CHIEF COMPLAINT: 

PRESENT ILLNESS: This is a 48 year old man who
anorexia and decreased urine output.  He is a man with a
history of alcoholic cirrhosis and Staphylococcus
endocarditis in [**2164-2-10**], and sacral osteomyelitis in
[**2164-3-12**].  He was in his usual state of health until two
weeks prior to admission when he began noticing increasing
dyspnea on exertion, weakness, anorexia and fatigue.  The
patient states that these symptoms have continued to worsen
notes that his chronic lower back pain has worsened over the
past seven days.  He also states that he has had decreased
urine output over the last 48 hours prior to admission.

MEDICAL HISTORY: 1.  Alcoholic cirrhosis with portal hypertension.
2.  Decompensated liver disease with two prior admissions for
    hepatic encephalopathy.
3.  Coagulase negative endocarditis in [**2164-2-10**] and
    sacral osteomyelitis in [**2164-3-12**].  The patient had
    received a total of 14 weeks of antibiotics with Rifampin,
    Ciprofloxacin and Cefazolin for the infections.  He did have
    clear blood cultures in [**2164-7-12**].
4.  Left knee trauma in [**2158**] complicated by hematoma that was
    operatively drained and subsequently complicated by a
    Staphylococcus infection.
5.  History of nephrolithiasis.
6.  History of seizures secondary to work related head
    injury.
7.  Hypothyroidism.
8.  Chronic lower back pain.
9.  Severe three plus to four plus aortic insufficiency with
    significant left ventricular dysfunction, ejection fraction
    of 30% with a small vegetation that was seen on last
    admission on the aortic valve.

MEDICATION ON ADMISSION: 1.  Spironolactone 100 mg p.o. q. day.
2.  Furosemide 40 mg p.o. q. day.
3.  Nadolol 20 mg p.o. q. day.
4.  Verapamil 40 mg p.o. twice a day.
5.  Levothyroxine 50 micrograms p.o. q. day.
6.  Lactulose 45 cc., p.o., three times a day titrated to
    three bowel movements per day.
7.  Gabapentin 600 mg p.o. three times a day.
8.  Oxycodone 5 mg p.o. q. four to six hours p.r.n.
9.  Metronidazole 250 mg p.o. twice a day.

ALLERGIES: 1.  Vancomycin that supposedly he develops neutropenia,
    eosinophilia and drug fever.
2.  Morphine, he gets seizures.
3.  Rifampin, he gets nausea and vomiting.

PHYSICAL EXAM: 

FAMILY HISTORY: There is a history of coronary artery
disease and diabetes mellitus within his family.

SOCIAL HISTORY: The patient states that he drank heavily
for 30 years but states that his last drink was in [**2164-7-12**].  He denies any history of tobacco or intravenous drug
use.  He lives with his wife and has two children.
Acute and subacute bacterial endocarditis,Bacteremia,Alcoholic cirrhosis of liver,Acute kidney failure, unspecified,Unspecified osteomyelitis, other specified sites
Ac/subac bact endocard,Bacteremia,Alcohol cirrhosis liver,Acute kidney failure NOS,Osteomyelit NOS-oth site
Admission Date:  [**2164-9-17**]       Discharge Date: [**2164-9-28**]

Date of Birth:   [**2116-2-28**]       Sex:  M

Service:  MEDICINE
THIS IS A DICTATION FOR CHANGE OF SERVICE:  I AM DICTATING
FOR COURSE IN HOSPITAL UNTIL [**2164-9-28**] FOR A CHANGE OF
SERVICE.

HISTORY OF PRESENT ILLNESS:   This is a 48 year old man who
anorexia and decreased urine output.  He is a man with a
history of alcoholic cirrhosis and Staphylococcus
endocarditis in [**2164-2-10**], and sacral osteomyelitis in
[**2164-3-12**].  He was in his usual state of health until two
weeks prior to admission when he began noticing increasing
dyspnea on exertion, weakness, anorexia and fatigue.  The
patient states that these symptoms have continued to worsen
notes that his chronic lower back pain has worsened over the
past seven days.  He also states that he has had decreased
urine output over the last 48 hours prior to admission.

He cannot identify any clear factor which might have
precipitated this constellation of symptoms.  He does note,
however, that his p.o. intake has been particularly poor over
the last 48 hours.  He has eaten only a muffin and an English
muffin and had only drank 30 ounces of fluid over this time.

He denied any fevers, chills, sweats, nausea, cough,
headache, neck stiffness, photophobia, upper respiratory
infection symptoms, nausea, vomiting, constipation, dysuria,
hematuria, hesitancy, myalgias, arthralgias, recent sick
contacts, recent travels, unusual foods or raw meats or
medication non-adherence.  He has been having three to four
bowel movements per day and denies any sensation of confusion
or altered mental status.  He stated that he has noticed a
sensation of chest pressure in association with his dyspnea
on exertion over the past four weeks since he was started on
a new "heart medication", possibly nifedipine.  This
sensation had been stable and did not occur at rest.

He stated that he was recently taken off his heart medicine
by his primary care physician and noted that he began taking
Verapamil four days prior to admission.

PAST MEDICAL HISTORY:
1.  Alcoholic cirrhosis with portal hypertension.
2.  Decompensated liver disease with two prior admissions for
    hepatic encephalopathy.
3.  Coagulase negative endocarditis in [**2164-2-10**] and
    sacral osteomyelitis in [**2164-3-12**].  The patient had
    received a total of 14 weeks of antibiotics with Rifampin,
    Ciprofloxacin and Cefazolin for the infections.  He did have
    clear blood cultures in [**2164-7-12**].
4.  Left knee trauma in [**2158**] complicated by hematoma that was
    operatively drained and subsequently complicated by a
    Staphylococcus infection.
5.  History of nephrolithiasis.
6.  History of seizures secondary to work related head
    injury.
7.  Hypothyroidism.
8.  Chronic lower back pain.
9.  Severe three plus to four plus aortic insufficiency with
    significant left ventricular dysfunction, ejection fraction
    of 30% with a small vegetation that was seen on last
    admission on the aortic valve.

ALLERGIES:
1.  Vancomycin that supposedly he develops neutropenia,
    eosinophilia and drug fever.
2.  Morphine, he gets seizures.
3.  Rifampin, he gets nausea and vomiting.

MEDICATIONS ON ADMISSION:
1.  Spironolactone 100 mg p.o. q. day.
2.  Furosemide 40 mg p.o. q. day.
3.  Nadolol 20 mg p.o. q. day.
4.  Verapamil 40 mg p.o. twice a day.
5.  Levothyroxine 50 micrograms p.o. q. day.
6.  Lactulose 45 cc., p.o., three times a day titrated to
    three bowel movements per day.
7.  Gabapentin 600 mg p.o. three times a day.
8.  Oxycodone 5 mg p.o. q. four to six hours p.r.n.
9.  Metronidazole 250 mg p.o. twice a day.

SOCIAL HISTORY:   The patient states that he drank heavily
for 30 years but states that his last drink was in [**2164-7-12**].  He denies any history of tobacco or intravenous drug
use.  He lives with his wife and has two children.

FAMILY HISTORY:  There is a history of coronary artery
disease and diabetes mellitus within his family.

PHYSICAL EXAMINATION:   On examination, the patient had a
temperature maximum and temperature current of 97.5 F.; blood
pressure ranging from 99 to 117 over 26 to 39; respiratory
rate ranged from 18 to 24; saturation at 97% on room air;
heart rate ranged from 45 to 49.  Intakes and outputs, 600 in
and 50 out over the last six hours.  In general, he is awake
and lying in bed, in no apparent distress.  HEENT:  No sinus
tenderness.  Pupils are equal, round and reactive to light
and accommodation.  Extraocular movements intact.
Conjunctivae minimally icteric.  Moist mucous membranes
without erythema, exudates or sublingual jaundice.  Neck
soft, supple, no lymphadenopathy, no jugular venous
distention.  Cardiovascular is regular rate and rhythm,
normal S1, S2, with a II/VI systolic ejection murmur at the
base and upper sternal border and diastolic murmur.
Pulmonary with decreased breath sounds with crackles at the
bases.  Abdomen is soft, nontender, nondistended with no
suprapubic tenderness and no abdominal bruits.  Extremities
with three plus pitting edema bilaterally, warm ruddy skin
with discoloration over the bilateral lower extremities.  No
calf tenderness.  Clubbing of the nail beds with
discoloration.  Neurological:  He had mild asterixis.  Skin:
No palmar erythema.  Diffuse truncal and bilateral upper
extremity spider angiomata.

LABORATORY:  On admission his white blood cell count was
15.9, up from 14.9; hematocrit was 32.4 up from 35 and his
platelets were 142.  PT 18, PTT 51.3, INR 2.3.  His arterial
blood gases was 7.32/24/83.  Chem-7 with sodium of 125,
potassium 5.4, chloride of 96, bicarbonate 13, BUN 56,
creatinine 5.7 and glucose 95.  His calcium is 7.8, magnesium
2.5, phosphorus of 7.0.

Urinalysis showed large blood, negative nitrites, 100
protein, trace ketones, mild leukocyte esterase, 9 red blood
cells, 12 white blood cells, moderate bacteria, occasional
yeast with no epithelial cells.  Total bilirubin was 2, AST
31, ALT 11, alkaline phosphatase 115, albumin 3.

Urine osms 298, sodium 12, creatinine 448; FEna 0.1%.  Serum
osmolality was 294.

Transesophageal echocardiogram in [**2164-7-12**] showed
dilated left atrium with patent foramen ovale with a left to
right shunt, left ventricular wall thickness was normal and
the left ventricular cavity was moderately dilated.  Moderate
global left ventricular hypokinesis and left ventricular
systolic function was markedly depressed.  He had a moderate
sized vegetation on the non-coronary cusp of the aortic
valve, moderate to severe three plus aortic regurgitation,
one plus mitral regurgitation and there was a small
pericardial effusion.

An abdominal ultrasound on [**2164-9-17**] showed patent left and
right portal veins with recanalized peri-umbilical veins.

Chest x-ray on [**2164-9-17**], diffuse bibasilar haziness
consistent with atelectasis, small bilateral pleural
effusions on the lateral view.

EKG on [**2164-9-17**] showed an irregularly irregular rate and
rhythm with no P waves and no acute ST segment or T wave
changes.

The patient was initially admitted to the Medical Intensive
Care Unit and then subsequently transferred to the [**Doctor Last Name **]
Medicine Team.

HOSPITAL COURSE BY ISSUES:
1.  INFECTIOUS DISEASE:  The patient had an elevated white
blood cell count with some PR interval prolongation and had a
history of Staphylococcus endocarditis.  While the patient
continued to have high-grade MRC bacteremia despite being on
Vancomycin and gentamicin and subsequently on echocardiogram
he was shown to have an increase in the vegetation on his
aortic valve of approximately 2 centimeters.

He also continued to have lower back pain.  A lumbar MRI of
the spine showed no obvious osteomyelitis that had increased
in the L2, L3 lumbar spine as well as in the sacroiliac
joints.  However, bone scan did reveal an increased uptake in
the thoracic spine and subsequent thoracic spine MRI was
performed which implicated an infectious process with no
obvious abscess for drainage.

The patient's course in the hospital was complicated by a
thrombus in the right axillary artery which was significant
and seemed to extend down to the brachial artery.  The
thought was that the clot formed subsequent to an embolus
from the aortic valve vegetation.  The patient was evaluated
by multiple services including Cardiothoracic Surgery,
Vascular Surgery and Interventional Radiology and has not
been deemed to be a surgical candidate for aortic valve
replacement nor thrombectomy for his clot.

Neurosurgery was also consulted and he was not a candidate
for any spinal debridement and should be managed medically.
The patient, at this point, continues to be culture positive
despite being on adequate serum levels of Vancomycin and
Gentamicin.

2.  RENAL:  The patient had developed acute renal failure.
There was a concern for hepatorenal syndrome.  Most likely
his cause was secondary to ATN versus prerenal.  He had [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 42508**] catheter placed in his right IJ, however, after
placement of the catheter, the patient began to urinate and
his acute renal failure resolved.  His last creatinine was
0.9.  The patient's renal function is to continue to be
followed since he is on gentamicin and is also receiving
Lasix for diuresis.

3.  ALCOHOLIC CIRRHOSIS:  He is a Child B/C patient and had
an elevated INR "auto anticoagulation" and usually had an INR
of greater than 2.  He received multiple doses of
subcutaneous Vitamin K, however, auto anti-coagulation is not
a good predictor for coagulation status.  The patient was not
started on heparin for his arterial embolus and thrombus in
his axillary artery in fear of the patient's great risk for
hemorrhage.  The patient's encephalopathy was controlled and
improved with Lactulose and Flagyl; continued to titrate for
about two to three bowel movements per day.  The patient's
asterixis resolved in the hospital.

The patient at this time is not a transplant candidate due to
his MRSA bacteremia and cardiac function and endocarditis.

4.  CARDIOLOGY:  For the patient's bradycardia, the patient's
nadolol and Verapamil were held and the patient's bradycardia
resolved.  He also is getting subsequent electrocardiograms
to look for prolongation of his PR interval which has not
become more prolonged than his previous.

5.  PAIN CONTROL:  His pain control has been an issue for
both his lower back pain and his right upper extremity
thrombus.  He is currently on a regimen of Fentanyl 75
micrograms per hour with Oxycodone 5 to 10 mg q. four to six
hours p.r.n. as well as Demerol 25 to 50 intravenously q.
four to six hours p.r.n.  There is a tight balance between
giving him too much medication for pain and causing
somnolence.

6.  Ascites and lower extremity edema:  The patient is on 40
mg of intravenous Lasix q. day.  He is to continue having
daily weights to monitor his fluid status.

7.  HEMATOLOGY:  In terms of hematology, the patient had a
thrombocytopenia which was stable and is currently improving,
most likely either secondary to splenic sequestration or due
to bone marrow suppression secondary to his infection.  His
hematocrit has been stable with a macrocytic anemia despite
occult blood positive stools.

DISCHARGE STATUS:   His Code Status was changed from Full
Code to "Do Not Resuscitate" "Do Not Intubate".  Dr. [**Last Name (STitle) 497**]
continues to talk with the family to consider Hospice care
since patient is not a surgical candidate and unless new
medical treatment with antibiotic regimen is able to help
with clearance of his MRSA bacteremia, the patient may benefit
from pursuing just comfort measures and comfort treatment.

If the patient does still want to pursue antibiotic therapy,
an eventual PICC line will be required for long-term
antibiotics.


                            [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], M.D.

Dictated By:[**Name8 (MD) 1020**]
MEDQUIST36

D:  [**2164-9-28**]  16:21
T:  [**2164-9-28**]  23:19
JOB#:  [**Job Number 42509**]







Name:  [**Known lastname 7687**], [**Known firstname **]                   Unit No:  [**Numeric Identifier 7688**]

Admission Date:  [**2164-10-1**]     Discharge Date:  [**2164-10-11**]

Date of Birth:   [**2116-2-28**]     Sex:  M

Service:

HOSPITAL COURSE:  The patient is a 48 year old pleasant male
with a history of severe alcoholic cirrhosis with a recent
diagnosis of severe 4+ endocarditis and atrial regurgitation,
vertebral osteomyelitis as well as right upper extremity
thrombus.  The patient was continued on his Vancomycin and
Gentamicin for his endocarditis.  The patient's blood
cultures remained negative during this admission except for a
blood pressure on [**2164-9-28**] which grew gram positive
cocci.  Subsequent blood cultures were all negative to date.
The patient was continued on his Vancomycin and Gentamicin.
Unfortunately, the patient's creatinine began to trend
upwards during the next three to four days.  This thought
primarily to be due to the patient's gentamicin dose.  It was
thought that Gentamicin was causing nephrotoxicity and
Gentamicin was stopped.  It was thought that the gentamicin
assisted in allowing the patient to clear his bacteremia but
the nephrotoxicity was quite concerning.  The patient's
creatinine continued to trend upwards even off of the
gentamicin going from 1.3 steadily to 1.5 to 1.8, 1.9 and
finally to 2.8 by the time the patient was discharged.  It
was thought that the patient's worsening kidney function was
due to not only antibiotic use but also to the patient's
prerenal physiology.  The patient's albumin was quite low and
the patient had substantial 3+ pitting edema, all the way to
the mid thigh due to his hepatic dysfunction.  Renal consult
was called to reassess if there was any further intervention
that could be taken.  Renal ultrasounds were done and did not
reveal any obstruction.  It was thought that the patient's 4+
aortic regurgitation in addition to his hypoalbuminuric state
caused the patient's kidneys to be very poorly perfused and
therefore worsening kidney function.  The patient was given
three to four doses of albumin to help his chronic pressure.
Unfortunately this did not stop the progression of his acute
and chronic renal failure.  The patient was also on
Spironolactone and Lasix due to his peripheral edema and both
of these agents were stopped.  Unfortunately, the patient's
peripheral edema began to get worse due to this.

The patient's hematocrit continued to steadily slide
downwards.  It was initially thought that the patient may
have some gastrointestinal source of his bleed since he was
auto anticoagulated.  The patient was given Vitamin K on two
occasions to help reverse his auto anticoagulation.
Unfortunately this did not work since the patient's liver
function was so dysregulated that he could not produce the
necessary cofactors for coagulation.  The patient was guaiac
negative times three and it was ruled out that his worsening
anemia was due to gastrointestinal blood loss.  The
infectious disease attending and fellow suggested that the
patient's progressive and steady anemia may be due to
Vancomycin myelosuppression.  The patient was given three
transfusions with less than appropriate bumps in his
hematocrit each time. The renal fellow commented that the
packed red blood cells and keeping the patient's hematocrit
at a relatively normal value would further help the patient's
renal perfusion.  Unfortunately, the patient's cardiac
function prevented large amounts of blood products and the
blood products had to be given very slowly.

The patient was continued on his lactulose and Flagyl for his
hepatic encephalopathy and did quite well during his
admission.  He had no problems with mental status changes at
this time.  The patient was made Do-Not-Resuscitate,
Do-Not-Intubate during this admission and Dr. [**Last Name (STitle) 833**] discussed
the possibility of changing the patient over to comfort
measures only, given his recent rejection for a liver
transplant at a major medical institution.  The patient and
family decided that they would wish to continue antibiotic
therapy and after the patient completed his antibiotic
course, they would reassess if blood cultures returned to
being positive and if this was the case, they would change
over the comfort measures only at that time.

The patient continued to be followed by Infectious Disease,
Renal fellows and Hepatology.  Given his numerous negative
blood cultures, his stable hematocrit and creatinine it was
thought that the patient could be safely discharged to home
on the Vancomycin.  The Vancomycin troughs, his creatinine
and his hematocrit would be checked periodically and sent to
Dr. [**Last Name (STitle) 833**] who would evaluate the values and make the needed
changes thereafter.  The patient was to stay off of his
Spironolactone and Lasix as it was thought this would worsen
his prerenal status.  The patient was given a special
mattress for prevention of decubitus ulcers given his
sedentary lifestyle and the patient was to follow up with Dr.
[**Last Name (STitle) 833**] in one to two weeks.

DISCHARGE DIAGNOSIS:
1.  Vertebral osteomyelitis.
2.  4+ Aortic regurgitation due to endocarditis.
3.  Right upper extremity thrombus.
4.  Acute and chronic renal failure.
5.  Anemia due to Vancomycin myelosuppression.
6.  Coagulopathy due to hepatic dysfunction.
7.  Peripheral edema which is severe due to hypoalbuminuric
state.

DISCHARGE CONDITION:  Fair.

DISCHARGE PLAN:
1.  The patient was to have [**Hospital6 1346**]
services draw his SMA 7, complete blood count and Vancomycin
trough levels and send these values to Dr. [**Last Name (STitle) 833**] who was to
guide management as an outpatient.  If the patient's
Vancomycin level were found to be too high there would be a
change in his Vancomycin dosing due to his worsening renal
function.
2.  The patient was to follow up with his primary care
physician in one to two weeks.



                          [**Name6 (MD) 1662**] [**Last Name (NamePattern4) 4337**], M.D.  [**MD Number(1) 4338**]

Dictated By:[**Name8 (MD) 995**]

MEDQUIST36

D:  [**2164-11-14**]  18:18
T:  [**2164-11-14**]  19:24
JOB#:  [**Job Number **]


Name:  [**Known lastname 7687**], [**Known firstname **]                   Unit No:  [**Numeric Identifier 7688**]

Admission Date:  [**2164-9-17**]     Discharge Date:  [**2164-10-12**]

Date of Birth:   [**2116-2-28**]     Sex:  M

Service:

ADDENDUM:  This addendum is from the dates [**2164-10-1**] to the
date [**2164-10-12**].

The patient's blood cultures were positive on [**2164-9-28**] when one out of two blood cultures grew out
staphylococcus coagulase-negative organisms.  The patient
remained afebrile and subsequent numerous blood cultures
thereafter remained negative until the date of discharge on
his vancomycin regimen.  The patient was also placed on
gentamicin for three days also to help his blood cultures
remain negative for the synergistic effect that vancomycin
and gentamicin have together.

Unfortunately, the patient's creatinine started to trend
upwards and gentamicin was discontinued at this time.  The
patient was also placed on spironolactone due to increasing
and worsening peripheral edema secondary to his hepatic
failure and low albumin state. Unfortunately, as the
patient's creatinine trended upward from a baseline of 1.1 up
to 1.7, the patient's Lasix and spironolactone were
discontinued.

The patient was also given blood transfusions three more
times during these dates.  The patient's white blood cell
count and platelets also started to trend downwards and it
was thought at this time that the patient's pancytopenia was
probably due to vancomycin myelosuppression.  The patient was
also started on Epogen 20,000 units once a week to help
increase his bone marrow production of his red blood cells.

The patient's kidney function continued to deteriorate and by
the time of discharge his creatinine had reached a level of
2.8.  The patient was also given albumin on three separate
occasions, 50 grams, 25 grams, and 50 grams on occasions to
help allow him to retain fluid intravascularly.

The patient was seen by the Renal Service who maintained that
the patient's worsening kidney function was most probably due
to his intervascular depleted state secondary to his
hypoalbuminuria as well as his 4+ AR which prevented forward
flow of the blood that he did still have intravascularly.

The patient continued on his vancomycin with no further
spikes in his temperature and remained afebrile and
clinically looked quite well at the time of discharge.  The
patient was to continue his eight week course of vancomycin
at which time he was to have blood cultures drawn.  If these
blood cultures remain negative there would be a possibility
of liver transplant.  If the blood cultures came back
positive, the patient and the family may decide at that time
to discontinue any further antibiotic therapies.

The patient was to have VNA services and to have daily CBC,
SMA-7, and albumin as well as vancomycin levels faxed to Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 833**]  who would follow the patient closely.  The
patient was to follow-up with the Infectious Disease Clinic
as well as Hepatology and his primary care provider once he
was discharged from [**Hospital6 2003**].



                                 [**Name6 (MD) 7689**] [**Name8 (MD) **], M.D.

Dictated By:[**Name8 (MD) 995**]

MEDQUIST36

D:  [**2164-10-12**]  10:37
T:  [**2164-10-13**]  06:17
JOB#:  [**Job Number 7690**]
{'Acute and subacute bacterial endocarditis,Bacteremia,Alcoholic cirrhosis of liver,Acute kidney failure, unspecified,Unspecified osteomyelitis, other specified sites'}


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: 

PRESENT ILLNESS: This is a 48 year old man who
anorexia and decreased urine output.  He is a man with a
history of alcoholic cirrhosis and Staphylococcus
endocarditis in [**2164-2-10**], and sacral osteomyelitis in
[**2164-3-12**].  He was in his usual state of health until two
weeks prior to admission when he began noticing increasing
dyspnea on exertion, weakness, anorexia and fatigue.  The
patient states that these symptoms have continued to worsen
notes that his chronic lower back pain has worsened over the
past seven days.  He also states that he has had decreased
urine output over the last 48 hours prior to admission.

MEDICAL HISTORY: 1.  Alcoholic cirrhosis with portal hypertension.
2.  Decompensated liver disease with two prior admissions for
    hepatic encephalopathy.
3.  Coagulase negative endocarditis in [**2164-2-10**] and
    sacral osteomyelitis in [**2164-3-12**].  The patient had
    received a total of 14 weeks of antibiotics with Rifampin,
    Ciprofloxacin and Cefazolin for the infections.  He did have
    clear blood cultures in [**2164-7-12**].
4.  Left knee trauma in [**2158**] complicated by hematoma that was
    operatively drained and subsequently complicated by a
    Staphylococcus infection.
5.  History of nephrolithiasis.
6.  History of seizures secondary to work related head
    injury.
7.  Hypothyroidism.
8.  Chronic lower back pain.
9.  Severe three plus to four plus aortic insufficiency with
    significant left ventricular dysfunction, ejection fraction
    of 30% with a small vegetation that was seen on last
    admission on the aortic valve.

MEDICATION ON ADMISSION: 1.  Spironolactone 100 mg p.o. q. day.
2.  Furosemide 40 mg p.o. q. day.
3.  Nadolol 20 mg p.o. q. day.
4.  Verapamil 40 mg p.o. twice a day.
5.  Levothyroxine 50 micrograms p.o. q. day.
6.  Lactulose 45 cc., p.o., three times a day titrated to
    three bowel movements per day.
7.  Gabapentin 600 mg p.o. three times a day.
8.  Oxycodone 5 mg p.o. q. four to six hours p.r.n.
9.  Metronidazole 250 mg p.o. twice a day.

ALLERGIES: 1.  Vancomycin that supposedly he develops neutropenia,
    eosinophilia and drug fever.
2.  Morphine, he gets seizures.
3.  Rifampin, he gets nausea and vomiting.

PHYSICAL EXAM: 

FAMILY HISTORY: There is a history of coronary artery
disease and diabetes mellitus within his family.

SOCIAL HISTORY: The patient states that he drank heavily
for 30 years but states that his last drink was in [**2164-7-12**].  He denies any history of tobacco or intravenous drug
use.  He lives with his wife and has two children. 

### Response:
{'Acute and subacute bacterial endocarditis,Bacteremia,Alcoholic cirrhosis of liver,Acute kidney failure, unspecified,Unspecified osteomyelitis, other specified sites'}
