CHIEF COMPLAINT: Fever and Weight loss

PRESENT ILLNESS: Mr. [**Known lastname 1968**] is a 68 yo male with RCA stenting in [**2190**], aortic
stenosis sp Mosaic aortic valve in [**2-/2192**], right hip
replacement in [**6-/2194**], BPH, and  ED who presents with FUO since
[**3-19**].

MEDICAL HISTORY: Stent to RCA [**2190**]
Mosaic Aortic Valve [**2-/2192**]
Right Hip Replacement [**6-/2194**]
BPH
ED
Prostatitis

MEDICATION ON ADMISSION: Fish oil 1000-mg/day
Aspirin 325-mg/day
Gemfibrozil 300-mg [**Hospital1 **]
Terazosin 10-mg/day
Singulair 10-mg/day
Advil 3x/day
Tylenol 3x/day
Tremix Injections (ED)

ALLERGIES: Percocet

PHYSICAL EXAM: VS: 97.7, 99/67, 68, 18, 99%RA
GENERAL: Patient appear ill, NAD, appropriate.
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, no mucosal
lesions in the mouth.
NECK: Supple, no JVD.
HEART: RRR, III/VI SEM heard across the precordium and radiating
to the carotids which has been noted previously, no heave.
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored.

FAMILY HISTORY: Grandmother, Grandfather with heart failure. Brother with MI at
age 70.

SOCIAL HISTORY: Retired. Lives in [**Location **],Ma. Married with two children. No
tobacco. Etoh 10 drinks weekly. No drugs.
Infection and inflammatory reaction due to cardiac device, implant, and graft,Acute and subacute bacterial endocarditis,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other specified bacteria,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Impotence of organic origin,Percutaneous transluminal coronary angioplasty status,Hip joint replacement,Other restorative surgery causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation
React-cardiac dev/graft,Ac/subac bact endocard,Oth specf bacteria,Crnry athrscl natve vssl,Hypertension NOS,BPH w/o urinary obs/LUTS,Impotence, organic orign,Status-post ptca,Joint replaced hip,Abn react-plast surg NEC
Admission Date:  [**2196-6-30**]              Discharge Date:   [**2196-7-9**]

Date of Birth:  [**2128-5-26**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
Percocet

Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Fever and Weight loss

Major Surgical or Invasive Procedure:
[**2196-7-2**] - 1. Aortic valve replacement with a size 21-mm
[**Last Name (un) 3843**]-[**Doctor Last Name **] Magna tissue valve.2. Pericardial patch
repair of left ventricular outflow tract.


History of Present Illness:
Mr. [**Known lastname 1968**] is a 68 yo male with RCA stenting in [**2190**], aortic
stenosis sp Mosaic aortic valve in [**2-/2192**], right hip
replacement in [**6-/2194**], BPH, and  ED who presents with FUO since
[**3-19**].

Of note, he had a dental bridge done in [**Month (only) 404**], for which he
was appropriately treated with Amoxicillin peri-operatively. On
[**3-19**] while snow shoeing in at Sunapee in [**Location (un) 3844**] he
developed a rigors, fever, cough and myalgias of his left thigh.
He remembers the date distinctly because of the intense rigors
and muscle pain in his left thigh. He was in all of his ski wear
with the heat on and could not shake the chills. The chills and
fevers have continued intermittently approx 2-3x weekly since
that time. His fever had peaked at 101.9-102, and last night had
fever to 103.

Since [**Month (only) 547**] he has noted a decline in appeptite (everything
smells horrible), 20 pound weight loss, fatigue, dizziness with
blood pressure that runs lower than normal for him.

He initially saw a pulmonologist for the cough. He was treated
with a Z-Pack for URI without improvement. He was given a
prednisone taper and his cough improved. He does not note any
changes in his fever pattern while on prednisone (no
improvement, or worsening). He also notes severe night sweats
soaking through 3 t-shirts per night. As an aside he notes the
red cross will not accept his blood because of positive
hepatitis antibodies (unknown what type) and says that occurred
after having a "booster" from his PCP.

He has travelled multiple places for skiing trips over the past
few months. He travelled to [**Country 6962**] in [**Month (only) 404**], [**State 8449**] in
[**Month (only) 958**], and [**Location (un) 3844**]. He took Amoxicillin 500mg daily for 4
weeks, to make himself feel better for skiing.

He has reportedly had negative radiographs and a negative CT for
his cough. He works on the Appalachian Trail, and reports that
he gets about [**11-16**] tic bites per year. Lyme titer was
reportedly negative. He has a new anemia with an HCT in the low
30s. A PPD was not placed due to the negative nature of his CT
and X-Rays.

He was evaluated by a hematologist/oncologist and after one
interview, he questioned endocarditis as a source. He discussed
this with Dr. [**Last Name (STitle) 1911**] and had a planned TEE for this
morning. However he developed a fever to 103 and went to [**Hospital3 25354**]. Two sets of blood cultures were drawn and one
gram vancomycin was given. He was then transported to our ED.

He endorses injecting Tremix into his penis for erectile
dysfunction 12-18 times since sometime mid last year. He says
that he never noticed an abnormal or cloudy vial. Patient
endorses a rash on his back and chest in [**Month (only) 958**] that resolved
without intervention and was papular in nature. Denies any chest
discomfort, palpitations, shortness of breath, lower extremity
swelling, orthopnea.

He has had mild headache, one episode of abdominal pain, no
changes in bowel habits, BRBPR, change in vision, weakness,
numbness, new lumps or bumps. He denies sexual activity with
anyone other than his wife, and denies knowing of his wife
having other sexual partners. [**Name (NI) **] denies drug use.

Overnight, blood cultures were sent. Gentimicin 210mg IV was
given in addition to the vanco he received. EKG was performed
with increase in ST depression/scooping laterally. CXR performed
and was unremarkable. Troponin flat at 0.11, 0.10 (MBs negative
x2).

This morning he is resting in bed, tired, with cough, but very
pleasant and otherwise feeling ok.


Past Medical History:
Stent to RCA [**2190**]
Mosaic Aortic Valve [**2-/2192**]
Right Hip Replacement [**6-/2194**]
BPH
ED
Prostatitis


Social History:
Retired. Lives in [**Location **],Ma. Married with two children. No
tobacco. Etoh 10 drinks weekly. No drugs.


Family History:
Grandmother, Grandfather with heart failure. Brother with MI at
age 70.


Physical Exam:
VS: 97.7, 99/67, 68, 18, 99%RA
GENERAL: Patient appear ill, NAD, appropriate.
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, no mucosal
lesions in the mouth.
NECK: Supple, no JVD.
HEART: RRR, III/VI SEM heard across the precordium and radiating
to the carotids which has been noted previously, no heave.
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored.

ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: No lower extremity edema. 2+ peripheral pulses.
Mild tenderness on palpation of the right hand, without
erythema, swelling.
SKIN: No obvious [**Last Name (un) **] lesions or splinter hemorrhages. No
rashes or lesions.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3, CNs II-XII intact, strength 5/5 in
upper/lower extremity. Normal sensation.


Pertinent Results:
Admission Labs:
[**2196-7-1**] 04:18AM BLOOD WBC-14.5*# RBC-3.75* Hgb-10.6* Hct-32.3*
MCV-86 MCH-28.2 MCHC-32.7 RDW-16.1* Plt Ct-232
[**2196-7-1**] 04:18AM BLOOD PT-13.8* PTT-26.9 INR(PT)-1.2*
[**2196-7-1**] 04:18AM BLOOD Glucose-125* UreaN-14 Creat-0.8 Na-140
K-4.0 Cl-105 HCO3-26 AnGap-13
[**2196-7-1**] 04:18AM BLOOD ALT-17 AST-27 LD(LDH)-292* CK(CPK)-31*
AlkPhos-177* TotBili-0.6
[**2196-7-1**] 04:18AM BLOOD Albumin-3.7 Calcium-9.0 Phos-3.5 Mg-2.0
Iron-10*

STUDIES:

TEE (Complete) Done [**2196-7-1**]
Conclusions
No spontaneous echo contrast is seen in the body of the left
atrium. 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 aortic arch and descending
thoracic aorta to 45 cm. A bioprosthetic aortic valve prosthesis
is present with abnormal rocking motion of the aortic annulus,
suggestive of partial dehiscence. The prosthetic aortic valve
leaflets are thickened with a moderate sized vegetation (0.4x0.8
cm) on the non-coronary cusp (clips 56, 61). No aortic valve
abscess is seen. Trace central aortic regurgitation is seen
(clips 14, 23). The mitral valve leaflets are mildly thickened
with trivial mitral regurgitation. No mass or vegetation is seen
on the mitral valve. The tricuspid valve leaflets are mildly
thickened. No vegetation/mass is seen on the pulmonic valve.
There is a trivial/physiologic pericardial effusion.

IMPRESSION: Moderate sized vegetation on the bioprothestic
aortic valve with partial dehiscence. Trace aortic
regurgitation. Normal biventricular systolic function.

Compared with the prior study (images reviewed) of [**2192-3-3**],
the vegetation and partial dehiscence of the bioprosthetic
aortic valve is new.


Brief Hospital Course:
Mr. [**Known lastname 1968**] presented with fevers, weightloss, malaise and cough
that began in [**Month (only) 956**]. He was admitted for a TEE to rule out
endocarditis given his prosthetic valve. He was initially
started on antibiotics at the OSH and in the Emergency
Department (Gentamicin, Vancomycin, Cefepime). ID was consulted
for medical management as well as Cardiac Surgery for surgical
management. Antibiotics were stopped in efforts to obtain
positive cultures. He had blood cultures drawn in the ED as well
as in the morning after admission. TEE showed a moderate sized
vegetation and partial valve dehiscence. He was taken to cardiac
surgery the following morning where he underwent a redo
sternotomy with an aortic valve replacement and a patch repair
of the left ventricular outflow tract. Please see operative note
for details. Postoperatively he was taken to the intensive care
unit for monitoring. Over the next 24 hours, he awoke
neurologically intact and was extubated.  Beta blocker was
initiated and the patient was gently diuresed toward the
preoperative weight.  The patient was transferred to the
telemetry floor for further recovery.  Chest tubes and pacing
wires were discontinued without complication.  The patient was
evaluated by the physical therapy service for assistance with
strength and mobility.  ID continued to follow and direct the
antibiotic course.  OR tissue culture would grow
ABIOTROPHIA/GRANULICATELLA SPECIES.  Antibiotics were changed to
Penicillin G and Gentamicin to continue through 6 weeks from
[**2196-7-2**].  He did develop a scant amount of serous drainage on
POD 5.  Diuresis was increased and this did improve.  By the
time of discharge on POD 6 the patient was ambulating, yet
deconditioned, the wound was healing and pain was controlled
with oral analgesics.  The patient was discharged to [**Hospital 1514**]
Health Care in good condition with appropriate follow up
instructions.

Medications on Admission:
Fish oil 1000-mg/day
Aspirin 325-mg/day
Gemfibrozil 300-mg [**Hospital1 **]
Terazosin 10-mg/day
Singulair 10-mg/day
Advil 3x/day
Tylenol 3x/day
Tremix Injections (ED)

Discharge Medications:
1. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 7  days: then decrease to 200mg by mouth [**Hospital1 **] x 1week,
then decrease to 200mg by mouth daily.
Disp:*28 Tablet(s)* Refills:*1*
2. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. potassium chloride 20 mEq Packet Sig: One (1)  PO once a day
for 7 days.
Disp:*7 tablets* Refills:*0*
4. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
5. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO four times
a day as needed for fevber/pain.
Disp:*30 Tablet(s)* Refills:*0*
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*30 Capsule(s)* Refills:*0*
7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
9. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
Disp:*QS ML(s)* Refills:*0*
10. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
Disp:*14 Suppository(s)* Refills:*0*
11. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. gemfibrozil 600 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
Disp:*30 Tablet(s)* Refills:*2*
13. terazosin 5 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
Disp:*30 Capsule(s)* Refills:*2*
14. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
15. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
16. Penicillin G Potassium 4 Million Units IV Q4H
17. Gentamicin 100 mg IV Q8H Start: In am


Discharge Disposition:
Extended Care

Facility:
[**Hospital 1514**] Health Care Center - [**Location (un) 1514**]

Discharge Diagnosis:
Primary:
Endocarditis with valve dehiscence

Past Medical History:
CAD s/p RCA stent [**2190**]
Mosaic aortic valve replacement [**2-12**]
Right hip replacement [**6-13**]
Htn
Prostatitis
BPH
ED
Past Surgical History:
s/p AVR [**2-12**]
s/p R THR [**6-13**]

Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema 1+


Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns [**Telephone/Fax (1) 170**]

*Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**


Followup Instructions:
You are scheduled for the following appointments
Surgeon: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2196-8-1**] 1:30
Cardiologist: Dr. [**Last Name (STitle) 1911**]

Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 28261**] [**Telephone/Fax (1) 28262**] in [**5-10**] weeks

**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**

Labs Q week: CBC with diff, Chem 7, Gent trough, ESR, CRP -
first draw 1 hr before 4th dose of Gent - Fax results to Dr
[**Last Name (STitle) 9461**] fax [**Telephone/Fax (1) 1419**]


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

Completed by:[**2196-7-9**]
{'Infection and inflammatory reaction due to cardiac device, implant, and graft,Acute and subacute bacterial endocarditis,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other specified bacteria,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Impotence of organic origin,Percutaneous transluminal coronary angioplasty status,Hip joint replacement,Other restorative surgery causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation'}


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 Weight loss

PRESENT ILLNESS: Mr. [**Known lastname 1968**] is a 68 yo male with RCA stenting in [**2190**], aortic
stenosis sp Mosaic aortic valve in [**2-/2192**], right hip
replacement in [**6-/2194**], BPH, and  ED who presents with FUO since
[**3-19**].

MEDICAL HISTORY: Stent to RCA [**2190**]
Mosaic Aortic Valve [**2-/2192**]
Right Hip Replacement [**6-/2194**]
BPH
ED
Prostatitis

MEDICATION ON ADMISSION: Fish oil 1000-mg/day
Aspirin 325-mg/day
Gemfibrozil 300-mg [**Hospital1 **]
Terazosin 10-mg/day
Singulair 10-mg/day
Advil 3x/day
Tylenol 3x/day
Tremix Injections (ED)

ALLERGIES: Percocet

PHYSICAL EXAM: VS: 97.7, 99/67, 68, 18, 99%RA
GENERAL: Patient appear ill, NAD, appropriate.
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, no mucosal
lesions in the mouth.
NECK: Supple, no JVD.
HEART: RRR, III/VI SEM heard across the precordium and radiating
to the carotids which has been noted previously, no heave.
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored.

FAMILY HISTORY: Grandmother, Grandfather with heart failure. Brother with MI at
age 70.

SOCIAL HISTORY: Retired. Lives in [**Location **],Ma. Married with two children. No
tobacco. Etoh 10 drinks weekly. No drugs. 

### Response:
{'Infection and inflammatory reaction due to cardiac device, implant, and graft,Acute and subacute bacterial endocarditis,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other specified bacteria,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Impotence of organic origin,Percutaneous transluminal coronary angioplasty status,Hip joint replacement,Other restorative surgery causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation'}
