CHIEF COMPLAINT: Pacemaker pocket infection

PRESENT ILLNESS: 82 y/o male with permanent afib with h/o stroke currently on
warfarin, [**Month/Day/Year **] sinus syndrome s/p single-chamber pacemaker
implantation [**2-/2105**], heart failure, presents with swelling
around site of single chamber st. [**Male First Name (un) **] pm, referred by Dr. [**Last Name (STitle) **]
with concern for pocket infection & plans to explant device.

MEDICAL HISTORY: # Congestive heart failure - LVEF 42% on [**2107-10-5**], mild
concentric LVH, mild septal hypokinesis, changed from [**11-3**]
echo: normal LVEF 56%
# permanent Afib on warfarin
# h/o stroke [**2-/2105**] - persistent memory problems and swallowing
problems
# [**Name2 (NI) **] sinus syndrome s/p St. [**Male First Name (un) 923**] single chamber pacemaker
# Hypertension
# Hyperlipidemia
# HX-PROSTATIC MALIGNANCY, s/p TURP, suprapubic catheter
# HX OF IRRADIATION
# JOINT DIS NEC-PELVIS
# OSTEITIS DEFORMANS NOS
# MITRAL VALVE disorder

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver[**Name (NI) 581**].
1. Multivitamins 1 TAB PO DAILY
2. Vitamin D 4000 UNIT PO DAILY
3. Warfarin 2.5 mg PO DAILY16
4. Simvastatin 20 mg PO DAILY Start: in pm
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
6. Alendronate Sodium 70 mg PO QMON
7. MetronidAZOLE Topical 1 % Gel 1 Appl TP DAILY
8. Furosemide 20 mg PO DAILY
Hold for SBP<90

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION PHYSICAL EXAMINATION:
VS- T 97.6 BP 150/91 P 79, R 20, O2 100%RA
GENERAL- WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT- NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: Mother died of heart failure

SOCIAL HISTORY: Lives with wife, uses [**Name2 (NI) **] to ambulate outside the house,
independent inside the house
-Tobacco history:  Smoked 0.5 ppd for 20 years, quit at age 37.
-ETOH:  none
-Illicit drugs:  none
Cardiac arrest,Acute respiratory failure following trauma and surgery,Cardiomyopathy in other diseases classified elsewhere,Cardiac complications, not elsewhere classified,Hematoma complicating a procedure,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Long-term (current) use of anticoagulants,Other and unspecified hyperlipidemia,Personal history of malignant neoplasm of prostate,Personal history of tobacco use,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Unspecified hypertensive heart disease with heart failure,Congestive heart failure, unspecified,Infection and inflammatory reaction due to cardiac device, implant, and graft
Cardiac arrest,Ac resp flr fol trma/srg,Cardiomyopath in oth dis,Surg compl-heart,Hematoma complic proc,Hx TIA/stroke w/o resid,Long-term use anticoagul,Hyperlipidemia NEC/NOS,Hx-prostatic malignancy,History of tobacco use,Abn react-artif implant,Hyp ht dis NOS w ht fail,CHF NOS,React-cardiac dev/graft
Admission Date:  [**2107-10-11**]              Discharge Date:   [**2107-10-19**]

Date of Birth:  [**2025-1-9**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Pacemaker pocket infection

Major Surgical or Invasive Procedure:
Pacemaker explantation [**2107-10-13**]
Cardiopulmonary resuscitation (CPR), intubation

History of Present Illness:
82 y/o male with permanent afib with h/o stroke currently on
warfarin, [**Month/Day/Year **] sinus syndrome s/p single-chamber pacemaker
implantation [**2-/2105**], heart failure, presents with swelling
around site of single chamber st. [**Male First Name (un) **] pm, referred by Dr. [**Last Name (STitle) **]
with concern for pocket infection & plans to explant device.

Pacemaker was placed in [**2105-2-23**] by Dr. [**Last Name (STitle) 1140**] at [**Hospital3 19345**] for atrial fibrillation w/ [**Hospital3 **] sinus syndrome.  Had
bleeding but no infection.  No recent manipulations.  A few
weeks ago developed swelling and redness at pacemaker site.

Mode of pacer set to VVIR with lower pacing rate of 60 bpm.
Pacing only 11% of the time mostly at night.  Takes warfarin due
to afib with hx of TIA.

[**2107-8-30**] presented to office feeling tired and having dyspnea with
moderate exertion.  Ordered for Lexiscan and Echo.

[**2107-10-5**] echo: LVEF is 42%, mild concentric LVH, left and right
atrium mild mildly dilated.  Mild MR.  Mild septal hypokinesis.
Changed from [**11-3**] echo: LVEF normal 56% with mild concentric
LVH

[**2107-9-27**]: Lexiscan: Normal perfusion, normal systolic function,
negative ECG.

Blood cultures drawn [**9-28**] were negative, ESR 20.  Denies fevers,
chills, rash, decreased appetite, weight loss.

Also complains of orthopnea, edema, PND.  Started on lasix on
[**10-5**] with some improvement in symptoms.  Referred by Dr.
[**Last Name (STitle) 5017**] for device explantation.

On arrival to the floor, patient denies any acute complaints.
Mild pacemaker pain.

REVIEW OF SYSTEMS
ROS:  negative for fevers, chills, chest pain, palpitations,
weight loss, rash, joint pains, lower extremity cramping or pain
when walking
positive for orthopnea, PND, lower extremity edema, weight gain,
worsening cough for the past 2 weeks

Past Medical History:
# Congestive heart failure - LVEF 42% on [**2107-10-5**], mild
concentric LVH, mild septal hypokinesis, changed from [**11-3**]
echo: normal LVEF 56%
# permanent Afib on warfarin
# h/o stroke [**2-/2105**] - persistent memory problems and swallowing
problems
# [**Name2 (NI) **] sinus syndrome s/p St. [**Male First Name (un) 923**] single chamber pacemaker
# Hypertension
# Hyperlipidemia
# HX-PROSTATIC MALIGNANCY, s/p TURP, suprapubic catheter
# HX OF IRRADIATION
# JOINT DIS NEC-PELVIS
# OSTEITIS DEFORMANS NOS
# MITRAL VALVE disorder

Social History:
Lives with wife, uses [**Name2 (NI) **] to ambulate outside the house,
independent inside the house
-Tobacco history:  Smoked 0.5 ppd for 20 years, quit at age 37.
-ETOH:  none
-Illicit drugs:  none

Family History:
Mother died of heart failure

Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS- T 97.6 BP 150/91 P 79, R 20, O2 100%RA
GENERAL- WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT- NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

NECK- Supple with JVP of [**9-2**] cm.
CARDIAC- normal s1, s2, irregularly irregular rate. no m/r/g
LUNGS- No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN- Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES- trace bilateral edema
soft tissue swelling palpated over entire surface of pacemaker,
mild erythema on skin surface, mildly tender to palpation. no
distinct fluid collection. no drainage.
SKIN- No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES-
Right: Carotid 2+  PT 2+
Left: Carotid 2+  PT 2+
GU:  suprapubic catheter

DISCHARGE PHYSICAL EXAMINATION


Pertinent Results:
ADMISSION LABS
[**2107-10-11**] 04:15PM BLOOD WBC-5.0 RBC-5.10 Hgb-14.8 Hct-45.5 MCV-89
MCH-29.0 MCHC-32.6 RDW-14.8 Plt Ct-182
[**2107-10-11**] 04:15PM BLOOD Neuts-71.2* Lymphs-19.7 Monos-7.2 Eos-1.2
Baso-0.8
[**2107-10-11**] 04:15PM BLOOD PT-33.9* PTT-47.3* INR(PT)-3.3*
[**2107-10-11**] 04:15PM BLOOD Glucose-142* UreaN-27* Creat-1.2 Na-139
K-3.8 Cl-102 HCO3-27 AnGap-14
[**2107-10-11**] 04:15PM BLOOD Calcium-8.9 Phos-3.6 Mg-2.0

CARDIAC ENZYMES
[**2107-10-11**] 04:15PM BLOOD cTropnT-0.07*
[**2107-10-12**] 06:19AM BLOOD cTropnT-0.07*
[**2107-10-13**] 11:50AM BLOOD cTropnT-0.05* proBNP-2460*
[**2107-10-13**] 10:20PM BLOOD CK-MB-4 cTropnT-0.06*
[**2107-10-14**] 03:59AM BLOOD CK-MB-5 cTropnT-0.06*

BLOOD GASES
[**2107-10-13**] 11:03AM BLOOD Type-ART pO2-70* pCO2-83* pH-7.16*
calTCO2-31* Base XS--1 Intubat-INTUBATED Vent-CONTROLLED
[**2107-10-13**] 11:55AM BLOOD Type-ART pO2-126* pCO2-48* pH-7.26*
calTCO2-23 Base XS--5 Intubat-INTUBATED Vent-CONTROLLED
[**2107-10-13**] 12:47PM BLOOD Type-ART Temp-36.4 Rates-/18 Tidal V-460
FiO2-100 pO2-233* pCO2-35 pH-7.42 calTCO2-23 Base XS-0 AADO2-454
REQ O2-77 Intubat-INTUBATED Vent-CONTROLLED

[**2107-10-13**] 11:03AM BLOOD Glucose-165* Lactate-1.7 Na-135 K-4.0
Cl-101 calHCO3-29
[**2107-10-13**] 12:47PM BLOOD Lactate-1.0

[**2107-10-13**] 11:50AM BLOOD Fibrino-315

DISCHARGE LABS:

IMAGING
[**2107-10-11**] CHEST X-RAY
IMPRESSION:  PA and lateral chest reviewed in the absence of any
prior chest imaging studies.
Transvenous right ventricular pacer lead terminates along the
anterior wall of the right ventricle.  Heart is moderately
enlarged, predominantly left atrial. Mild interstitial
abnormality could be chronic.  There is no appreciable vascular
congestion or any pleural effusion to suggest that it is acute
edema. Right upper costal pleural thickening could be
asbestos-related plaque, but there are no other findings to
suggest asbestos-related diseases.

[**2107-10-13**] CHEST X-RAY
IMPRESSION:  New endotracheal tube in appropriate position.  New
hilar and juxta patchy opacities, compatible with pulmonary
edema.

[**2107-10-13**] TTE
Preoperative:
The left atrial appendage emptying velocity is depressed
(<0.2m/s). No thrombus is seen in the left atrial appendage.
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the descending thoracic aorta.
There are three aortic valve leaflets. The aortic valve leaflets
are moderately thickened with fusion between the left and
noncoronary cusps. There is mild aortic valve stenosis (valve
area 1.5 cm2). Trace aortic regurgitation is seen. Mild to
moderate ([**1-24**]+) mitral regurgitation is seen with vena contracta
of 0.6 cm. Estimated Ejection Fraction is 40% with moderate
global hypokinesis. There is no pericardial effusion. Dr.
[**Last Name (STitle) **] was notified in person of the results on [**2107-10-13**] at
1000.

Post operative:
There is no pericardial effusion post lead extraction. There is
no evidence of new or worsened tricuspid insufficiency.

[**2107-10-15**] CHEST X-RAY
REASON FOR EXAMINATION:  Flash pulmonary edema clinically.
Portable AP radiograph of the chest was compared to [**10-14**], [**10-13**], [**2107**].

Cardiomegaly is unchanged.  Mediastinum is stable.  Minimal
interstitial edema is seen, but no overt alveolar pulmonary
edema is present.  Atelectasis in the left perihilar area has
improved.  No interval increase in pleural effusion or
development of pneumothorax is present.

DISCHARGE LABS
[**2107-10-17**] 06:27AM BLOOD WBC-7.2 RBC-5.09 Hgb-14.6 Hct-45.1 MCV-89
MCH-28.7 MCHC-32.4 RDW-14.8 Plt Ct-211
[**2107-10-17**] 06:27AM BLOOD PT-23.0* PTT-39.6* INR(PT)-2.2*
[**2107-10-17**] 06:27AM BLOOD Glucose-101* UreaN-37* Creat-1.1 Na-136
K-4.3 Cl-97 HCO3-30 AnGap-13
[**2107-10-17**] 06:27AM BLOOD Calcium-9.2 Phos-3.6 Mg-1.9

MICROBIOLOGY:

[**2107-10-13**] 11:40 am
      SWAB      LEFT PACER:  Per ID = consistent with skin flora


   GRAM STAIN (Final [**2107-10-13**]):
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.

   WOUND CULTURE (Preliminary):
      This culture contains mixed bacterial types (>=3) so an
abbreviated
      workup is performed. Any growth of P.aeruginosa, S.aureus
and beta
      hemolytic streptococci will be reported. IF THESE BACTERIA
ARE NOT
      REPORTED BELOW, THEY ARE NOT PRESENT in this culture..
      IDENTIFICATION AND SENSITIVITY TESTING PER DR. [**Last Name (STitle) **]
([**Numeric Identifier **]).
      STAPHYLOCOCCUS, COAGULASE NEGATIVE.    RARE GROWTH.
      STAPHYLOCOCCUS, COAGULASE NEGATIVE.    RARE GROWTH.
         SECOND MORPHOLOGY.
      GRAM POSITIVE RODS.    SPARSE GROWTH.  UNABLE TO IDENTIFY
FURTHER.

   ANAEROBIC CULTURE (Final [**2107-10-17**]):    NO ANAEROBES ISOLATED.


FINAL NEGATIVE:
[**2107-10-13**] 	MRSA SCREEN 	MRSA SCREEN-FINAL
[**2107-10-13**] 	FOREIGN BODY 	WOUND CULTURE-FINAL 	
[**2107-10-12**] 	SWAB 	R/O VANCOMYCIN RESISTANT
ENTEROCOCCUS-FINAL 	
[**2107-10-11**] 	BLOOD CULTURE 	Blood Culture, FINAL
[**2107-10-11**] 	BLOOD CULTURE 	Blood Culture, FINAL

Brief Hospital Course:
82 y/o male with permanent afib with h/o stroke/TIA currently on
warfarin, [**Numeric Identifier **] sinus syndrome s/p single-chamber pacemaker
implantation [**2-/2105**], recently diagnosed heart failure (EF 44%),
presents with swelling around site of single chamber st. [**Male First Name (un) **]
pm, referred by Dr. [**Last Name (STitle) **] with concern for pocket infection with
plan to explant device.

# PACEMAKER POCKET SWELLING / INFECTION:  Pt had [**Last Name (STitle) **] sinus
syndrome s/p single-chamber pacemaker implantation 2/[**2105**].
Onset of swelling several weeks prior to admission.  Seemed to
be isolated pocket infection given no systemic signs/symptoms,
leukocytosis or fevers, negative blood cultures, duration and
indolence. Blood cultures on [**9-28**] negative. Blood cultures on
[**10-11**] negative. Consulted ID, who recommended no antibiotics
given as this is likely chronic infection without systemic
spread. Successful pacemaker explantation [**2107-10-13**], but after
extubation, had cardiopulmonary arrest (detailed below). No
frank pus in pocket on explantation.  Culture of pacemaker
showed sparse growth of coag-negative staph, consistent with
skin flora. Got 1 dose IV vancomycin after explantation but no
further antibiotics; did not spike fevers or develop
leukocytosis, so infection is unlikely; unclear why he developed
swelling, warmth, and erythema at site, so perhaps he had an
indolent infection.  The device has been removed so source
control achieved. Normally, would cover for skin flora, however,
the risk of antibiotics seems to outweigh the benefits,
especially since suspicion for persistent infection is low.
Bactrim is associated with severe increased risk of bleeding
when given with warfarin, doxycycline is associated with
moderate risk. If patient develops fever or signs/symptoms of
infection, would empirically treat with doxycycline 100mg q12h
for 7-10 days, and monitor INR daily because of moderate
increased risk of bleeding while concurrently on warfarin.

# Hematoma - developed hematoma post-op; expanded on POD3; dc'ed
heparin gtt, applied pressure & applied pressure dressing;
stabilized, no need to evacuate.  Continue wound care and
application of pressure as needed.

# Afib with slow ventricular response ([**Month/Day/Year **] sinus syndrome, s/p
pacemaker placement in [**2105**]), h/o stroke/TIA. On warfarin at
home, supratherapeutic on admission, held warfarin and bridged
with hep gtt for procedure.  After the procedure, heparin gtt &
warfarin were initially held given rib fracture but restarted on
[**10-14**], heparin gtt discontinued [**10-16**] once therapeutic on
coumadin. Prior to explantation, pacemaker settings adjusted,
rate reduced to 30bpm to evaluate for pacemaker dependence. On
interrogation, he was pacemaker dependent only 11% of the time.
Discharged with [**Doctor Last Name **] of Hearts monitor to evaluate need to
replace pacemaker. Pt will follow-up with EP Dr. [**Last Name (STitle) **] to decide
whether he will need replacement of pacemaker 2 weeks after
discharge.

# CARDIOPULMONARY ARREST:  After explantation of device without
complications, in the PACU, after extubation, pt was alert,
interactive.  Pt developed progressive dyspnea, then respiratory
failure, CXR confirmed pulmonary edema.  Reintubated.  Went into
PEA arrest, coded, CPR performed for 15 sec, with return of
pulse, ribs were broken.  Bedside TTE done, no gross
abnormalities.  SBP in 80s.  Transferred to CCU for further
management.  Likely etiology is flash pulmonary edema in the
setting of peri-operative catecholaminergic surge, hypertensive
with SBP to 190s leading to respiratory failure and subsequent
PEA arrest.

CCU Course:
The patient was admitted to CCU from [**Hospital1 1516**] on [**10-13**] and was
transferred back to [**Hospital1 1516**] on [**10-15**].  Given risk of infection and
poor utilization, EP planned for extraction on [**10-13**].  During the
procedure, lead removal was uncomplicated, and no pus was noted
around pacer. He received vancomycin and cefazolin during the
procedure. After the procedure, patient became hypertensive to
200s systolic.  This was followed by hypoxemic respiratory
distress (likely due to flash pulmonary edema), PEA Arrest with
ROSC after 15s with compressions, no shock, and intubation. His
BP dropped to the 60s systolic. After intubation, pt was given
Lasix 20 mg x 1 dose, and started on phenylephrine.  On arrival
to the CCU, the patient's BP was 118/69.  Overnight, he was
weaned off the pressor.  He was further diuresed in the CCU, and
he was net over 2 L negative on [**10-13**].  On the morning of [**10-14**],
he was weaned off sedation and was successfully extubated.  His
warfarin was restarted.  He was given oxycodone for rib pain.
On [**10-15**], we put him back on his home dose of Lasix 20mg PO daily
and also started lisinopril 2.5mg daily.  He was transferred
back to [**Hospital1 1516**] in stable condition for further management.

# MIXED SYSTOLIC/DIASTOLIC CONGESTIVE HEART FAILURE - acute on
chronic systolic and diastolic congestive heart failure.  1.5
weeks prior to admission, developed heart failure symptoms,
started on PO lasix with improvement of sx.  [**2107-10-5**] TTE showed
new depressed systolic function LVEF 44% (compared to 55%
10/[**2106**]). DDx: ischemia (no chest pain, EKG stable, stable
cardiac enzymes), progression of hypertensive cardiomyopathy.
Pt had recent regadenoson stress test in early [**Month (only) **] which
was read as normal, normal EF and no signs of ischemia.  This
makes ischemia less likely.  Per discussion with outpatient
cardiologist, the recent TTE may have been overread, and he does
not think there is new systolic dysfunction.  Patient does have
concentric LVH.  Most likely, pt has mixed sys/[**Last Name (un) **] heart
failure [**2-24**] to hypertensive cardiomyopathy. [**2107-10-13**] TTE showed
Ejection Fraction is 40% with moderate global hypokinesis.
Developed flash pulm edema post-procedure as above. Diuresed a
total 3L, restarted home lasix. STARTED lisinopril 5mg daily.

# Ventricular tachycardia:  intermittent runs of VT on tele (17
beat run of VT on [**10-12**]) asymptomatic. Monitored on tele and
repleted electrolytes prn.

TRANSITION OF CARE ISSUES
- You will have [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor until you can be seen
by Dr. [**Last Name (STitle) **] to evaluate whether you will need a new pacemaker.
- Continue anticoagulation with warfarin and follow-up with Dr.
[**Last Name (STitle) 40797**] once discharged from rehab.
- If patient develops fever or signs/symptoms of infection,
would empirically treat with doxycycline 100mg q12h for [**8-2**]
days, and monitor INR daily because of moderate increased risk
of bleeding while concurrently on warfarin.
- If concerned for expanding hematoma, apply pressure, inform
Dr. [**Last Name (STitle) **]
- Please make sure patient has suprapubic catheter changed at
appointment listed on discharge planning on [**2107-10-24**].

Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver[**Name (NI) 581**].
1. Multivitamins 1 TAB PO DAILY
2. Vitamin D 4000 UNIT PO DAILY
3. Warfarin 2.5 mg PO DAILY16
4. Simvastatin 20 mg PO DAILY Start: in pm
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
6. Alendronate Sodium 70 mg PO QMON
7. MetronidAZOLE Topical 1 % Gel 1 Appl TP DAILY
8. Furosemide 20 mg PO DAILY
Hold for SBP<90



Discharge Medications:
1. Alendronate Sodium 70 mg PO QMON
2. Fluticasone Propionate NASAL 1 SPRY NU DAILY
3. Furosemide 20 mg PO DAILY
Hold for SBP<90

4. MetronidAZOLE Topical 1 % Gel 1 Appl TP DAILY
5. Multivitamins 1 TAB PO DAILY
6. Simvastatin 20 mg PO DAILY
7. Vitamin D 4000 UNIT PO DAILY
8. Psyllium Wafer 1 WAF PO DAILY
9. Warfarin 2.5 mg PO DAILY16
10. Acetaminophen 650 mg PO Q6H:PRN pain
11. Docusate Sodium 100 mg PO BID:PRN constipation
12. OxycoDONE (Immediate Release)  5 mg PO Q4H:PRN pain
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. Senna 1 TAB PO BID:PRN constipation
15. Lisinopril 2.5 mg PO DAILY
hold for SBP <90


Discharge Disposition:
Extended Care

Facility:
Nevins Nursing and Rehabilitation Center

Discharge Diagnosis:
Pacemaker pocket infection
Cardiopulmonary arrest due to flash pulmonary edema


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or [**Name (NI) **]).


Discharge Instructions:
Dear Mr. [**Known lastname **],

It was a pleasure being involved in your care during your
hospitalization for pacemaker pocket infection.  You had your
pacemaker taken out for concern of infection. Luckily there were
no signs of infection during or after the procedure.

After the procedure, you developed respiratory distress from
fluid going into your lungs and had a short period where your
heart stopped.  You were intubated until you were able to
breathe well on your own. You went to the coronary care unit
where you received lasix to help with the fluid in the lungs and
were able to be extubated without issue.

TRANSITION OF CARE ISSUES
- Your rehab facility will set you up with an appointment to see
your primary care physician
[**Name Initial (PRE) **] [**Name10 (NameIs) **] will have [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor until you can be seen
by Dr. [**Last Name (STitle) **] to evaluate whether you will need a new pacemaker.
- Continue anticoagulation with warfarin and follow-up with Dr.
[**Last Name (STitle) 40797**] once discharged from rehab.
- If concerned for increased swelling at surgical site, apply
pressure and inform Dr. [**Last Name (STitle) **]

The following changes were made to your medications:
START lisinopril for high blood pressure, diabetes
START oxycodone as needed for pain

Followup Instructions:
Please go to the following appointment to have your suprapubic
catheter changed:
Name: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**], NP
Location: [**University/College 5130**] Urology
Address: [**Location (un) 112504**], [**Location 9583**], MA
Phone: [**Telephone/Fax (1) 112505**]
Appointment: Monday, [**10-24**] at 10:20am

Please also follow up with your doctors at the following
appointments:
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Location (un) **] CARDIOLOGY
Address: [**Last Name (un) 39144**], STE#404, [**Hospital1 **],[**Numeric Identifier 39146**]
Phone: [**Telephone/Fax (1) 5424**]
Appointment: Tuesday [**2107-10-25**] 1:00pm

Department: CARDIAC SERVICES
When: FRIDAY [**2107-11-4**] at 9:40 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

Name: STUPNYTSKYI,OLEKSANDR
Address: [**Last Name (un) 39144**] [**Apartment Address(1) 75552**], [**Hospital1 **],[**Numeric Identifier 66038**]
Phone: [**Telephone/Fax (1) 83705**]
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.




Completed by:[**2107-10-20**]
{'Cardiac arrest,Acute respiratory failure following trauma and surgery,Cardiomyopathy in other diseases classified elsewhere,Cardiac complications, not elsewhere classified,Hematoma complicating a procedure,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Long-term (current) use of anticoagulants,Other and unspecified hyperlipidemia,Personal history of malignant neoplasm of prostate,Personal history of tobacco use,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Unspecified hypertensive heart disease with heart failure,Congestive heart failure, unspecified,Infection and inflammatory reaction due to cardiac device, implant, and graft'}


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: Pacemaker pocket infection

PRESENT ILLNESS: 82 y/o male with permanent afib with h/o stroke currently on
warfarin, [**Month/Day/Year **] sinus syndrome s/p single-chamber pacemaker
implantation [**2-/2105**], heart failure, presents with swelling
around site of single chamber st. [**Male First Name (un) **] pm, referred by Dr. [**Last Name (STitle) **]
with concern for pocket infection & plans to explant device.

MEDICAL HISTORY: # Congestive heart failure - LVEF 42% on [**2107-10-5**], mild
concentric LVH, mild septal hypokinesis, changed from [**11-3**]
echo: normal LVEF 56%
# permanent Afib on warfarin
# h/o stroke [**2-/2105**] - persistent memory problems and swallowing
problems
# [**Name2 (NI) **] sinus syndrome s/p St. [**Male First Name (un) 923**] single chamber pacemaker
# Hypertension
# Hyperlipidemia
# HX-PROSTATIC MALIGNANCY, s/p TURP, suprapubic catheter
# HX OF IRRADIATION
# JOINT DIS NEC-PELVIS
# OSTEITIS DEFORMANS NOS
# MITRAL VALVE disorder

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver[**Name (NI) 581**].
1. Multivitamins 1 TAB PO DAILY
2. Vitamin D 4000 UNIT PO DAILY
3. Warfarin 2.5 mg PO DAILY16
4. Simvastatin 20 mg PO DAILY Start: in pm
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
6. Alendronate Sodium 70 mg PO QMON
7. MetronidAZOLE Topical 1 % Gel 1 Appl TP DAILY
8. Furosemide 20 mg PO DAILY
Hold for SBP<90

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION PHYSICAL EXAMINATION:
VS- T 97.6 BP 150/91 P 79, R 20, O2 100%RA
GENERAL- WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT- NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: Mother died of heart failure

SOCIAL HISTORY: Lives with wife, uses [**Name2 (NI) **] to ambulate outside the house,
independent inside the house
-Tobacco history:  Smoked 0.5 ppd for 20 years, quit at age 37.
-ETOH:  none
-Illicit drugs:  none 

### Response:
{'Cardiac arrest,Acute respiratory failure following trauma and surgery,Cardiomyopathy in other diseases classified elsewhere,Cardiac complications, not elsewhere classified,Hematoma complicating a procedure,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Long-term (current) use of anticoagulants,Other and unspecified hyperlipidemia,Personal history of malignant neoplasm of prostate,Personal history of tobacco use,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Unspecified hypertensive heart disease with heart failure,Congestive heart failure, unspecified,Infection and inflammatory reaction due to cardiac device, implant, and graft'}
