CHIEF COMPLAINT: transfered here for epicardial abscess management

PRESENT ILLNESS: 65 y.o. M with steroid dependent COPD/asthma, recurrent
pulmonary infections due to MRSA/pseudomonas, s/p [**Hospital 39700**]
transferred from [**Hospital3 **] on [**2146-4-12**] with endocarditis
and complete heart black with temporary pacer with no escape
rhythm.
.
Patient was admitted to [**Hospital1 **] on [**4-9**] with presumed COPD
exacerbation and CHF. Overnight he became more tachypnic with
hypercarbic respiratory failure and was intubated in the morning
of [**4-10**]. He was also found to have [**3-23**] second paused and
responded to atropine. Patient was also hypotensive to 80s
during the episode and then recovered to SBP of 100s. Patient
was also found with with 3:4 Wenckebach rhythm varying with
Mobitz pattern rhythm, then PAF with tachyarrhythmia 1-teens,
with 4-5 second pauses. TEE was performed on [**4-10**]. He went into
patient was found to be in in complete heart block. Luckily, by
that point he had a single temporary V wire inserted through R
IJ on [**4-10**]. Since then patient with no escape rhythm.
.
Patient has severe undelrying COPD (FEV1 0.79) requiring chronic
high dose steroids. He was started on high dose solumedrol at
[**Hospital1 **]. Patient was also found to be bacteremic with MRSA [**3-22**]
BCx upon initial admission with less than 24 hours, started on
Vanco and Levo. Gentamycin was added the next day for synnergy.
Patient also with 4/23 GNR in his sputum. Patient was recently
treated for MRSA bacteremia and sepsis back in [**10-23**]. Presumed
source was IV thrombophlebitis. Patient was also found to have
lung septic embolic. Patient underwent 6 week course of Vanco IV
and 4 week of Linezolid (for presumed improved pulmonary
penetration). Repeat CT on [**1-/2146**] showed improvement of
pulmonary cavitations on chest CT.
.
Patient was transfered to [**Hospital1 18**] for further management. On the
morning of transfer patient with Hct from 33 to 27 with minimal
coffee ground emesis and guiac positive stools. Hct appears to
be stable @ 27 upon repeat.
ROS: upon arrival to CCU, patient is intubated, he stays he is
in mil pain. He denies any cp, sob. No fevers/chills.
Communication is limited due to intubation but he appears lucid.

MEDICAL HISTORY: # NO known CAD
# HTN
# COPD - FEV1 .79 ~ 29%, requiring persistent high dose steroids
and mulitiple admission to [**Hospital3 **]/[**Hospital1 1872**] Rehab. CO2
33 on [**4-9**] with pH of 7.39, CO2 63, pO2 74, HCO3 38, Sats 94%.
# Multiple cavitary lession- NOS - in lungs after MRSA skin
infection in [**2145-10-19**], appears to be improved [**1-/2146**]
# MRSA septicemia - [**10-23**] from IV line Tx with Vanco 6 weeks,
then Linezolid x 4 weeks with septic emboli to the lungs.
# Pseudomonas in sputum
# Cervical disk disease - C4-5 discectomy [**2142-9-18**]
- chornic management with moderate narcotics
# ? epidrual abscess or a large disk herniation - due to
complain of increased neck pain detected on MRI on [**12/2145**]
---- repeat CT on [**4-11**] showed no evidence of epidural mass
although a small epidural abscess may not be excluded if very
small and unable to be picked up by CT resolution
---- C3-C4 small posterior protrusion, also milD dorSal bulging
consistent with degenerative narrowing of C5-C6 narrowing of
left C6 foramen, same @ C6-C7.
# Chronic Hepatitis C -s/p succesful IFN therapy 8 years ago
# Chronic Anemia -
# Multiple surgeries including ventral hernia repair s/p bullet
wound in 20s.
# Chronic Anxiety and depression
# Nl renal function - Cr 0.7 upon admission to [**Hospital1 **] [**4-9**]
# Recurrent epistaxis - s/p septal repair - thus no
anticoagulation

MEDICATION ON ADMISSION: Prednisone 10 mg QD
Albuterol nebs [**Hospital1 **]
Spririva 18 mcg QD
Fentanyl 50 mcg q72
Ativan 0.5 mg PO BID
KCl 20 mg QD
Advair 500/50 1 puff [**Hospital1 **]
Ranitidine 150 mg QD
Percocet 3/325 1 tab po TID
Vitamin D 50,000 po Qwk
.
from [**Hospital1 **]:
Methylpred 40 mg IV q8
Vanco 1 gm q12
Levquin 500 mg IV qd
Gentamicin 60 mg IV q8
Lipitor 80 QD
Fentanyl patch 50 mcg every 72 hrs
Protonix 40 IV QD
ECASA 325
NTP 0.5

ALLERGIES: Sulfa (Sulfonamides) / Cephalosporins

PHYSICAL EXAM: Vitals: wt 61.5 97.1 HR 60 BP 102/60 RR 15 100%
Gen: awake, frail, elder gentleman, ETT, NAD
HEENT: anicteric, left inferio-medial conjuctival hemorrhage, MM
dry, R IJ cordis with pacer wire, no JVD appreciated on L side,

FAMILY HISTORY: FHx: emphysema in mother, no other known CAD

SOCIAL HISTORY: SHx: h/o tobacco, no etoh. No IVDU. Chronic narcotic use. Lives
alone. single.
.
Methicillin susceptible Staphylococcus aureus septicemia,Septic shock,Acute and subacute bacterial endocarditis,Abscess of lung,Acute respiratory failure,Acquired coagulation factor deficiency,Obstructive chronic bronchitis with (acute) exacerbation,Pneumonia due to Pseudomonas,Atrioventricular block, complete,Chronic hepatitis C without mention of hepatic coma,Thrombocytopenia, unspecified,Blood in stool,Ulcer of heel and midfoot,Embolism and thrombosis of other specified artery,Psoas muscle abscess,Cerebral embolism without mention of cerebral infarction,Long-term (current) use of steroids,Infection with microorganisms resistant to penicillins,Severe sepsis,Degeneration of cervical intervertebral disc,Unspecified essential hypertension
Meth susc Staph aur sept,Septic shock,Ac/subac bact endocard,Abscess of lung,Acute respiratry failure,Acq coagul factor defic,Obs chr bronc w(ac) exac,Pseudomonal pneumonia,Atriovent block complete,Chrnc hpt C wo hpat coma,Thrombocytopenia NOS,Blood in stool,Ulcer of heel & midfoot,Arterial embolism NEC,Psoas muscle abscess,Crbl emblsm wo infrct,Long-term use steroids,Inf mcrg rstn pncllins,Severe sepsis,Cervical disc degen,Hypertension NOS
Admission Date:  [**2146-4-12**]              Discharge Date:   [**2146-4-22**]

Date of Birth:  [**2080-11-19**]             Sex:   M

Service: MEDICINE

Allergies:
Sulfa (Sulfonamides) / Cephalosporins

Attending:[**First Name3 (LF) 2698**]
Chief Complaint:
transfered here for epicardial abscess management

Major Surgical or Invasive Procedure:
Intubated, R-SCV placed, A-line, Pacer Wire placed, PICC line

History of Present Illness:
65 y.o. M with steroid dependent COPD/asthma, recurrent
pulmonary infections due to MRSA/pseudomonas, s/p [**Hospital 39700**]
transferred from [**Hospital3 **] on [**2146-4-12**] with endocarditis
and complete heart black with temporary pacer with no escape
rhythm.
.
Patient was admitted to [**Hospital1 **] on [**4-9**] with presumed COPD
exacerbation and CHF. Overnight he became more tachypnic with
hypercarbic respiratory failure and was intubated in the morning
of [**4-10**]. He was also found to have [**3-23**] second paused and
responded to atropine. Patient was also hypotensive to 80s
during the episode and then recovered to SBP of 100s. Patient
was also found with with 3:4 Wenckebach rhythm varying with
Mobitz pattern rhythm, then PAF with tachyarrhythmia 1-teens,
with 4-5 second pauses. TEE was performed on [**4-10**]. He went into
patient was found to be in in complete heart block. Luckily, by
that point he had a single temporary V wire inserted through R
IJ on [**4-10**]. Since then patient with no escape rhythm.
.
Patient has severe undelrying COPD (FEV1 0.79) requiring chronic
high dose steroids. He was started on high dose solumedrol at
[**Hospital1 **]. Patient was also found to be bacteremic with MRSA [**3-22**]
BCx upon initial admission with less than 24 hours, started on
Vanco and Levo. Gentamycin was added the next day for synnergy.
Patient also with 4/23 GNR in his sputum. Patient was recently
treated for MRSA bacteremia and sepsis back in [**10-23**]. Presumed
source was IV thrombophlebitis. Patient was also found to have
lung septic embolic. Patient underwent 6 week course of Vanco IV
and 4 week of Linezolid (for presumed improved pulmonary
penetration). Repeat CT on [**1-/2146**] showed improvement of
pulmonary cavitations on chest CT.
.
Patient was transfered to [**Hospital1 18**] for further management. On the
morning of transfer patient with Hct from 33 to 27 with minimal
coffee ground emesis and guiac positive stools. Hct appears to
be stable @ 27 upon repeat.
ROS: upon arrival to CCU, patient is intubated, he stays he is
in mil pain. He denies any cp, sob. No fevers/chills.
Communication is limited due to intubation but he appears lucid.



Past Medical History:
# NO known CAD
# HTN
# COPD - FEV1 .79 ~ 29%, requiring persistent high dose steroids
and mulitiple admission to [**Hospital3 **]/[**Hospital1 1872**] Rehab. CO2
33 on [**4-9**] with pH of 7.39, CO2 63, pO2 74, HCO3 38, Sats 94%.
# Multiple cavitary lession- NOS - in lungs after MRSA skin
infection in [**2145-10-19**], appears to be improved [**1-/2146**]
# MRSA septicemia - [**10-23**] from IV line Tx with Vanco 6 weeks,
then Linezolid x 4 weeks with septic emboli to the lungs.
# Pseudomonas in sputum
# Cervical disk disease - C4-5 discectomy [**2142-9-18**]
- chornic management with moderate narcotics
# ? epidrual abscess or a large disk herniation - due to
complain of increased neck pain detected on MRI on [**12/2145**]
---- repeat CT on [**4-11**] showed no evidence of epidural mass
although a small epidural abscess may not be excluded if very
small and unable to be picked up by CT resolution
---- C3-C4 small posterior protrusion, also milD dorSal bulging
consistent with degenerative narrowing of C5-C6 narrowing of
left C6 foramen, same @ C6-C7.
# Chronic Hepatitis C -s/p succesful IFN therapy 8 years ago
# Chronic Anemia -
# Multiple surgeries including ventral hernia repair s/p bullet
wound in 20s.
# Chronic Anxiety and depression
# Nl renal function - Cr 0.7 upon admission to [**Hospital1 **] [**4-9**]
# Recurrent epistaxis - s/p septal repair - thus no
anticoagulation

Social History:
SHx: h/o tobacco, no etoh. No IVDU. Chronic narcotic use. Lives
alone. single.
.


Family History:
FHx: emphysema in mother, no other known CAD

Physical Exam:
Vitals: wt 61.5 97.1 HR 60 BP 102/60 RR 15 100%
Gen: awake, frail, elder gentleman, ETT, NAD
HEENT: anicteric, left inferio-medial conjuctival hemorrhage, MM
dry, R IJ cordis with pacer wire, no JVD appreciated on L side,

NECK: no adenopathy
CV: RRR, nl S1, S2, unable to appreciate murmur given increased
AP diameter of chest.
Chest: diffuse rales, no wheezes, no crackles, mechanical breath
sounds, barrel chested.
Abd: + BS - faint, snt/nd, no masses
Ext: no edema, no cyanosis, no clubbing
Skin: both hand (palms) and feet(soles) with Osler nodes and
[**Last Name (un) **] lesions.
Vasc: + 1 DP b/l


Pertinent Results:
Labs:
from OSH:
[**4-9**] BCx x 2 - total 6 cultures, each day + for MRSA
[**4-10**] Sputum: GNR, staph
[**4-12**]
146/4.4 109/32 45/0.8 Ca7.7 Alb 1.5 tProt 5.5 tBili 1.8 Dbili
0.8 AlkPhos 117 ALT 67 AST 85
WBC 16K 22% B [**4-9**] -> 22.2 -> 16.3 -> 13.7 @ [**Hospital1 18**]
Hct 33 -> 27.2 Plt 112
Trop [**4-9**] 0.52 -> 0.49 -> 0.71
BNP 756 [**4-9**]
.
Labs:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2146-4-21**] 05:04AM    17.1* 3.84* 10.8* 32.4* 84 28.1 33.4
19.1* 91

[**2146-4-12**] 12:30PM    13.7* 3.29* 8.6* 28.9* 88 26.2* 29.8*
16.3* 90
            Neuts Bands Lymphs Monos Eos Baso Atyps Metas Myelos

[**2146-4-12**] 12:30PM    95* 3 0 2 0 0 0 0 0
.
Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2146-4-21**] 05:04AM    120* 23* 0.4* 136 3.7 100 32 8
.
HEMOLYSIS LABS:
Fibrino FDP D-Dimer
[**2146-4-20**] 03:17PM      40-80
[**2146-4-18**] 06:02AM      40-80
[**2146-4-18**] 06:02AM    132*   2753
.
ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili IndBili
[**2146-4-20**] 03:17PM        438*       2.2
                     Hapto
[**2146-4-20**] 03:17PM    25
.
HEPATITIS:
HCV Ab
[**2146-4-19**] 05:09PM    POSITIVE
[**2146-4-19**] 5:09 pm IMMUNOLOGY      Source: Line-aline.

   HCV VIRAL LOAD
      >700,000 IU/ml.
.
MICRO:
[**4-20**] SPUTUM: *FINAL REPORT [**2146-4-22**]**

   GRAM STAIN (Final [**2146-4-20**]):
      >25 PMNs and <10 epithelial cells/100X field.
      4+   (>10 per 1000X FIELD):   GRAM NEGATIVE ROD(S).

   RESPIRATORY CULTURE (Final [**2146-4-22**]):
      OROPHARYNGEAL FLORA ABSENT.
      PSEUDOMONAS AERUGINOSA.    MODERATE GROWTH.
.
[**4-19**] SPUTUM: 5:09 pm SPUTUM      Source: Endotracheal.

   GRAM STAIN (Final [**2146-4-19**]):
      >25 PMNs and <10 epithelial cells/100X field.
      3+  (5-10 per 1000X FIELD):   GRAM NEGATIVE ROD(S).
      2+   (1-5 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND CLUSTERS.

   RESPIRATORY CULTURE (Preliminary):
      OROPHARYNGEAL FLORA ABSENT.
      PSEUDOMONAS AERUGINOSA.    MODERATE GROWTH.
      STAPH AUREUS COAG +.    MODERATE GROWTH.
.
[**4-12**] BCX:
[**2146-4-12**] 12:10 pm BLOOD CULTURE      Random.

                            **FINAL REPORT [**2146-4-18**]**

   AEROBIC BOTTLE (Final [**2146-4-17**]):
      [**2146-4-15**] REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13478**] AT 7:00 AM.
      PSEUDOMONAS AERUGINOSA.
.
[**Date range (1) 11757**] BCX: NO GROWTH
.
[**4-16**] BCX:[**2146-4-16**] 6:34 pm BLOOD CULTURE

                            **FINAL REPORT [**2146-4-22**]**

   AEROBIC BOTTLE (Final [**2146-4-22**]):    NO GROWTH.

   ANAEROBIC BOTTLE (Final [**2146-4-20**]):
      STAPH AUREUS COAG +.
.
5/2BCX:
[**2146-4-19**] 5:22 pm BLOOD CULTURE

   AEROBIC BOTTLE (Preliminary):
      STAPH AUREUS COAG +.    FINAL SENSITIVITIES.
         Oxacillin RESISTANT Staphylococci
5/3BCX: Pending
.
[**4-13**]: TEE: Large mobile anterior leaflet mitral valve vegetation
with leaflet perforation and moderate-severe mitral
regurgitation. Echolucent space consistent with an abscess in
the interatrial septum posterior to the aortic root and color
flow consistent with fistulous connection into the right atrium.
Smaller mobile vegetation on the tricuspid valve.
.
[**4-13**]: CT head: Two small foci of increased density within the
right frontal lobe. The study is limited by the lack of a
non-contrast acquisition, however, these findings could
represent enhancing vessels versus small foci of extra-axial
hemorrhage or cortical enhancement.
.
[**4-13**]: CT neck: Multiple cavitating and noncavitating pulmonary
nodules at the right and left lung apices, and bilateral pleural
effusions. The findings are consistent with septic emboli. No
definite evidence of epidural abscess.
.
[**4-17**]: Chest CT:
IMPRESSION:
1. Numerous nodular opacities throughout the lungs, many of
which are cavitary consistent with septic emboli. The largest is
within the right middle lobe measuring 3.6 x 3.0 cm with an
air-fluid level.
2. Small bilateral pleural effusions.
3. Striated, hyperdense nephrograms bilaterally concerning for
renal failure.
.
[**4-17**] RUQ US:
FINDINGS: Multiple small 3-5 mm likely polyps are present within
the gallbladder. No stones are identified. The gallbladder wall
is mildly thickened measuring 5 mm. There is moderate ascites in
the right upper quadrant. No shadowing gallstones are
identified. The common bile duct is not clearly identified, and
thus is likely not dilated. The proximal pancreas is normal.
IMPRESSION: Edematous gallbladder wall likely secondary to third
spacing. No gallstones identified. Right upper quadrant ascites.
.
[**4-18**] CXR:
PORTABLE SEMI-UPRIGHT CHEST RADIOGRAPH:
The endotracheal tube is seen at the thoracic inlet. The carina
is not well visualized. There is no significant change in
positioning compared to prior study. Pacer wire is again noted
and unchanged. Right-sided PICC line tip is seen within the
distal SVC.
Again noted are multiple bilateral cavitary opacities (better
seen on recent CT), consistent with multifocal infection and
possible septic emboli that are unchanged compared to prior.

Brief Hospital Course:
A/P: 65 y.o. M with severe steroid dependent COPD, recent MRSA
cellulitis in [**10-23**] with pulmonary septal emboli/cavitations,
myocardial abscess, MV vegetation, [**Last Name (un) 1003**] lessions and MRSA
bacteremia, intubated for increasing tachypnea and hypoxia.
.
# Valves/Mitral Valve: MRSA bacterial endocarditis
w/paravalvular abscess, vegetations - seen on TEE with
myocardial abscess.  Pt had evidence of septal emboli in
conjuctivae, fingertip, lungs, spleen, spine, and 2 foci in
brain. Pt did not have any neurological deficits and no signs of
hemorrhage in brain. He was closely followed by ID. He was
started on Vanc and completed 5 days of Gentamycin for Abx
synergy. His blood cultures cleared from [**4-13**] as well as
remained afebrile. His blood cultures were followed daily, his
WBC fluctuated without any specific pattern but remained
elevated. CT [**Doctor First Name **] was following pt for possible surgery but the
following concerns for sugery included;  1. inability to suspend
new valve, 2. persistent bacteremia 3. lack of CHF or urgency
for surgery 4. septic emboli 5. poor PFTs 6. GIB. Per the
Brother, if surgery was a possibility then to proceed with
surgery. However, per the pt he did not want any heroic
measures. There was a tentative plan for OR on [**5-2**], awaiting
for Brain foci to mature, improve his nutrition as his albumin
was 1.5. Multiple discussions were had with CT surgery, Dr.
[**Last Name (STitle) **], Dr. [**Last Name (STitle) 66985**] regarding surgical intervention. On [**4-21**]
there was a discussion with the pt whom did not want to proceed
with surgery, and did not want to be intubated. The pt
understood completely that without the surgery he would die. The
pt was adamant that he did not want to proceed with the surgery
nor remain intubated. The pt was lucid and it was agreed upon
with the brother and medical team to proceed with extubation.
The pt expired the following morning on [**4-22**] at 6am.
.
.
# Rhythm/Complete Heart Block - Patient with complete heart
block; initial presentation was with tachy/brady arrythmias,
pacer wire placed for severe bradycardia w/ intermittent
block-->eventual CHB. Wire place [**4-10**]. Transition from EMS pacer
to CCU pacer showed evidence of CHB w/o escape rhythm.
- paced @ 60, no issues, per ID will leave temporary wire in
- EP: s/p screwed in R V - VVI wire with external RSCL pacer -
[**4-13**].  On day of extubation the pt had many episodes of pacer
not capturing in setting of respiratory distress.
.
# Pump - patient with no h/o CHF, per prelim echo appears to
have nl EF with +1MR, echo here showed + 3 MR.  Pt did not have
any evidence of fluid overload. Captopril 6.25 TID to help with
MR, however it was held on several occasions for hypotension.
.
# CAD - patient with + troponins, flat CKs and no ischemic EKG
changes@ OSH, peak CK 24, peak Trop .71, most likely due to
myocardial abscess and associated myocardial necrosis.  No ASA
was given in the setting of GIB and possible surgery. He was not
on Lipitor, BB, and Ace as no prior known disease.
.
# Respiratory failure - most likely due to severe underlying
COPD, ?flair. Currently intubated due to respiratory distress
(tachypneic to 40, shallow breathing, tiring out): hypercarbic
respiratory failure (per ABG). Pt was kept intubated for
>10days. Pulmonary was consulted in setting of possible
extubation. He was maintained on steroids and weaned to 10mg
Prednisone daily. He was also found to have pseudomonas in his
sputum and treated w/10days of Aztreonam. He continued to show
psuedomonas in his sputum cultures following Aztreonam
treatment. However, pt requested to be extubated. On [**4-21**] post
extubation, pt eventually had respiratory distress, his O2 sats
dropped to 70s and expired early morning on [**2146-4-22**].
.
# MRSA bacteremia - primary bacteremia vs secondary bacteremia
from pulmonary cavitation vs ? epidural abscess. Pt was
continued on Vanco with 6 days of Gent synergy. Daily
surveillance cultures were followed, as well as fever curve and
WBC. Endocarditis as mentioned above. On [**4-19**] started to have
fevers, his A line was resited, his PICC was kept in place as
difficulty with access and possible interference with pacer
wires. Plan for PICC line removal when BCX returned as started
to have new + blood cultures from [**4-19**]. However, pt shortly
expired post extubation on [**2146-4-22**] in am.
.
# ? epidural abscess - patient evaluated by IR @ [**Hospital1 **], it may
be one of the sources for recurrent septicemia. Percutaneous C&S
of pre-vertebral Abnormality @ C5 was enteretained. However,
patient is very high risk and there is no neurological
involvement. Also, previous MRI w/o evidence of abscess, CT of
cervical vertebrae could not exclude a small epidural abscess.
repeat CT [**4-13**] showed no clear evidence in C3-4, but ? of
abscess in L4 region.  As there was no neurological deficits and
given his more pressing MV endocarditis no further w/u for spine
done. Continued IV Vanco.
.
# Anemia - patient with admission Hct of 33, this AM with a drop
to 27.2 of almost 6 points. Hct here of 28.9. NGT with minimal
coffee grounds initially that resolved. He had a few episodes of
BRBPR as well as ~200cc blood from ETT. He received 2 UPRBC as
well as a bag of platelets.  Stool were grossly positive for
ocult blood.  GI was consulted and advised to stop ASA, protonix
IV BID. He was ruled out for a retroperitoneal bleed with CT on
[**4-14**]. His HCT was followed closely. Hemolysis labs were checked
and showed a mild DIC picture, but no schistocytes, stable PLTs.
Heme was consulted for persisten Thrombocytopenia. Most likely
etiology was poor synthetic function rather than DIC picture or
loss. Heme recommended supportive care as needed with clotting
factors in setting of bleeding. Pt remained HD stable and did
not require further transfusions beyond [**4-15**].
.
# Hypernatremia - patient appears dehydrated with free water
deficit of 2.4L
- give 1/2 NS x 2L over next 24 hours
- high BUN with high bicarb suggest contraction alkalosis as
well vs. baseline given severe COPD.  His hypernatremia
resolved.
.
# Elevated INR - [**1-20**] to old HepC, vs malnutrition (alb 1.2) vs.
current levo, vs infiltrative/embolic liver disease, vs recently
started statin
- d/c statin, continue to follow, reverse if needed for
procedures with FFP, IVF
- vitamin k 10mg x1 on [**4-12**] - improving INR
- nutrition consult
.
# HCP - [**Name (NI) **] [**Name (NI) 66986**]: [**Telephone/Fax (1) 66987**]
.
# DNR

Medications on Admission:
Prednisone 10 mg QD
Albuterol nebs [**Hospital1 **]
Spririva 18 mcg QD
Fentanyl 50 mcg q72
Ativan 0.5 mg PO BID
KCl 20 mg QD
Advair 500/50 1 puff [**Hospital1 **]
Ranitidine 150 mg QD
Percocet 3/325 1 tab po TID
Vitamin D 50,000 po Qwk
.
from [**Hospital1 **]:
Methylpred 40 mg IV q8
Vanco 1 gm q12
Levquin 500 mg IV qd
Gentamicin 60 mg IV q8
Lipitor 80 QD
Fentanyl patch 50 mcg every 72 hrs
Protonix 40 IV QD
ECASA 325
NTP 0.5

Discharge Medications:
None

Discharge Disposition:
Expired

Discharge Diagnosis:
Expired

Discharge Condition:
Expired

Discharge Instructions:
N/A

Followup Instructions:
N/A


Completed by:[**2146-4-23**]
{'Methicillin susceptible Staphylococcus aureus septicemia,Septic shock,Acute and subacute bacterial endocarditis,Abscess of lung,Acute respiratory failure,Acquired coagulation factor deficiency,Obstructive chronic bronchitis with (acute) exacerbation,Pneumonia due to Pseudomonas,Atrioventricular block, complete,Chronic hepatitis C without mention of hepatic coma,Thrombocytopenia, unspecified,Blood in stool,Ulcer of heel and midfoot,Embolism and thrombosis of other specified artery,Psoas muscle abscess,Cerebral embolism without mention of cerebral infarction,Long-term (current) use of steroids,Infection with microorganisms resistant to penicillins,Severe sepsis,Degeneration of cervical intervertebral disc,Unspecified essential hypertension'}


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: transfered here for epicardial abscess management

PRESENT ILLNESS: 65 y.o. M with steroid dependent COPD/asthma, recurrent
pulmonary infections due to MRSA/pseudomonas, s/p [**Hospital 39700**]
transferred from [**Hospital3 **] on [**2146-4-12**] with endocarditis
and complete heart black with temporary pacer with no escape
rhythm.
.
Patient was admitted to [**Hospital1 **] on [**4-9**] with presumed COPD
exacerbation and CHF. Overnight he became more tachypnic with
hypercarbic respiratory failure and was intubated in the morning
of [**4-10**]. He was also found to have [**3-23**] second paused and
responded to atropine. Patient was also hypotensive to 80s
during the episode and then recovered to SBP of 100s. Patient
was also found with with 3:4 Wenckebach rhythm varying with
Mobitz pattern rhythm, then PAF with tachyarrhythmia 1-teens,
with 4-5 second pauses. TEE was performed on [**4-10**]. He went into
patient was found to be in in complete heart block. Luckily, by
that point he had a single temporary V wire inserted through R
IJ on [**4-10**]. Since then patient with no escape rhythm.
.
Patient has severe undelrying COPD (FEV1 0.79) requiring chronic
high dose steroids. He was started on high dose solumedrol at
[**Hospital1 **]. Patient was also found to be bacteremic with MRSA [**3-22**]
BCx upon initial admission with less than 24 hours, started on
Vanco and Levo. Gentamycin was added the next day for synnergy.
Patient also with 4/23 GNR in his sputum. Patient was recently
treated for MRSA bacteremia and sepsis back in [**10-23**]. Presumed
source was IV thrombophlebitis. Patient was also found to have
lung septic embolic. Patient underwent 6 week course of Vanco IV
and 4 week of Linezolid (for presumed improved pulmonary
penetration). Repeat CT on [**1-/2146**] showed improvement of
pulmonary cavitations on chest CT.
.
Patient was transfered to [**Hospital1 18**] for further management. On the
morning of transfer patient with Hct from 33 to 27 with minimal
coffee ground emesis and guiac positive stools. Hct appears to
be stable @ 27 upon repeat.
ROS: upon arrival to CCU, patient is intubated, he stays he is
in mil pain. He denies any cp, sob. No fevers/chills.
Communication is limited due to intubation but he appears lucid.

MEDICAL HISTORY: # NO known CAD
# HTN
# COPD - FEV1 .79 ~ 29%, requiring persistent high dose steroids
and mulitiple admission to [**Hospital3 **]/[**Hospital1 1872**] Rehab. CO2
33 on [**4-9**] with pH of 7.39, CO2 63, pO2 74, HCO3 38, Sats 94%.
# Multiple cavitary lession- NOS - in lungs after MRSA skin
infection in [**2145-10-19**], appears to be improved [**1-/2146**]
# MRSA septicemia - [**10-23**] from IV line Tx with Vanco 6 weeks,
then Linezolid x 4 weeks with septic emboli to the lungs.
# Pseudomonas in sputum
# Cervical disk disease - C4-5 discectomy [**2142-9-18**]
- chornic management with moderate narcotics
# ? epidrual abscess or a large disk herniation - due to
complain of increased neck pain detected on MRI on [**12/2145**]
---- repeat CT on [**4-11**] showed no evidence of epidural mass
although a small epidural abscess may not be excluded if very
small and unable to be picked up by CT resolution
---- C3-C4 small posterior protrusion, also milD dorSal bulging
consistent with degenerative narrowing of C5-C6 narrowing of
left C6 foramen, same @ C6-C7.
# Chronic Hepatitis C -s/p succesful IFN therapy 8 years ago
# Chronic Anemia -
# Multiple surgeries including ventral hernia repair s/p bullet
wound in 20s.
# Chronic Anxiety and depression
# Nl renal function - Cr 0.7 upon admission to [**Hospital1 **] [**4-9**]
# Recurrent epistaxis - s/p septal repair - thus no
anticoagulation

MEDICATION ON ADMISSION: Prednisone 10 mg QD
Albuterol nebs [**Hospital1 **]
Spririva 18 mcg QD
Fentanyl 50 mcg q72
Ativan 0.5 mg PO BID
KCl 20 mg QD
Advair 500/50 1 puff [**Hospital1 **]
Ranitidine 150 mg QD
Percocet 3/325 1 tab po TID
Vitamin D 50,000 po Qwk
.
from [**Hospital1 **]:
Methylpred 40 mg IV q8
Vanco 1 gm q12
Levquin 500 mg IV qd
Gentamicin 60 mg IV q8
Lipitor 80 QD
Fentanyl patch 50 mcg every 72 hrs
Protonix 40 IV QD
ECASA 325
NTP 0.5

ALLERGIES: Sulfa (Sulfonamides) / Cephalosporins

PHYSICAL EXAM: Vitals: wt 61.5 97.1 HR 60 BP 102/60 RR 15 100%
Gen: awake, frail, elder gentleman, ETT, NAD
HEENT: anicteric, left inferio-medial conjuctival hemorrhage, MM
dry, R IJ cordis with pacer wire, no JVD appreciated on L side,

FAMILY HISTORY: FHx: emphysema in mother, no other known CAD

SOCIAL HISTORY: SHx: h/o tobacco, no etoh. No IVDU. Chronic narcotic use. Lives
alone. single.
. 

### Response:
{'Methicillin susceptible Staphylococcus aureus septicemia,Septic shock,Acute and subacute bacterial endocarditis,Abscess of lung,Acute respiratory failure,Acquired coagulation factor deficiency,Obstructive chronic bronchitis with (acute) exacerbation,Pneumonia due to Pseudomonas,Atrioventricular block, complete,Chronic hepatitis C without mention of hepatic coma,Thrombocytopenia, unspecified,Blood in stool,Ulcer of heel and midfoot,Embolism and thrombosis of other specified artery,Psoas muscle abscess,Cerebral embolism without mention of cerebral infarction,Long-term (current) use of steroids,Infection with microorganisms resistant to penicillins,Severe sepsis,Degeneration of cervical intervertebral disc,Unspecified essential hypertension'}
