CHIEF COMPLAINT: fevers/chills, gastrointestinal distress

PRESENT ILLNESS: 30 year old male well known to cardiac surgery with a history of
AV endocarditis with MSSA in [**2137**] and [**2140**], enteroccocus in
[**2142**], s/p AVR x 2 in [**2140**] and [**2142**] who presented to [**Hospital 57051**]
medical center on [**2145-4-2**] with 1 week of
intermittent crampy abdominal pain, fatigue, chills, diarrhea,
loose stools, headache and neck pain. He states his pain
originated 5-7 days ago, is sharp and constant in intensity, and
was not relieved by over the counter analgesics. The pain in his
head and neck with worse with changing positions. Upon arrival
to the OSH, he was febrile to 100.7, found to have a WBC of 9
wtih bandemia to 18%, with blood cultures growing GNR in [**4-11**]
bottles. He was started on vancomycin amikacin and cefepime
(vancomycin was discontinued after GNR were discovered on
culture). TTE demonstrated EF 55% with LVF, AV not well
visualized, but no vegetations observed. Now found to have most
likely recurrent
endocaridits given progression on TEE, continuing to spike
fevers and dital embolism secondary to vegetation. He was
referred to cardiac surgery for redo AVR x4/+/-possible Bentall.

MEDICAL HISTORY: 1. Bicuspid Aortic Valve- s/p Aortic Valvuolplasty at age 15
2. MSSA Recurrent Aortic Valve Endocarditis, ([**2137**], [**2139**])
----[**12/2137**]: MSSA endocarditis: with a 6 week course of
nafcillin and ultimately [**Year (4 digits) 1834**] a Bentall procedure utilizing
homograft along with VSD closure and debridement of aortic root
abscess.
----[**3-/2140**]: MSSA? Endocarditis: Redo aortic valve replacement
with a size 27 mm Onyx mechanical valve and ascending aortic
interposition graft with a size 24 mm Dacron graft
3. History of Septic Emboli to Spleen, Kidney and Cerebrum;
hepatic pseudoaneurysm embolization in [**2137**]
4. Intravenous Drug Abuser; patient states last time used IVDs
was prior to his last surgery in [**2139**].
5. History encephalomalacia of the right parietal lobe from a
prior infarct, and minimal chronic microvascular ischemic
changes.
6. Chronic systolic heart failure

MEDICATION ON ADMISSION: Carvedilol 12.5mg [**Hospital1 **]
ASA 81mg daily
Ferrous sulfate 325mg daily
Warfarin 10mg daily

ALLERGIES: Zosyn / Gentamicin

PHYSICAL EXAM: Pulse:90 Resp:18  O2 sat:98/RA
B/P  117/74
Height:5'[**43**]"     Weight:100.9 kgs

FAMILY HISTORY: Patient adopted and does not know family history.

SOCIAL HISTORY: Quit tobacco just prior to admission h/o [**2-8**] ppd for 12 years.
Denies ETOH over the last year. He currently lives with his
parents. Several years of IVDU but denies since last AVR.
Other septicemia due to gram-negative organisms,Acute and subacute bacterial endocarditis,Infection and inflammatory reaction due to cardiac device, implant, and graft,Chronic diastolic heart failure,Acute kidney failure, unspecified,Cellulitis and abscess of foot, except toes,Hyposmolality and/or hyponatremia,Cardiac tamponade,Enteritis due to norwalk virus,Arterial embolism and thrombosis of lower extremity,Septic arterial embolism,Severe sepsis,Thrombocytopenia, unspecified,Tobacco use disorder,Dermatitis due to drugs and medicines taken internally,Iron deficiency anemia, unspecified,Other acute postoperative pain,Adjustment disorder with anxiety,Anemia of other chronic disease,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Penicillins causing adverse effects in therapeutic use,Long-term (current) use of anticoagulants
Gram-neg septicemia NEC,Ac/subac bact endocard,React-cardiac dev/graft,Chr diastolic hrt fail,Acute kidney failure NOS,Cellulitis of foot,Hyposmolality,Cardiac tamponade,Int inf norwalk virus,Lower extremity embolism,Septic arterial embolism,Severe sepsis,Thrombocytopenia NOS,Tobacco use disorder,Drug dermatitis NOS,Iron defic anemia NOS,Acute postop pain NEC,Adjustment dis w anxiety,Anemia-other chronic dis,Hx TIA/stroke w/o resid,Adv eff penicillins,Long-term use anticoagul
Admission Date:  [**2145-4-3**]              Discharge Date:   [**2145-5-25**]

Date of Birth:  [**2114-4-25**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
Zosyn / Gentamicin

Attending:[**First Name3 (LF) 165**]
Chief Complaint:
fevers/chills, gastrointestinal distress

Major Surgical or Invasive Procedure:
[**2145-5-7**] Fifth time redo sternotomy and aortic root replacement,
Bentall procedure, with a size #25 St. [**Male First Name (un) 923**] composite graft


History of Present Illness:
30 year old male well known to cardiac surgery with a history of
AV endocarditis with MSSA in [**2137**] and [**2140**], enteroccocus in
[**2142**], s/p AVR x 2 in [**2140**] and [**2142**] who presented to [**Hospital 57051**]
medical center on [**2145-4-2**] with 1 week of
intermittent crampy abdominal pain, fatigue, chills, diarrhea,
loose stools, headache and neck pain. He states his pain
originated 5-7 days ago, is sharp and constant in intensity, and
was not relieved by over the counter analgesics. The pain in his
head and neck with worse with changing positions. Upon arrival
to the OSH, he was febrile to 100.7, found to have a WBC of 9
wtih bandemia to 18%, with blood cultures growing GNR in [**4-11**]
bottles. He was started on vancomycin amikacin and cefepime
(vancomycin was discontinued after GNR were discovered on
culture). TTE demonstrated EF 55% with LVF, AV not well
visualized, but no vegetations observed. Now found to have most
likely recurrent
endocaridits given progression on TEE, continuing to spike
fevers and dital embolism secondary to vegetation. He was
referred to cardiac surgery for redo AVR x4/+/-possible Bentall.


Past Medical History:
1. Bicuspid Aortic Valve- s/p Aortic Valvuolplasty at age 15
2. MSSA Recurrent Aortic Valve Endocarditis, ([**2137**], [**2139**])
----[**12/2137**]: MSSA endocarditis: with a 6 week course of
nafcillin and ultimately [**Year (4 digits) 1834**] a Bentall procedure utilizing
homograft along with VSD closure and debridement of aortic root
abscess.
----[**3-/2140**]: MSSA? Endocarditis: Redo aortic valve replacement
with a size 27 mm Onyx mechanical valve and ascending aortic
interposition graft with a size 24 mm Dacron graft
3. History of Septic Emboli to Spleen, Kidney and Cerebrum;
hepatic pseudoaneurysm embolization in [**2137**]
4. Intravenous Drug Abuser; patient states last time used IVDs
was prior to his last surgery in [**2139**].
5. History encephalomalacia of the right parietal lobe from a
prior infarct, and minimal chronic microvascular ischemic
changes.
6. Chronic systolic heart failure

Social History:
Quit tobacco just prior to admission h/o [**2-8**] ppd for 12 years.
Denies ETOH over the last year. He currently lives with his
parents. Several years of IVDU but denies since last AVR.


Family History:
Patient adopted and does not know family history.

Physical Exam:
Pulse:90 Resp:18  O2 sat:98/RA
B/P  117/74
Height:5'[**43**]"     Weight:100.9 kgs

General: AAOx3 NAD
Skin: Dry [] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck:  Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x]  Irregular []  Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x]
Extremities: Warm [x], well-perfused [x]  Edema [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral      Right: palp   Left: palp
DP           Right: strongly dop Left: palp
PT           [**Name (NI) 167**]: palp   Left: palp
Radial       Right: palp   Left: palp

Carotid Bruit        Right: none    Left: none


Pertinent Results:
[**2145-5-7**]:
PRE-BYPASS:
No spontaneous echo contrast is seen in the body of the left
atrium or left atrial appendage. No atrial septal defect is seen
by 2D or color Doppler.
There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity is moderately dilated. There is mild
regional left ventricular systolic dysfunction with focalities
in the septal wall. Overall left ventricular systolic function
is mildly depressed (LVEF= 40)
The right ventricular cavity is moderately dilated with moderate
global free wall hypokinesis.
The appearance of the ascending aorta is consistent with a
normal tube graft.
A mechanical aortic valve prosthesis is present. The transaortic
gradient is normal for this prosthesis. There is a
moderate-sized vegetation (1.4 cm x 1.8 cm on the aortic valve.
An aortic annular abscess is seen at the junction of the aortic
and anterior mitral leafllet. There is no flow within the
abscess. There are no flow connections from the cavity to
outside [**Doctor Last Name 1754**]. Mild (1+) aortic regurgitation is seen.
No mass or vegetation is seen on the mitral valve. Mild (1+)
mitral regurgitation is seen.
There is no pericardial effusion.
POST-BYPASS:
The patient is in sinus rhythm. The patient is on epinephrine,
norepinephrine, and vasopressin infusions.
Left ventricular function is moderately depressed (LVEF =
30-35%). The septum and inferior wall remain severely
hypokinetic.
Right ventricular function remains moderately depressed.
There is a mechanical prosthetic valve in the aortic position.
No paravalvular leak is seen. There is a mean gradient of 6 mmHg
at a cardiac output of 7.0 L/min. The aortic valve vegetation is
no longer present.
An ascending aortic tube graft is seen.
Mitral regurgitation is unchanged.
The aortic arch and descending aorta are intact
post-decannulation
.

[**2145-5-23**] 05:50AM BLOOD WBC-5.6 RBC-3.21* Hgb-9.2* Hct-28.4*
MCV-88 MCH-28.6 MCHC-32.4 RDW-15.1 Plt Ct-508*
[**2145-5-22**] 06:45AM BLOOD WBC-5.9 RBC-3.31* Hgb-9.4* Hct-29.4*
MCV-89 MCH-28.3 MCHC-31.9 RDW-15.3 Plt Ct-555*
[**2145-5-25**] 05:50AM BLOOD PT-22.9* INR(PT)-2.2*
[**2145-5-24**] 06:23AM BLOOD PT-18.1* PTT-68.8* INR(PT)-1.7*
[**2145-5-24**] 12:05AM BLOOD PT-17.2* PTT-78.0* INR(PT)-1.6*
[**2145-5-23**] 05:50AM BLOOD PT-15.4* PTT-86.9* INR(PT)-1.4*
[**2145-5-22**] 06:45AM BLOOD PT-13.9* PTT-106.9* INR(PT)-1.3*
[**2145-5-21**] 05:41AM BLOOD PT-13.8* PTT-68.5* INR(PT)-1.3*
[**2145-5-20**] 01:04AM BLOOD PT-14.5* PTT-51.9* INR(PT)-1.4*
[**2145-5-19**] 06:33PM BLOOD PT-15.1* PTT-68.8* INR(PT)-1.4*
[**2145-5-19**] 12:35PM BLOOD PT-14.4* PTT-56.6* INR(PT)-1.3*
[**2145-5-19**] 03:11AM BLOOD PT-14.5* PTT-49.9* INR(PT)-1.4*
[**2145-5-23**] 05:50AM BLOOD Glucose-122* UreaN-27* Creat-1.0 Na-135
K-3.9 Cl-98 HCO3-27 AnGap-14
[**2145-5-22**] 06:45AM BLOOD Glucose-91 UreaN-23* Creat-0.9 Na-135
K-4.3 Cl-98 HCO3-27 AnGap-14
[**2145-5-21**] 05:41AM BLOOD Glucose-111* UreaN-23* Creat-1.0 Na-137
K-4.1 Cl-99 HCO3-31 AnGap-11

Brief Hospital Course:
This is a 30 year old man with a past medical history
significant for bicuspid AV, AVR x 2, Endocarditis x 3(MSSA and
enteroccocus) last AVR in [**2142**] who presents with shortness of
breath, cough, fevers, diarrhea/nausea and gram negative
bacteremia.
Initially, Mr. [**Known lastname 57041**] was treated with gram negative
bacteremia/possible PNA with zosyn and levaquin. However he
developed a diffuse erythematous maculopapular rash and severe
eyelid swelling following his first dose of zosyn. Zosyn was
discontinued given apparent allergy and cefepime/Flagyl were
started instead. Blood and urine cultures were repeated and were
negative. TEE was obtained which initially did not show
vegetations, but on repeat studies, small echo densities were
seen on the aortic leaflets.  These were serially monitored and
were noted to increase.  As below, the patient developed sudden
severe foot pain which was felt to be secondary to a septic
embolic. Repeat imaging confirmed that the vegetation had
decreased in size.  He was continually monitored and the size of
his vegetation remained stable, however on a study from [**2145-5-4**],
it was noted that there was liquid pocket near the aortic root,
c/w an abscess.  He was taken to the OR for an aortic valve
replacement on [**2145-5-7**]. He [**Date Range 1834**] a fifth time redo
sternotomy and aortic root replacement, Bentall procedure, with
a size #25 St. [**Male First Name (un) 923**] composite graft.  See operative note for
full details.  Overall the patient tolerated the procedure well
and was transferred to the CVICU in stable condition. He was
weaned off all vasoactive medications by POD # 1 and within 24
hours he was extubated without incident. The patient was
neurologically intact and hemodynamically stable on POD 1.  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.
He developed shortness of breath and echo revealed a moderate to
large pericardial effusion.  There were no signs of tamponade.
Coumadin was stopped and he was bridged with heparin.  He
received a pericardial drain in the cath [**Male First Name (un) **].  This was removed
days later without incident.
He was continued on Meropenem per the Infectious disease team
via left sided PICC.  Final antibiotic recommendations were
Ertapenem for 6 weeks from the date of surgery
([**Date range (3) 57052**]).  He should have weekly safety labs with this
which will include a CBC with differential, chemistry panel, ESR
and C-reactive protein. Results should be faxed to ([**Telephone/Fax (1) 10739**]. Acute pain service was consulted for aid in pain
management.  His pain was well controlled with Dilaudid,
Gabapentin and Ativan at the time of discharge.  The patient was
evaluated by the physical therapy service for assistance with
strength and mobility.  By the time of discharge on POD 18 the
patient was ambulating freely, the wound was healing and pain
was controlled with oral analgesics.  The patient was discharged
to his parents' home in good condition with appropriate follow
up instructions.  Dr. [**Last Name (STitle) 24127**] will continue to follow the INR and
dose coumadin.  Home infusion will assist with antibiotic
administration and he will have VNA services.




Medications on Admission:
Carvedilol 12.5mg [**Hospital1 **]
ASA 81mg daily
Ferrous sulfate 325mg daily
Warfarin 10mg daily

Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*100 Capsule(s)* Refills:*2*
3. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
4. hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q2H (every 2
hours) as needed for pain for 2 weeks.
Disp:*50 Tablet(s)* Refills:*0*
5. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO three
times a day.
Disp:*135 Tablet(s)* Refills:*2*
6. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): 1/2 hour before Dilaudid.
Disp:*60 Tablet(s)* Refills:*2*
7. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
9. Coumadin 5 mg Tablet Sig: as directed Tablet PO once a day:
Disp:*100 Tablet(s)* Refills:*2*
10. Outpatient [**Hospital1 **] Work
ESR, CRP,Chem 7, CBC w3/ diff weekly begin [**5-31**], through
[**2145-6-18**].
Fax results to [**Hospital1 18**] Infectious Diseases at [**Telephone/Fax (1) 1419**]
11. ertapenem 1 gram Recon Soln Sig: One (1)  Intravenous once a
day for 23 days: through [**2145-6-18**].
Disp:*qs * Refills:*0*
12. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
13. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO HS
(at bedtime) as needed for insomnia.
14. white petrolatum-mineral oil     Cream Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day).
15. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
16. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day for 5 days.
Disp:*10 Tablet Extended Release(s)* Refills:*0*
17. ipratropium-albuterol 18-103 mcg/actuation Aerosol Sig: [**2-8**]
Puffs Inhalation Q6H (every 6 hours) as needed for dyspnea.
Disp:*qs * Refills:*0*
18. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
19. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
Disp:*qs * Refills:*2*
20. 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.


Discharge Disposition:
Home With Service

Facility:
[**Location (un) **] VNA

Discharge Diagnosis:
Enterobacter Bacteremia
recurrent aortic valve Endocarditis
Aortic root abscess
congenital bicuspid aortic valve
s/p aortic valvuloplasty age 15
s/p redo sternotomy,homograft aortic valve
replacement,ventricular septal defect closure [**2137**]
s/p redo sternotomy,Bentall(Onxy) [**2140**]
s/p Bentall ([**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Mechanical) [**2142**]
s/p evacuation of tamponade [**2142**]
s/p redo(5th) sternotomy, Bentall(25mm St. [**Male First Name (un) **] mechanical
composite)

MSSA Endocarditis [**2137**] with septic emboli to spleen,
kidney,cerebrum in [**2137**],
s/p hepatic psuedoaneurysm embolization
Recurrent MSSA endocarditis [**2140**]
prosthetic Aortic Insufficiency
Congestive Heart Failue
h/o IV drug abuse
Gentamycin induced Right ototoxicity
prior occipital blindness-prior to 1st heart surgery


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


Discharge Instructions:
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
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart

No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]

**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: Dr. [**First Name (STitle) **]([**Telephone/Fax (1) 170**]) on [**2145-6-15**] @ 1:15pm in the
[**Hospital Unit Name **] [**Last Name (NamePattern1) **] [**Hospital Unit Name **]

Cardiologist: Dr. [**First Name (STitle) 437**] ([**Telephone/Fax (1) 62**]) on [**2145-6-2**] at9:20am

Infectious Disease: Dr. [**Last Name (STitle) 7443**] ([**Telephone/Fax (1) 457**]) on [**2145-5-28**] at
10:00am
and Dr.[**Last Name (STitle) **]  on [**2145-6-18**] at 10:30a
-Check CBC, BMP,LFTs weekly and fax results to [**Telephone/Fax (1) 1419**]

Please call to schedule appointments with:
Primary Care: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**2-8**] weeks ([**Telephone/Fax (1) 57053**])
Local Cardiologist: Dr. [**Last Name (STitle) 24127**] [**0-0-**]

**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: PT/INR for Coumadin ?????? indication mechanical AVR
(to be drawn at Dr.[**Name (NI) 57054**] office)
Goal INR 2.5-3.5
First draw [**2145-5-26**]
Results to: Dr. [**Last Name (STitle) 24127**] phone: [**0-0-**], [**Hospital **] clinic
fax: [**Telephone/Fax (1) 57055**]


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

Completed by:[**2145-5-25**]

Name:  [**Known lastname 10622**],[**Known firstname **]                 Unit No:   [**Numeric Identifier 10623**]

Admission Date:  [**2145-4-3**]              Discharge Date:   [**2145-5-25**]

Date of Birth:  [**2114-4-25**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
Zosyn / Gentamicin

Attending:[**First Name3 (LF) 265**]
Addendum:
Of note, the patient demonstrated an elevated right
hemi-diaphragm post-operatively.  He remained stable from a
clinical standpoint.  Dr. [**First Name (STitle) **] is aware of the finding.  He is
discharged home with detailed follow-up instructions.

Discharge Disposition:
Home With Service

Facility:
[**Location (un) 10624**] VNA

                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]

Completed by:[**2145-5-25**]
{'Other septicemia due to gram-negative organisms,Acute and subacute bacterial endocarditis,Infection and inflammatory reaction due to cardiac device, implant, and graft,Chronic diastolic heart failure,Acute kidney failure, unspecified,Cellulitis and abscess of foot, except toes,Hyposmolality and/or hyponatremia,Cardiac tamponade,Enteritis due to norwalk virus,Arterial embolism and thrombosis of lower extremity,Septic arterial embolism,Severe sepsis,Thrombocytopenia, unspecified,Tobacco use disorder,Dermatitis due to drugs and medicines taken internally,Iron deficiency anemia, unspecified,Other acute postoperative pain,Adjustment disorder with anxiety,Anemia of other chronic disease,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Penicillins causing adverse effects in therapeutic use,Long-term (current) use of anticoagulants'}


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: fevers/chills, gastrointestinal distress

PRESENT ILLNESS: 30 year old male well known to cardiac surgery with a history of
AV endocarditis with MSSA in [**2137**] and [**2140**], enteroccocus in
[**2142**], s/p AVR x 2 in [**2140**] and [**2142**] who presented to [**Hospital 57051**]
medical center on [**2145-4-2**] with 1 week of
intermittent crampy abdominal pain, fatigue, chills, diarrhea,
loose stools, headache and neck pain. He states his pain
originated 5-7 days ago, is sharp and constant in intensity, and
was not relieved by over the counter analgesics. The pain in his
head and neck with worse with changing positions. Upon arrival
to the OSH, he was febrile to 100.7, found to have a WBC of 9
wtih bandemia to 18%, with blood cultures growing GNR in [**4-11**]
bottles. He was started on vancomycin amikacin and cefepime
(vancomycin was discontinued after GNR were discovered on
culture). TTE demonstrated EF 55% with LVF, AV not well
visualized, but no vegetations observed. Now found to have most
likely recurrent
endocaridits given progression on TEE, continuing to spike
fevers and dital embolism secondary to vegetation. He was
referred to cardiac surgery for redo AVR x4/+/-possible Bentall.

MEDICAL HISTORY: 1. Bicuspid Aortic Valve- s/p Aortic Valvuolplasty at age 15
2. MSSA Recurrent Aortic Valve Endocarditis, ([**2137**], [**2139**])
----[**12/2137**]: MSSA endocarditis: with a 6 week course of
nafcillin and ultimately [**Year (4 digits) 1834**] a Bentall procedure utilizing
homograft along with VSD closure and debridement of aortic root
abscess.
----[**3-/2140**]: MSSA? Endocarditis: Redo aortic valve replacement
with a size 27 mm Onyx mechanical valve and ascending aortic
interposition graft with a size 24 mm Dacron graft
3. History of Septic Emboli to Spleen, Kidney and Cerebrum;
hepatic pseudoaneurysm embolization in [**2137**]
4. Intravenous Drug Abuser; patient states last time used IVDs
was prior to his last surgery in [**2139**].
5. History encephalomalacia of the right parietal lobe from a
prior infarct, and minimal chronic microvascular ischemic
changes.
6. Chronic systolic heart failure

MEDICATION ON ADMISSION: Carvedilol 12.5mg [**Hospital1 **]
ASA 81mg daily
Ferrous sulfate 325mg daily
Warfarin 10mg daily

ALLERGIES: Zosyn / Gentamicin

PHYSICAL EXAM: Pulse:90 Resp:18  O2 sat:98/RA
B/P  117/74
Height:5'[**43**]"     Weight:100.9 kgs

FAMILY HISTORY: Patient adopted and does not know family history.

SOCIAL HISTORY: Quit tobacco just prior to admission h/o [**2-8**] ppd for 12 years.
Denies ETOH over the last year. He currently lives with his
parents. Several years of IVDU but denies since last AVR. 

### Response:
{'Other septicemia due to gram-negative organisms,Acute and subacute bacterial endocarditis,Infection and inflammatory reaction due to cardiac device, implant, and graft,Chronic diastolic heart failure,Acute kidney failure, unspecified,Cellulitis and abscess of foot, except toes,Hyposmolality and/or hyponatremia,Cardiac tamponade,Enteritis due to norwalk virus,Arterial embolism and thrombosis of lower extremity,Septic arterial embolism,Severe sepsis,Thrombocytopenia, unspecified,Tobacco use disorder,Dermatitis due to drugs and medicines taken internally,Iron deficiency anemia, unspecified,Other acute postoperative pain,Adjustment disorder with anxiety,Anemia of other chronic disease,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Penicillins causing adverse effects in therapeutic use,Long-term (current) use of anticoagulants'}
