CHIEF COMPLAINT: Infected right AV graft

PRESENT ILLNESS: 66 year-old male with multiple medical problems including CAD
status post CABG, HTN, PAF not on anticoagulation [**1-21**] history of
GI bleed, and ESRD on hemodialysis who has had multiple RUE AV
access procedures. He was found to have an exposed RUE AV
fistula/graft in clinic on [**2166-12-25**], and was sent to Pre-Op for
a planned repair where he became febrile to 103.0, with chills.
No headache, sore throat, cough, chest pain, shortness of
breath, N/V, rash or abdominal pain. Mr. [**Known lastname **] does not void.

MEDICAL HISTORY: 1. Coronary artery disease s/p MI in [**12/2164**], status post 2
stents to the LAD. Cath in [**1-/2165**] revealed re-stenosis of both
stents. He is status post 3-vessel CABG on [**2165-2-20**] with LIMA to
LAD, saphenous vein to RCA, saphenous vein to OM.
2. ESRD x 5 years on HD (MWF), felt secondary to HTN
3. Status post CVA in [**2149**] with residual left-sided hemiparesis
4. Hypertension
5. UGIB after cardiac cath on [**12/2164**]
6. Gout
7. Pancreatitis
8. Diverticulosis
9. History of multiple E coli bacteremias
10. Anemia of chronic disease
11. Hypercholesteremia
12. COPD
13. Afib/Aflutterm, not on anticoagulation secondary to history
of GI bleed.

MEDICATION ON ADMISSION: Lipitor 10mg qd
Nephrocaps 1 [**Hospital1 **]
Protonix 40mg qd
Renagel 1200mg tid
ASA 325mg qd
Norvasc 5mg qd
Clonidine 0.1mg [**Hospital1 **]
Enalapril 20mg qd

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Per transplant surgery admission note on [**2166-12-25**]:
VITALS: T 193, HR 99, BP 130/59, RR 18
GEN: In NAD. Alert and oriented X 3.
HEENT: No icterus. Clear OP.
LN: No cervical or axillary LAD
RESP: Chest CTA bilaterally. No wheezes.
CVS: RRR.
GI: BS normoactive. Abdomen soft and non-tender. No hernia. No
mass.
EXT: No pedal edema. Calves non-tender.
INTEGUMENT: No rash.

FAMILY HISTORY: Mother with hypertension
No history of no strokes, seizures, or heart disease

SOCIAL HISTORY: The patient lives at home with his wife & daughter in a [**Location (un) 6332**] apartment with an elevator. No VNA care was necessary
prior to admission, and the patient could attend to all of his
own ADLs.
Infection and inflammatory reaction due to other vascular device, implant, and graft,Bacteremia,Chronic airway obstruction, not elsewhere classified,Atrial flutter,Cerebral artery occlusion, unspecified with cerebral infarction,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Hyperpotassemia,Viral hepatitis B without mention of hepatic coma, acute or unspecified, without mention of hepatitis delta,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Disorders of phosphorus metabolism,Anemia, unspecified
React-oth vasc dev/graft,Bacteremia,Chr airway obstruct NEC,Atrial flutter,Crbl art ocl NOS w infrc,Hyp kid NOS w cr kid V,Hyperpotassemia,Hpt B acte wo cm wo dlta,Abn react-procedure NEC,Other staphylococcus,Cor ath unsp vsl ntv/gft,Aortocoronary bypass,Dis phosphorus metabol,Anemia NOS
Admission Date:  [**2166-12-25**]              Discharge Date:   [**2167-1-17**]

Date of Birth:  [**2100-11-15**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 826**]
Chief Complaint:
Infected right AV graft

Major Surgical or Invasive Procedure:
Excision of right arm AV graft
Placement of right IJ permacath on [**2166-12-28**]
Placement of a right groin temporary HD catheter
Placement of a right tunneled HD line on [**2167-1-9**]


History of Present Illness:
66 year-old male with multiple medical problems including CAD
status post CABG, HTN, PAF not on anticoagulation [**1-21**] history of
GI bleed, and ESRD on hemodialysis who has had multiple RUE AV
access procedures. He was found to have an exposed RUE AV
fistula/graft in clinic on [**2166-12-25**], and was sent to Pre-Op for
a planned repair where he became febrile to 103.0, with chills.
No headache, sore throat, cough, chest pain, shortness of
breath, N/V, rash or abdominal pain. Mr. [**Known lastname **] does not void.

Past Medical History:
1. Coronary artery disease s/p MI in [**12/2164**], status post 2
stents to the LAD. Cath in [**1-/2165**] revealed re-stenosis of both
stents. He is status post 3-vessel CABG on [**2165-2-20**] with LIMA to
LAD, saphenous vein to RCA, saphenous vein to OM.
2. ESRD x 5 years on HD (MWF), felt secondary to HTN
3. Status post CVA in [**2149**] with residual left-sided hemiparesis
4. Hypertension
5. UGIB after cardiac cath on [**12/2164**]
6. Gout
7. Pancreatitis
8. Diverticulosis
9. History of multiple E coli bacteremias
10. Anemia of chronic disease
11. Hypercholesteremia
12. COPD
13. Afib/Aflutterm, not on anticoagulation secondary to history
of GI bleed.

Social History:
The patient lives at home with his wife & daughter in a [**Location (un) 6332**] apartment with an elevator. No VNA care was necessary
prior to admission, and the patient could attend to all of his
own ADLs.

Family History:
Mother with hypertension
No history of no strokes, seizures, or heart disease

Physical Exam:
Per transplant surgery admission note on [**2166-12-25**]:
VITALS: T 193, HR 99, BP 130/59, RR 18
GEN: In NAD. Alert and oriented X 3.
HEENT: No icterus. Clear OP.
LN: No cervical or axillary LAD
RESP: Chest CTA bilaterally. No wheezes.
CVS: RRR.
GI: BS normoactive. Abdomen soft and non-tender. No hernia. No
mass.
EXT: No pedal edema. Calves non-tender.
INTEGUMENT: No rash.

Pertinent Results:
Admission labs [**2166-12-25**]:
WBC-11.5*# HGB-11.8* HCT-35.2* PLT COUNT-166
GLUCOSE-139* UREA N-56* CREAT-9.3*# SODIUM-135 POTASSIUM-4.2
CHLORIDE-90* TOTAL CO2-31* ANION GAP-18
ALT(SGPT)-9 AST(SGOT)-20 ALK PHOS-145* TOT BILI-0.4
ALBUMIN-4.3 CALCIUM-11.2* PHOSPHATE-4.4 MAGNESIUM-1.9
PT-13.9* PTT-27.7 INR(PT)-1.2

[**2166-12-25**] EKG: Afib, rate 104. Lateral ST-T wave changes.

[**2166-12-25**] CXR: No acute disease
Relevant studies in hospital:
[**2166-12-30**] CT HEAD: FINDINGS: There is an area of decreased
attenuation involving the white and [**Doctor Last Name 352**] matter of the posterior
left frontal lobe. This could be consistent with an evolving
infarct. Diffuse areas of low attenuation in the periventricular
white matter is consistent with chronic microvascular
angiopathy. No intracranial mass lesion, hydrocephalus, or shift
of normally midline structures is apparent. There is no evidence
of intracranial hemmorage. Numerous calcifications are noted in
the sulci, brain parenchyma and ventricles.

Osseous and soft tissue structures are unremarkable.

IMPRESSION:
1. Likely evolving infarct of the left posterior frontal lobe,
which would be consistent with the patient's history of new
expressive aphasia.
2. Numerous intracranial scattered calcifications, which could
represent prior cystercercosis infection. Clinical correlation
is recommended.
3. No evidence of intracranial hemorrhage.

[**2166-12-30**] MRI HEAD: There is a wedge-shaped area of slow
diffusion in the ventral portion of the left pons, consistent
with an acute infarction. There is also slow diffusion involving
the posterior aspect of the insular cortex, operculum, and
anterior aspect of the left parietal lobe consistent with an
acute infarction. There are multiple areas of increased T2
signal in the periventricular subcortical white matter
consistent with chronic small vessel infarctions. There is also
a region of magnetic susceptibility artifact in the posterior
right thalamus, consistent with sequela from a prior
intraparenchymal hemorrhage. There is associated Wallerian
degeneration in the right cerebral peduncle. There are multiple
areas of magnetic susceptiblity artifact throughout both
cerebral hemispheres, which correspond to the multiple
intraparenchymal calcifications, consisent with sequela from
prior cystercercosis infection. On the postcontrast images,
there is no abnormal enhancement in the brain parenchyma.

In the MRA images, there is no evidence of a vascular occlusion,
stenosis, or aneurysm involving the arteries in the circle of
[**Location (un) 431**]. There is some motion artifact which limits the study. We
do not have a good evaluation of the distal smaller branches of
the intracerebral vasculature. The vertebral arteries, basilar
arteries, intracranial internal carotid arteries, and the middle
and anterior cerebral arteries are patent.

There is a small T1- and T2-hyperintense mass in the soft
tissues of the left frontal scalp. This may represent a small
sebaceous or proteinaceous cyst.

IMPRESSION: Acute infarctions involving the left ventral pons
and the posterior left insular cortex, left temporal operculum,
and left anterior parietal lobe.

[**2166-12-31**] U/S carotids: Bilateral < 40% stenosis

[**2166-12-31**] TTE: The left atrium is elongated. The right atrium is
moderately dilated. There is moderate symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
are mildly thickened. There is no aortic valve stenosis. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. There is
no pericardial effusion.

Compared with the prior study (tape reviewed) of [**2165-3-4**],
there is no
significant change.

[**2167-1-6**] TEE: The left atrium is mildly dilated. 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. The interatrial septum is
aneurysmal with a very small superior left-to-right shunt color
Doppler at rest. There is mild symmetric left ventricular
hypertrophy with normal cavity size and systolic function
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. There are complex (>4mm non-mobile) atheroma in the
descending thoracic aorta. The aortic valve leaflets are
moderately thickened but severe aortic stenosis is not suggested
and no discrete vegetations are seen. Mild to
moderate ([**12-21**]+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened but no discrete vegetations are
seen. Trivial mitral
regurgitation is seen. There is no pericardial effusion.

Brief Hospital Course:
66 year-old male with multiple medical problems including CAD
s/p CABG, PAF on no anticoagulation [**1-21**] history of GU bleed,
HTN, and ESRD on HD, admitted with an exposed and infected AV
graft. His hospital course will be reviewed by problems.

1) Exposed/infected AV graft and MSSA bacteremia: Mr. [**Known lastname **] was
initially admitted to the transplant surgery service and taken
to the OR on [**2166-12-25**] for the emergent removal of his
exposed/infected RUE AV graft. The infected portions were
removed. A temporary right groin HD catheter was placed. He was
initially started on empiric Vancomycin, Levofloxacin and
Flagyl. Blood cultures drawn on [**2166-12-25**] eventually all grew
methicillin-sensitive Staph aureus, 6/6 bottles. Flagyl was
D/C'd, and Vancomycin was eventually switched to Linezolid PO,
which unfortunately was ordered but never approved. He received
a short course of Oxacillin ([**2166-12-30**]), and ID was consulted on
[**2166-12-31**], at which time antibiotics were switched to Cefazolin
2gm IV with hemodialysis ([**2166-12-31**]). Blood cultures from [**12-26**]
grew MSSA 1/4 bottles. Surveillance blood cultures on [**12-27**] and
[**12-31**] negative.

Given his Staph aureus bacteremia, a TTE was performed on
[**2166-12-31**] which was negative for vegetations. A TEE was
subsequently performed on [**2167-1-6**], which was also negative for
vegetations, although it revealed a small ASD. Nonetheless, per
ID, given his high-grade staphylococcus aureus bacteremia on
admission, removal of only the infected portions of the AV graft
(? ends), negative TEE but possibly in the setting of having
already thrown a vegetation, decision was taken to complete 6
weeks of antibiotherapy. Hence, plan is to continue Cefazolin 2
gm IV with hemodialysis, counting from [**2166-12-27**] (first negative
blood cultures). Last dose on
[**2167-2-7**].

2) CVA: Mr. [**Known lastname **] has a known history of PAF, and was not on
anticoagulation on admission given a prior history of GI bleed.
He also has a prior history of CVA, with residual left
hemiparesis. On [**2166-12-30**], Mr. [**Known lastname **] was noted to have new
expressive aphasia, with a left sided mouth droop. CT head and
MRI head were consistent with an acute infarct involving the
left ventral pons and the posterior left insular cortex, left
temporal operculum, and left anterior parietal lobe. Neurology
was consulted, and Mr. [**Known lastname **] was started on anticoagulation
with Coumadin, as well as aspirin. Goal MAP>90. Of note, given
his poor vascular access, Heparin could not be given. Lovenox
was also not an option in the setting of his ESRD. Coumadin was
temporarily held on [**2167-1-9**] for line placement.

The etiology of his CVA was felt most likely cardioembolic in
the setting of known PAF (in atrial fibrillation in hospital)
and no anticoagulation. Septic embolus was also a concern given
his MSSA bacteremia. Hence, he underwent a TTE on [**2166-12-31**],
which was negative for vegetations. A carotid ultrasound
revealed bilateral <40% stenosis of his carotids. A TEE was also
performed on [**2167-1-6**], which was also negative for vegetations,
although it revealed a small ASD.

He is to remain on anticoagulation with goal INR [**1-22**], as well as
ASA. He will need follow-up of his INR. INR 1.3 at discharge.
Follow-up to be arranged with the [**Hospital3 **].

3) ESRD: Mr. [**Known lastname **] was followed by the renal service throughout
his stay. He was continued on hemodialysis 3 times per week.
Meds were renally dosed. Of note, while in hospital, he was
noted to have persistent hyperkalemia despite hemodialysis,
which was felt secondary to dietary indiscretions and food
brought by family. He was kept on a low potassium diet, with
good results. He will need continued close monitoring of his
electrolytes, especially phosphate with possible up titration of
his meds.

Of note, Mr. [**Known lastname **] has extremely poor vascular access.
Temporary lines were placed in his right groin and right IJ. A
tunneled HD line was placed on [**2167-1-9**]. Permanent vascular
access should be delayed until after completion of 6 weeks of IV
antibiotics and documentation of sterile blood cultures 3 days
after discontinuation of antibiotics.

4) CAD: Mr. [**Known lastname **] has known CAD, and is status post CABG. No
acute issues in hospital. He was continued on ASA, statin, ACE
inhibitor. It is unclear why he is not on a beta-blocker as an
out-patient.

5) Anemia: Mr. [**Known lastname 32641**] hematocrit was between 28-34 while in
hospital. Iron studies on [**2167-1-6**] revealed Fe 43, TRF 148,
Ferritin [**2142**], TIBC 192. He was transfused a single unit of
PRBCs on [**2166-12-29**], and remained fairly stable afterwards.
Hematocrit 28.8 at discharge.

6) FEN: Cardiac heart healthy ([**2-20**] gm Na)/ Renal diet. Ensure
low potassium.

Medications on Admission:
Lipitor 10mg qd
Nephrocaps 1 [**Hospital1 **]
Protonix 40mg qd
Renagel 1200mg tid
ASA 325mg qd
Norvasc 5mg qd
Clonidine 0.1mg [**Hospital1 **]
Enalapril 20mg qd

Discharge Medications:
1. Clonidine HCl 0.1 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).

4. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Enalapril Maleate 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Cefazolin Sodium 10 g Recon Soln Sig: Two (2) grams Injection
Q HEMODIALYSIS ().
7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Sevelamer HCl 400 mg Tablet Sig: Five (5) Tablet PO TID (3
times a day).
10. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime for 2
days: Please give Coumadin 5 mg PO QHS on [**2167-1-10**] and [**2167-1-11**]
and check INR daily. Please adjust subsequent Coumadin dose for
goal INR [**1-22**]. INR on [**2167-1-10**] 1.3.

Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]

Discharge Diagnosis:
Infected right arm AV graft
Staphylococcus aureus bacteremia
Atrial fibrillation
Cerebrovascular accident
End-stage renal disease

Secondary diagnoses:
Coronary artery disease


Discharge Condition:
Patient stable at discharge.

Discharge Instructions:
Please see below for recommended follow-up appointments.

Please take all medications as prescribed.

Please return to the ED if you develop recurrent temperature
>101.5, weakness, slurred speach, confusion, chest pain,
shortness of breath, redness or drainage from right groin
catheter, increased redness or drainage from right arm,
persistent pain, or any other worrisome symptoms.

Followup Instructions:
With Dr. [**First Name (STitle) **] in one week.  Please call for appt.
[**Telephone/Fax (1) 673**]
Please call your nephrologist and schedule an appointment to see
him within 1 week of discharge. You will continue HD 3 times per
week.

Please call your PCP and schedule and appointment to see him/her
withinh 2 weeks of discharge.

We will call the neurology clinic at [**Hospital1 18**] and schedule an
appointment. We will call you with the appointment date and
time.

You will need follow-up in the [**Hospital3 **]. We will
notify you with your appointment date and time.



Completed by:[**2167-1-10**]

Name:  [**Known lastname 5644**],[**Known firstname 5645**]               Unit No:   [**Numeric Identifier 5646**]

Admission Date:  [**2166-12-25**]              Discharge Date:   [**2167-1-17**]

Date of Birth:  [**2100-11-15**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 3435**]
Addendum:
The patient was not discharged on [**2167-1-10**] as had been
anticipated due to difficulties with the rehabilitation facility
placement.
.
The patient's hct dropped to 26.6 on [**2167-1-14**] and he had guaiac
positive stool.  He anticoagulation was stopped and he was
transfused 2u pRBCs on [**2167-1-15**].  The patient's hct recovered
after the transfusion and remained stable for the remainder of
his hospitalization.
.
He was discharged to [**Hospital 5662**] Hospital on [**2167-1-17**]

Discharge Disposition:
Extended Care

Facility:
[**Hospital3 14**] & Rehab Center - [**Hospital1 15**]

                             [**Name6 (MD) 116**] [**Last Name (NamePattern4) 1531**] MD [**MD Number(1) 1532**]

Completed by:[**2167-1-17**]
{'Infection and inflammatory reaction due to other vascular device, implant, and graft,Bacteremia,Chronic airway obstruction, not elsewhere classified,Atrial flutter,Cerebral artery occlusion, unspecified with cerebral infarction,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Hyperpotassemia,Viral hepatitis B without mention of hepatic coma, acute or unspecified, without mention of hepatitis delta,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Disorders of phosphorus metabolism,Anemia, unspecified'}


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: Infected right AV graft

PRESENT ILLNESS: 66 year-old male with multiple medical problems including CAD
status post CABG, HTN, PAF not on anticoagulation [**1-21**] history of
GI bleed, and ESRD on hemodialysis who has had multiple RUE AV
access procedures. He was found to have an exposed RUE AV
fistula/graft in clinic on [**2166-12-25**], and was sent to Pre-Op for
a planned repair where he became febrile to 103.0, with chills.
No headache, sore throat, cough, chest pain, shortness of
breath, N/V, rash or abdominal pain. Mr. [**Known lastname **] does not void.

MEDICAL HISTORY: 1. Coronary artery disease s/p MI in [**12/2164**], status post 2
stents to the LAD. Cath in [**1-/2165**] revealed re-stenosis of both
stents. He is status post 3-vessel CABG on [**2165-2-20**] with LIMA to
LAD, saphenous vein to RCA, saphenous vein to OM.
2. ESRD x 5 years on HD (MWF), felt secondary to HTN
3. Status post CVA in [**2149**] with residual left-sided hemiparesis
4. Hypertension
5. UGIB after cardiac cath on [**12/2164**]
6. Gout
7. Pancreatitis
8. Diverticulosis
9. History of multiple E coli bacteremias
10. Anemia of chronic disease
11. Hypercholesteremia
12. COPD
13. Afib/Aflutterm, not on anticoagulation secondary to history
of GI bleed.

MEDICATION ON ADMISSION: Lipitor 10mg qd
Nephrocaps 1 [**Hospital1 **]
Protonix 40mg qd
Renagel 1200mg tid
ASA 325mg qd
Norvasc 5mg qd
Clonidine 0.1mg [**Hospital1 **]
Enalapril 20mg qd

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Per transplant surgery admission note on [**2166-12-25**]:
VITALS: T 193, HR 99, BP 130/59, RR 18
GEN: In NAD. Alert and oriented X 3.
HEENT: No icterus. Clear OP.
LN: No cervical or axillary LAD
RESP: Chest CTA bilaterally. No wheezes.
CVS: RRR.
GI: BS normoactive. Abdomen soft and non-tender. No hernia. No
mass.
EXT: No pedal edema. Calves non-tender.
INTEGUMENT: No rash.

FAMILY HISTORY: Mother with hypertension
No history of no strokes, seizures, or heart disease

SOCIAL HISTORY: The patient lives at home with his wife & daughter in a [**Location (un) 6332**] apartment with an elevator. No VNA care was necessary
prior to admission, and the patient could attend to all of his
own ADLs. 

### Response:
{'Infection and inflammatory reaction due to other vascular device, implant, and graft,Bacteremia,Chronic airway obstruction, not elsewhere classified,Atrial flutter,Cerebral artery occlusion, unspecified with cerebral infarction,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Hyperpotassemia,Viral hepatitis B without mention of hepatic coma, acute or unspecified, without mention of hepatitis delta,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Disorders of phosphorus metabolism,Anemia, unspecified'}
