAL HISTORY: 1.  Coronary artery disease
  - status post anterior wall myocardialinfarction in [**2126**]
  - MI c/b large apical aneurysm and VT/VF s/p ablation [**2126**]
  - s/p biventricular pacer implantation [**2135**] (replaced previous
dual chamber ICD) for complete heart block
  - pacemaker interrogated [**7-12**]
2.  Systolic heart failure
  - ejection fraction 20% on TTE in [**2141-11-22**]
3.  Atrial fibrillation, status post cardioversion [**2141-5-23**], on
anticoagulation, managed by Dr.[**Name (NI) 1912**] office.
4.  Hypertension.
5.  Hypothyroidism.
6.  Anemia.
7.  Irritable bowel syndrome.
8.  Constipation.
9.  Obesity.
10.  Hearing loss, requiring bilateral hearing aids.
11.  Squamous cell carcinoma of the left lower eyelid [**2138**].
12.  Vitamin D deficiency.
13.  Cerebral infarction [**2132**].
14.  Gait disorder with history of falls.
15.  Compression fractures.
16.  Bile duct dysplasia s/p ERCP/stent/sphincterotomy [**4-/2139**]
and  Whipple operation c/b E. coli and Klebsiella bacteremia (at
[**Hospital1 2025**]). Apparently, the source of the bacteremia was his teeth.
He is s/p removal of all of his teeth.
17.  Abdominal hernia secondary to a local procedure.
18.  Syncope.
19.  Hemorrhoids.
20.  VRE infection

MEDICATION ON ADMISSION: AMIODARONE 200 mg daily
BUPROPION HCL 150 mg daily
FUROSEMIDE 60 mg daily
LEVOTHYROXINE 100 mcg Tablet daily\
LIPASE-PROTEASE-AMYLASE [CREON] - unknown dose
LISINOPRIL 2.5 mg daily
METOPROLOL TARTRATE 12.5mg [**Hospital1 **]
OXYGEN 2.5L via nasal cannula daily upon exertion
PRAMIPEXOLE 0.125 mg QHS PRN restless legs
RANITIDINE HCL 75 mg [**Hospital1 **]
WARFARIN 1-4 mg daily
ASPIRIN 81mg daily
CHOLECALCIFEROL (VITAMIN D3) 1,000 unit daily
DOCUSATE SODIUM [COLACE] 100 mg Capsule TID PRN
FERROUS SULFATE 325 mg (65 mg iron) daily (MWF)
GUAR GUM [BENEFIBER (GUAR GUM)] packet daily
SENNOSIDES [SENOKOT] 8.6 mg [**Hospital1 **] PRN

ALLERGIES: Penicillins / Ambien / Trazodone

PHYSICAL EXAM: Admission Physical Exam:
Vitals: T: 99.2 (37.3) BP: 92/56 P: 75 RR: 16 SpO2: 96% NC
General: Alert, oriented x3, conversant, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, adentulous
Neck: supple, JVP not appreciated, no LAD
Lungs: Crackles at the bases bilaterally, no wheezes
CV: Paced, regular rate and rhythm.  Holosystolic murmur,
loudest at LLSB with radiation to the apex.  No carotid bruits.
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
small midline ventral hernia.
GU: + foley
Ext: Warm, well-perfused, 2+ pulses, fingernails mostly white
with thin reddish line at tip (c/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 15569**] nails), no edema

FAMILY HISTORY: Father died of stroke age 59.  Mother died of MI at age 70.
Brother with MI in his 50s, deceased.  Second brother deceased
with pancreatic cancer.

SOCIAL HISTORY: The patient lives with his significant other,
[**Name (NI) **] [**Name (NI) **].  He is divorced, and has two grown daughters.  [**Name (NI) **]
taught British and American History at [**Last Name (un) **] and [**Last Name (un) 15565**].
- Tobacco: Previous smoker.  Began smoking cigarettes in high
school and continued until age 60.  Also, smoked a pipe until
age 60.
- Alcohol: [**12-24**] glasses of wine per day.
- Illicits: None ever.
Bacteremia,Acute kidney failure, unspecified,Chronic systolic heart failure,Other chronic pulmonary heart diseases,Systemic inflammatory response syndrome, unspecified,Atrial fibrillation,Other convulsions,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms,Other specified forms of chronic ischemic heart disease,Old myocardial infarction,Unspecified essential hypertension,Mitral valve disorders,Unspecified acquired hypothyroidism,Obesity, unspecified,Anemia, unspecified,Irritable bowel syndrome,Unspecified vitamin D deficiency,Unspecified hearing loss,Abnormality of gait,Automatic implantable cardiac defibrillator in situ,Long-term (current) use of anticoagulants,Other postprocedural status,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,History of fall
Bacteremia,Acute kidney failure NOS,Chr systolic hrt failure,Chr pulmon heart dis NEC,SIRS, NOS,Atrial fibrillation,Convulsions NEC,Oth gram negatv bacteria,Chr ischemic hrt dis NEC,Old myocardial infarct,Hypertension NOS,Mitral valve disorder,Hypothyroidism NOS,Obesity NOS,Anemia NOS,Irritable bowel syndrome,Vitamin D deficiency NOS,Hearing loss NOS,Abnormality of gait,Status autm crd dfbrltr,Long-term use anticoagul,Post-proc states NEC,Hx TIA/stroke w/o resid,Personal history of fall
Admission Date:  [**2142-7-21**]              Discharge Date:   [**2142-7-27**]

Date of Birth:  [**2069-2-9**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins / Ambien / Trazodone

Attending:[**First Name3 (LF) 2610**]
Chief Complaint:
fever and altered mental status

Major Surgical or Invasive Procedure:
transesophageal echocardiogram on [**2142-7-25**].
IMPRESSION: Pacing wires present with shaggy echodensities that
could represent presence of clot / fibrin / vegetations. No
valvular vegetations seen. Severely depressed left ventricular
function. Moderate mitral regurgitation.

PICC placement


History of Present Illness:
73 year old male with CAD, CHF (EF 20%), v-tach s/p ICD
placement, AFib on warfarin, s/p whipple, chronic dyspnea with
2.5L NC at baseline, presenting with fever (100.2 at home),
rigors, and altered mental status. Patient has a history of
aspiration pneumonia, with admission in [**2142-4-22**] requiring an
ICU stay and ventilation.

Patient relates that symptoms began yesterday with fevers,
shaking chills and overall malaise.  He did have a cough prior
to admission, which was not productive of sputum, but usually
brought up undigested food.  Due to constipation, the patient
took extra Colace and Senna yesterday, and he had [**3-27**] bowel
movements.  After straining during one bowel movement, he felt
short of breath and dizzy.  He denies having any chest pain
yesterday, although history in the ED had noted some chest pain
prior to admission.  At his baseline, the patient sometimes has
dyspnea on exertion (walking around his home) and sleeps on 2
pillows at night.  He denies any leg swelling.  He denies any
nausea, vomiting, abdominal pain, diarrhea, hematochezia,
melena, dysuria or hematuria.

In the ED, initial vs were: 99.2 74 95/64 16 99%.  He was alert
and oriented x2, pale, diaphoretic, and hypotensive to SBP 75.
Of note, from recent previous OMR records, baseline BP is
105/68.  RIJ placed, with CVP 13 and MAP ~60.  After <500 cc of
fluids and abx, pt with improved MS though still not oriented to
time.  Vanc + levoflox given.  CXR showed bilateral opacities
c/w atelectasis vs. infection.  Total IVF given ~750cc with
resolving pressures to BP 91/51.  Given no meningismus, HA, or
neck pain, LP was deferred. Vitals on transfer: 101.8, 75,
91/51, 17, 97% 2L NC and CVP 13.

In the ICU, the patient was comfortable, oriented x3 and
conversant.  He knew that he was in the [**Hospital1 18**] ICU, but not in
the "nice" ICU that is in the clinical center.  He was breathing
comfortably on supplemental oxygen by nasal cannula.  He was
able to provide details of his history.


Past Medical History:
1.  Coronary artery disease
  - status post anterior wall myocardialinfarction in [**2126**]
  - MI c/b large apical aneurysm and VT/VF s/p ablation [**2126**]
  - s/p biventricular pacer implantation [**2135**] (replaced previous
dual chamber ICD) for complete heart block
  - pacemaker interrogated [**7-12**]
2.  Systolic heart failure
  - ejection fraction 20% on TTE in [**2141-11-22**]
3.  Atrial fibrillation, status post cardioversion [**2141-5-23**], on
anticoagulation, managed by Dr.[**Name (NI) 1912**] office.
4.  Hypertension.
5.  Hypothyroidism.
6.  Anemia.
7.  Irritable bowel syndrome.
8.  Constipation.
9.  Obesity.
10.  Hearing loss, requiring bilateral hearing aids.
11.  Squamous cell carcinoma of the left lower eyelid [**2138**].
12.  Vitamin D deficiency.
13.  Cerebral infarction [**2132**].
14.  Gait disorder with history of falls.
15.  Compression fractures.
16.  Bile duct dysplasia s/p ERCP/stent/sphincterotomy [**4-/2139**]
and  Whipple operation c/b E. coli and Klebsiella bacteremia (at
[**Hospital1 2025**]). Apparently, the source of the bacteremia was his teeth.
He is s/p removal of all of his teeth.
17.  Abdominal hernia secondary to a local procedure.
18.  Syncope.
19.  Hemorrhoids.
20.  VRE infection

Past Surgical History (per OMR):
1.  Replacement of pacemaker and ICD implantation with
revisions.
2.  Knee surgery.
3.  Squamous cell removal of the left lower eyelid.
4.  Whipple procedure.
5.  Right eye cataract surgery

Social History:
The patient lives with his significant other,
[**Name (NI) **] [**Name (NI) **].  He is divorced, and has two grown daughters.  [**Name (NI) **]
taught British and American History at [**Last Name (un) **] and [**Last Name (un) 15565**].
- Tobacco: Previous smoker.  Began smoking cigarettes in high
school and continued until age 60.  Also, smoked a pipe until
age 60.
- Alcohol: [**12-24**] glasses of wine per day.
- Illicits: None ever.

Family History:
Father died of stroke age 59.  Mother died of MI at age 70.
Brother with MI in his 50s, deceased.  Second brother deceased
with pancreatic cancer.

Physical Exam:
Admission Physical Exam:
Vitals: T: 99.2 (37.3) BP: 92/56 P: 75 RR: 16 SpO2: 96% NC
General: Alert, oriented x3, conversant, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, adentulous
Neck: supple, JVP not appreciated, no LAD
Lungs: Crackles at the bases bilaterally, no wheezes
CV: Paced, regular rate and rhythm.  Holosystolic murmur,
loudest at LLSB with radiation to the apex.  No carotid bruits.
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
small midline ventral hernia.
GU: + foley
Ext: Warm, well-perfused, 2+ pulses, fingernails mostly white
with thin reddish line at tip (c/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 15569**] nails), no edema

Discharge Physical Exam:
VS: T 100.8 HR 75 BP 93/49 RR 21 95%/2L O2xNC
Gen: NAD, comfortable, scab/thickened skin on forehead
Cardiac: RRR, holosystolic murmur loudest at LLSB
Abd: soft, nt, pos bs, ventral hernia, very mildly distended
abdomen
Ext: warm, perfused


Pertinent Results:
[**2142-7-21**] 05:50PM   WBC-8.5# RBC-3.36* HGB-11.5* HCT-33.5*
MCV-100* MCH-34.3* MCHC-34.4 RDW-15.1
[**2142-7-21**] 05:50PM   NEUTS-90.8* LYMPHS-5.2* MONOS-2.0 EOS-1.6
BASOS-0.5
[**2142-7-21**] 05:50PM   GLUCOSE-114* UREA N-34* CREAT-1.3* SODIUM-133
POTASSIUM-5.2* CHLORIDE-98 TOTAL CO2-24 ANION GAP-16
[**2142-7-21**] 10:51PM   PT-29.9* PTT-34.0 INR(PT)-2.9*
[**2142-7-21**] 05:50PM   cTropnT-<0.01 proBNP-3062*
[**2142-7-21**] 06:07PM   LACTATE-1.6
[**2142-7-21**] 06:10PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG

Micro:
[**7-22**] MRS [**Last Name (STitle) 15570**] pending
[**7-21**] BCx x2 pending
[**7-21**] UCx pending

Imaging:
CXR [**7-21**]: Left-sided pacemaker device is noted with
leads terminating in the right atrium, right ventricle, and
coronary sinus.  Abandoned leads are also noted. There are low
lung volumes. The heart size is moderately enlarged. The aortic
knob is calcified, and there is mild tortuosity of the thoracic
aorta. There is mild pulmonary vascular
congestion. No focal consolidation, pleural effusion or
pneumothorax is
present. Streaky opacities in the lung bases may reflect
atelectasis, though infection is not excluded. There are no
acute osseous abnormalities.
IMPRESSION: Mild pulmonary vascular congestion. Low lung volumes
with streaky opacities in the lung bases, possibly atelectasis,
although infection is not excluded. Repeat films with improved
inspiration may be helpful for further evaluation.

[**2142-7-21**] 6:05 pm BLOOD CULTURE   (2 bottles)
   Blood Culture, Routine (Preliminary):
      GRAM NEGATIVE ROD(S).
   Aerobic Bottle Gram Stain (Final [**2142-7-22**]):
      GRAM NEGATIVE ROD(S).
      Reported to and read back by [**First Name8 (NamePattern2) 15571**] [**Last Name (NamePattern1) 15572**] [**2142-7-22**]
12:12PM.
   Anaerobic Bottle Gram Stain (Final [**2142-7-22**]):    GRAM
NEGATIVE ROD(S).

[**2142-7-25**] TEE:
Pacing wires present with shaggy echodensities that could
represent presence of clot / fibrin / vegetations. No valvular
vegetations seen. Severely depressed left ventricular function.
Moderate mitral regurgitation.
Compared with the prior study (images reviewed) of [**2141-3-14**],
there appears to be more material associated with the wires,
although less views of the wires were taken previously.


Brief Hospital Course:
73 M with extensive cardiovascular history including CHF
secondary to ischemic cardiomyopathy with EF 20%, implanted
biventricular pacer and atrial fibrillation on warfarin, as well
as recent hospital admission for aspiration pneumonia, who was
admitted to the hospital for aspiration pneumonitis and
Klebsiella oxytoca bacteremia. Pt was initialy admitted to the
ICU and then transfered to the medical floor.

Active Diagnoses:
# GNR Bacteremia/Hypotension. Pt initial febrile, hypotensive
(low 80s) and found to have klebsiella oxytoca bacteremia.
Unclear source of infection as CT abd and Pelvis unrevealing for
GI source and urine neg for source. TEE showed no signs of
endocarditis but there were ?fibrinous material on the leads
suspicious for fibrin clot versus vegetations. He was intialy
given vanco/levoflox/flagyl for empiric coverage and then
transitioned to cefepime for a few days followed by ceftriaxone.
He will go home with 2 weeks of ceftriaxone (though [**8-8**])
followed by Cefpodaxime 200mg [**Hospital1 **] PO therafter. BP remained
primarily in the 90-110 range.

#Aspiration pneumonitis. Patient's history of difficulty
swallowing and presentation with fever, hypotension, clear CXR,
and quick resolution of elevated WBC was suggestive of
aspiration pneumonitis rather than aspiration PNA. Maintained on
regular diet with thickened liquids and aspiration precautions.

# Systolic CHF: Baseline low EF with evidence of pulmonary
congestion in CXR, although exam not consistent with volume
overload. Continued home furosemide, beta blocker, and ASA. Held
lisinopril given acute kidney injury.  Repeat TTE showed EF
15-20 %. Severely hypokinetic,dilated right ventricle. Apical
left ventricular aneurysm without clot seen. Moderate pulmonary
artery systolic hypertension. Similar to that on 12/[**2140**].

# AMS: Cleared quickly. Thought to be secondary to cerebral
hypoperfusion due to baseline decreased systolic function that
was exacerbated by SIRS from infection. Pt A+O x3 at time of
discharge.

# [**Last Name (un) **]: Creatinine peaked to 1.3 (from baseline 1.1), with BUN
34.  Likely prerenal azotemia from baseline poor systolic
function, with decreased preload secondary to SIRS, and cardiac
inability to increase stroke volume.  Cr improved with some
gentle IVF. His Cr at baseline was 0.8-1.0.

# Anemia: Macrocytic, chronic. Stable at discharge Hct (29).

#A fib: Pt with paroxysmal A fib years ago. He was last in A fib
2 yrs ago. He was continued on coumadin with goal INR [**1-25**]. INR
at discharge was 2.5.

PENDING:
-blood cx from [**7-22**], [**7-23**], [**7-24**], [**7-25**], [**7-26**]

TRANSITIONAL ISSUES:
- has recurrent gram neg rod bacteremia. Unclear primary source.
Possibly GI although CT abd and pevlis unremarkable. He will
follow up with his [**Hospital1 2025**] GI doctors.
- TEE showed some thick fibrinous material on the leads. Unclear
if this is infected. Will be treated for 2 weeks IV antibiotics
followed by PO antibiotics.
- Recurrent aspiration events. S&S saw pt in house and made
reccomendations:
1. PO diet: thin liquids, soft solids.
2. Small pills whole, large pills crushed with puree.
3. Take small sips of liquid.
4. Alternate bites and sips.
5. [**Hospital1 **] oral care.
6. Assistance with meals as needed.
- MRSA positive in nares
-TEE: Pacing wires present with shaggy echodensities that could
represent presence of clot / fibrin / vegetations. No valvular
vegetations seen. Severely depressed left ventricular function.
Moderate mitral regurgitation.

Medications on Admission:
AMIODARONE 200 mg daily
BUPROPION HCL 150 mg daily
FUROSEMIDE 60 mg daily
LEVOTHYROXINE 100 mcg Tablet daily\
LIPASE-PROTEASE-AMYLASE [CREON] - unknown dose
LISINOPRIL 2.5 mg daily
METOPROLOL TARTRATE 12.5mg [**Hospital1 **]
OXYGEN 2.5L via nasal cannula daily upon exertion
PRAMIPEXOLE 0.125 mg QHS PRN restless legs
RANITIDINE HCL 75 mg [**Hospital1 **]
WARFARIN 1-4 mg daily
ASPIRIN 81mg daily
CHOLECALCIFEROL (VITAMIN D3) 1,000 unit daily
DOCUSATE SODIUM [COLACE] 100 mg Capsule TID PRN
FERROUS SULFATE 325 mg (65 mg iron) daily (MWF)
GUAR GUM [BENEFIBER (GUAR GUM)] packet daily
SENNOSIDES [SENOKOT] 8.6 mg [**Hospital1 **] PRN

Discharge Medications:
1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. bupropion HCl 150 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO DAILY (Daily).
3. furosemide 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
4. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
6. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
8. pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO qHS PRN ()
as needed for restless leg syndrome.
9. ranitidine HCl 150 mg Tablet Sig: 0.5 Tablet PO BID (2 times
a day).
10. warfarin 2 mg Tablet Sig: One (1) Tablet PO 6X/WEEK
([**Doctor First Name **],MO,TU,WE,TH,SA).
11. warfarin 2 mg Tablet Sig: Two (2) Tablet PO 1X/WEEK (FR).
12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. ferrous sulfate 300  mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
16. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
17. ceftriaxone 2 gram Recon Soln Sig: One (1)  Intravenous once
a day for 20 days: Take through [**2142-8-8**].
Disp:*20 days* Refills:*0*
18. Oxygen 2.5L NC  Sig: as directed   as directed: Uses 2- 2.5L
NC at all times.
19. cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a
day: *START: [**2142-8-8**]. Continue until infectious disease doctor
says.
20. Lab Draw  Sig: One (1)   once a week: CBC with diff, chem 7,
INR/PTT, LFTs. Fax results to: ATTN Dr. [**Last Name (STitle) 3197**] [**Telephone/Fax (1) 1419**].

21. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation.
22. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.


Discharge Disposition:
Extended Care

Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]

Discharge Diagnosis:
Gram Negative Rod Bacteremia
Congstive Heart Failure


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking care of you at [**Hospital1 827**]!  You were admitted with a fever and confusion.
You were found to have gram negative rod bacteria in your blood
culture, and you were treated with antibiotics.  You were found
by laboratory testing and physical exam not to have other causes
of fever such as pneumonia, meningitis, encephalitis, colitis,
gastroenteritis, or pulmonary embolism.  Your mental status
improved throughout hospitalization. We will send you home on
ceftriaxone, an IV antibiotic for 2 weeks. The last day of your
IV antibiotics will be [**8-8**]. You have an appointment with Dr.
[**Last Name (STitle) 5461**] scheduled for [**8-8**] at 1pm. Dr. [**Last Name (STitle) 5461**] will be
able to further direct your management.

MEDICATION CHANGES:
START:
ceftriaxone 2gm IV

Continue taking your regular medications as prescribed

Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.

Followup Instructions:
Please follow-up this hospitalization with the following
appointments:

Please make sure you arrange an appointment with your GI doctor
from [**Hospital1 2025**] in the next 2 weeks.

Department: GERONTOLOGY
When: THURSDAY [**2142-8-2**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2847**], MD [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2142-8-8**] at 10:30 AM
With: [**First Name11 (Name Pattern1) 3688**] [**Last Name (NamePattern4) 10476**], MD [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: INFECTIOUS DISEASE
When: WEDNESDAY [**2142-8-8**] at 1 PM
With: [**First Name8 (NamePattern2) 1955**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST    Best Parking: [**Hospital Ward Name **] Garage

Department: DERMATOLOGY AND LASER
When: MONDAY [**2142-8-13**] at 1:15 PM
With: [**Doctor Last Name **],KATHEEN [**Telephone/Fax (1) 3965**]
Building: [**Location (un) 3966**] ([**Location (un) 55**], MA) [**Location (un) **]
Campus: OFF CAMPUS     Best Parking: Free Parking on
Site\nDepartment: CARDIAC SERVICES
When: THURSDAY [**2142-8-23**] at 3:00 PM
With: [**Name6 (MD) 1918**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage



Completed by:[**2142-8-1**]
{'Bacteremia,Acute kidney failure, unspecified,Chronic systolic heart failure,Other chronic pulmonary heart diseases,Systemic inflammatory response syndrome, unspecified,Atrial fibrillation,Other convulsions,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms,Other specified forms of chronic ischemic heart disease,Old myocardial infarction,Unspecified essential hypertension,Mitral valve disorders,Unspecified acquired hypothyroidism,Obesity, unspecified,Anemia, unspecified,Irritable bowel syndrome,Unspecified vitamin D deficiency,Unspecified hearing loss,Abnormality of gait,Automatic implantable cardiac defibrillator in situ,Long-term (current) use of anticoagulants,Other postprocedural status,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,History of fall'}


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



### Clinical text :
CHIEF COMPLAINT: fever and altered mental status

PRESENT ILLNESS: 73 year old male with CAD, CHF (EF 20%), v-tach s/p ICD
placement, AFib on warfarin, s/p whipple, chronic dyspnea with
2.5L NC at baseline, presenting with fever (100.2 at home),
rigors, and altered mental status. Patient has a history of
aspiration pneumonia, with admission in [**2142-4-22**] requiring an
ICU stay and ventilation.

MEDICAL HISTORY: 1.  Coronary artery disease
  - status post anterior wall myocardialinfarction in [**2126**]
  - MI c/b large apical aneurysm and VT/VF s/p ablation [**2126**]
  - s/p biventricular pacer implantation [**2135**] (replaced previous
dual chamber ICD) for complete heart block
  - pacemaker interrogated [**7-12**]
2.  Systolic heart failure
  - ejection fraction 20% on TTE in [**2141-11-22**]
3.  Atrial fibrillation, status post cardioversion [**2141-5-23**], on
anticoagulation, managed by Dr.[**Name (NI) 1912**] office.
4.  Hypertension.
5.  Hypothyroidism.
6.  Anemia.
7.  Irritable bowel syndrome.
8.  Constipation.
9.  Obesity.
10.  Hearing loss, requiring bilateral hearing aids.
11.  Squamous cell carcinoma of the left lower eyelid [**2138**].
12.  Vitamin D deficiency.
13.  Cerebral infarction [**2132**].
14.  Gait disorder with history of falls.
15.  Compression fractures.
16.  Bile duct dysplasia s/p ERCP/stent/sphincterotomy [**4-/2139**]
and  Whipple operation c/b E. coli and Klebsiella bacteremia (at
[**Hospital1 2025**]). Apparently, the source of the bacteremia was his teeth.
He is s/p removal of all of his teeth.
17.  Abdominal hernia secondary to a local procedure.
18.  Syncope.
19.  Hemorrhoids.
20.  VRE infection

MEDICATION ON ADMISSION: AMIODARONE 200 mg daily
BUPROPION HCL 150 mg daily
FUROSEMIDE 60 mg daily
LEVOTHYROXINE 100 mcg Tablet daily\
LIPASE-PROTEASE-AMYLASE [CREON] - unknown dose
LISINOPRIL 2.5 mg daily
METOPROLOL TARTRATE 12.5mg [**Hospital1 **]
OXYGEN 2.5L via nasal cannula daily upon exertion
PRAMIPEXOLE 0.125 mg QHS PRN restless legs
RANITIDINE HCL 75 mg [**Hospital1 **]
WARFARIN 1-4 mg daily
ASPIRIN 81mg daily
CHOLECALCIFEROL (VITAMIN D3) 1,000 unit daily
DOCUSATE SODIUM [COLACE] 100 mg Capsule TID PRN
FERROUS SULFATE 325 mg (65 mg iron) daily (MWF)
GUAR GUM [BENEFIBER (GUAR GUM)] packet daily
SENNOSIDES [SENOKOT] 8.6 mg [**Hospital1 **] PRN

ALLERGIES: Penicillins / Ambien / Trazodone

PHYSICAL EXAM: Admission Physical Exam:
Vitals: T: 99.2 (37.3) BP: 92/56 P: 75 RR: 16 SpO2: 96% NC
General: Alert, oriented x3, conversant, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, adentulous
Neck: supple, JVP not appreciated, no LAD
Lungs: Crackles at the bases bilaterally, no wheezes
CV: Paced, regular rate and rhythm.  Holosystolic murmur,
loudest at LLSB with radiation to the apex.  No carotid bruits.
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
small midline ventral hernia.
GU: + foley
Ext: Warm, well-perfused, 2+ pulses, fingernails mostly white
with thin reddish line at tip (c/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 15569**] nails), no edema

FAMILY HISTORY: Father died of stroke age 59.  Mother died of MI at age 70.
Brother with MI in his 50s, deceased.  Second brother deceased
with pancreatic cancer.

SOCIAL HISTORY: The patient lives with his significant other,
[**Name (NI) **] [**Name (NI) **].  He is divorced, and has two grown daughters.  [**Name (NI) **]
taught British and American History at [**Last Name (un) **] and [**Last Name (un) 15565**].
- Tobacco: Previous smoker.  Began smoking cigarettes in high
school and continued until age 60.  Also, smoked a pipe until
age 60.
- Alcohol: [**12-24**] glasses of wine per day.
- Illicits: None ever. 

### Response:
{'Bacteremia,Acute kidney failure, unspecified,Chronic systolic heart failure,Other chronic pulmonary heart diseases,Systemic inflammatory response syndrome, unspecified,Atrial fibrillation,Other convulsions,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms,Other specified forms of chronic ischemic heart disease,Old myocardial infarction,Unspecified essential hypertension,Mitral valve disorders,Unspecified acquired hypothyroidism,Obesity, unspecified,Anemia, unspecified,Irritable bowel syndrome,Unspecified vitamin D deficiency,Unspecified hearing loss,Abnormality of gait,Automatic implantable cardiac defibrillator in situ,Long-term (current) use of anticoagulants,Other postprocedural status,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,History of fall'}
