CHIEF COMPLAINT: Orinal complaint - R eye vision loss

PRESENT ILLNESS: 71yo man h/o MDS, CAD, PAD, and DM who presents with sudden
vision loss and eye pain. He was driving in [**State 108**] when he
noticed these symptoms 3 days prior to presentation. He was on a
trip visiting [**Location (un) 86**] and was feeling progressively worse with
associated fevers, chills, malaise, arthralgias, and myalgias
and decided to come to the ED for further evaluation.
.
In the ED, initial vs were: 96.4 66 102/59 18 96% RA. Patient
was given percocet 5/325 x 2. Last set of vitals were 70 118/62
16 95%RA. Opthalmology was consulted who recommended urgent
vitrectomy. Patient was sent to [**Hospital Ward Name 23**] OR where he underwent
diagnostic and therapeutic vitrectomy and [**Hospital Ward Name **] pus was
expressed from the vitreous fluid. They injected tetracaine
2gtt, intraocular vancomycin 0.1ml (1mg), ceftazidime 0.1ml
(2mg), amphotericine 0.1ml (5mcg), and amphotericin, and
recommended work up for systemic sources of infection. They also
gave 200cc of LR and patient was given remifentanil 50mcg IV
ONCE at 2245. Last set of vitals were 120/55 80 16 90%RA.
.
On the floor, the patient complains of right shoulder and right
sided chest pain. He describes it as sharp, radiating to the
back and down his right arm and right chest. He says he's never
had this pain before. He says the pain gets worse with movement
althouth he has not been moving much. His anginal equivalent is
dyspnea, and this is different that angina. He says he has no
history of arthritis in his shoulder, but was given cortisol
injections in his shoulder which did not help. Percocets in the
ED did help with the pain. He denies any associated SOB, nausea,
vomitting, diaphoresis, dizziness. There is no association with
coughing or taking deep breaths. He did go on a long car ride on
Sunday (12 hours), denies calf pain, swelling, cough,
hemoptysis. He denies abdominal pain, diarrhea, constipation. He
does report flu-like symptoms with rhinorrhea, fevers to 104,
chills, sore throat, arthralgias and myalgias. His arthralgias
and myalgias seem to persist into his current R shoulder, R
chest, and left arm pain.
.
Review of systems:
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denied
cough, shortness of breath. Denied chest tightness,
palpitations. Denied nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.

MEDICAL HISTORY: AAA with illiac artery aneurysms treated with an aortobifemoral
graft [**2089**].
Bilat carotid endarterectomies
CAD - coronary angioplasty and stenting [**2103**]
CABG (LIMA to LAD, SVG to diagonal, SVG to OM, sequential
SVG to AM/PDA)[**2089**]
Hyperlipidemia
HTN
AODM
Cerebral hemorrhage mid [**2085**]??????s
Prior CVA
Asbestos exposure

MEDICATION ON ADMISSION: 1) Glimipremide 2mg PO daily
2) Genuvia 100mg PO daily
3) Plavix 75mg PO Daily
4) nitro SL PRN chest pain
5) Lopressor 50mg PO daily
6) nortryptaline 25mg PO HS
7) Vytorin 10-40mg PO daily

ALLERGIES: Penicillins

PHYSICAL EXAM: Vitals: T: 98.1 BP: 133/87 P: 93 R: 24 SaO2: 97% 3L

FAMILY HISTORY: non contributory

SOCIAL HISTORY: married, large family w/ many kids and grandkids.
Pt & wife spend most of the year living in [**State 108**].
-Occupation/Hobbies: pt is a retired pipe fitter & manager. He
enjoys hunting and has a new gun that he has been looking
forward
to using per his family
-Sources of Support: tight-knit family
-Religion/Spirituality: not explored
-Coping: family is struggling to cope w/ patient's decline
-Health-care [**Doctor Last Name 360**]/proxy: wife
Streptococcal septicemia,Subendocardial infarction, initial episode of care,Acute endocarditis, unspecified,Duodenitis, with hemorrhage,Toxic encephalopathy,Acute respiratory failure,Acute endophthalmitis,Septic arterial embolism,Arterial embolism and thrombosis of lower extremity,Cellulitis and abscess of trunk,Infection and inflammatory reaction due to other vascular device, implant, and graft,Alkalosis,Hematoma complicating a procedure,Acute kidney failure, unspecified,Severe sepsis,Myelodysplastic syndrome, unspecified,Acute lymphadenitis,Disorders of bursae and tendons in shoulder region, unspecified,Thrombocytopenia, unspecified,Other esophagitis,Aortocoronary bypass status,Coronary atherosclerosis of native coronary artery,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure
Streptococcal septicemia,Subendo infarct, initial,Ac/subac endocardit NOS,Duodenitis w hmrhg,Toxic encephalopathy,Acute respiratry failure,Acute endophthalmitis,Septic arterial embolism,Lower extremity embolism,Cellulitis of trunk,React-oth vasc dev/graft,Alkalosis,Hematoma complic proc,Acute kidney failure NOS,Severe sepsis,Myelodysplastic synd NOS,Acute lymphadenitis,Rotator cuff synd NOS,Thrombocytopenia NOS,Other esophagitis,Aortocoronary bypass,Crnry athrscl natve vssl,Abn react-anastom/graft,Abn react-cardiac cath
Admission Date:  [**2105-12-14**]              Discharge Date:   [**2106-2-12**]

Date of Birth:  [**2034-7-2**]             Sex:   M

Service: SURGERY

Allergies:
Penicillins

Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Orinal complaint - R eye vision loss

Major Surgical or Invasive Procedure:
[**2105-12-14**]
A diagnostic and therapeutic 23-gauge pars plana vitrectomy with
injection of vancomycin 2 mg ceftazidime 2 mg and amphotericin 5
mcg right eye.

[**2105-12-25**]
Incision and drainage of right groin abscess,
radical debridement of right groin and sartorius muscle flap
closure of groin wound.

[**2105-12-31**]
Successful PTCA and stenting of the proximal left circumflex
artery
with a Xience (3x18mm) drug eluting stent. Final angiography
demonstrated no angiographically apparent dissection, no
residual
stenosis and TIMI III flow throughout the vessel (See PTCA
comments).

[**2106-1-7**]
Debridement and drainage of groin; removal of distal end of
aortobifemoral graft and replacement with rifampin-soaked 8-mm
interposition Dacron graft segment; complete removal of
femoropopliteal graft; oversewing of popliteal artery.

[**2106-1-28**]
Percutaneous endoscopic gastrostomy.

History of Present Illness:
71yo man h/o MDS, CAD, PAD, and DM who presents with sudden
vision loss and eye pain. He was driving in [**State 108**] when he
noticed these symptoms 3 days prior to presentation. He was on a
trip visiting [**Location (un) 86**] and was feeling progressively worse with
associated fevers, chills, malaise, arthralgias, and myalgias
and decided to come to the ED for further evaluation.
.
In the ED, initial vs were: 96.4 66 102/59 18 96% RA. Patient
was given percocet 5/325 x 2. Last set of vitals were 70 118/62
16 95%RA. Opthalmology was consulted who recommended urgent
vitrectomy. Patient was sent to [**Hospital Ward Name 23**] OR where he underwent
diagnostic and therapeutic vitrectomy and [**Hospital Ward Name **] pus was
expressed from the vitreous fluid. They injected tetracaine
2gtt, intraocular vancomycin 0.1ml (1mg), ceftazidime 0.1ml
(2mg), amphotericine 0.1ml (5mcg), and amphotericin, and
recommended work up for systemic sources of infection. They also
gave 200cc of LR and patient was given remifentanil 50mcg IV
ONCE at 2245. Last set of vitals were 120/55 80 16 90%RA.
.
On the floor, the patient complains of right shoulder and right
sided chest pain. He describes it as sharp, radiating to the
back and down his right arm and right chest. He says he's never
had this pain before. He says the pain gets worse with movement
althouth he has not been moving much. His anginal equivalent is
dyspnea, and this is different that angina. He says he has no
history of arthritis in his shoulder, but was given cortisol
injections in his shoulder which did not help. Percocets in the
ED did help with the pain. He denies any associated SOB, nausea,
vomitting, diaphoresis, dizziness. There is no association with
coughing or taking deep breaths. He did go on a long car ride on
Sunday (12 hours), denies calf pain, swelling, cough,
hemoptysis. He denies abdominal pain, diarrhea, constipation. He
does report flu-like symptoms with rhinorrhea, fevers to 104,
chills, sore throat, arthralgias and myalgias. His arthralgias
and myalgias seem to persist into his current R shoulder, R
chest, and left arm pain.
.
Review of systems:
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denied
cough, shortness of breath. Denied chest tightness,
palpitations. Denied nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.

Past Medical History:
AAA with illiac artery aneurysms treated with an aortobifemoral
graft [**2089**].
Bilat carotid endarterectomies
CAD - coronary angioplasty and stenting [**2103**]
CABG (LIMA to LAD, SVG to diagonal, SVG to OM, sequential
SVG to AM/PDA)[**2089**]
Hyperlipidemia
HTN
AODM
Cerebral hemorrhage mid [**2085**]??????s
Prior CVA
Asbestos exposure


Social History:
married, large family w/ many kids and grandkids.
Pt & wife spend most of the year living in [**State 108**].
-Occupation/Hobbies: pt is a retired pipe fitter & manager. He
enjoys hunting and has a new gun that he has been looking
forward
to using per his family
-Sources of Support: tight-knit family
-Religion/Spirituality: not explored
-Coping: family is struggling to cope w/ patient's decline
-Health-care [**Doctor Last Name 360**]/proxy: wife


Family History:
non contributory

Physical Exam:
Vitals: T: 98.1 BP: 133/87 P: 93 R: 24 SaO2: 97% 3L

General: Lethargic, but arousable to voice. Lying bed
uncomfortably
HEENT: NCAT, PERRL, EOMI, no scleral icterus, MMM, no lesions
noted in OP
Neck: supple, no significant JVD or carotid bruits appreciated
Pulmonary: Lungs CTA in the anterior fields
Cardiac: RR, nl S1 S2, 2/6 SEM across the sternum, No rubs or
gallops appreciated
Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or
organomegaly noted
Extremities: Right groin dressing c/d/i VAC placed.  Underneath
reveals a 5 x 5 cm wound with some granulation tissue, no [**Doctor Last Name **]
puss appreciated, The RLE is warm with faint distal pulses
Skin: no rashes or lesions noted. Toes are pink on the right.
Left leg is tender to touch, and is covered with linear
excorations which appear old
Neurologic: Patient unable to speak or follow simple commands.
Lack of attention noted. Withdraws all 4 extremities to pain.



Pertinent Results:
Admission Labs:

[**2105-12-14**] 07:20PM

LACTATE-1.7

[**2105-12-14**] 02:25PM

GLUCOSE-343* UREA N-15 CREAT-1.1 SODIUM-129* POTASSIUM-4.5
CHLORIDE-95* TOTAL CO2-25 ANION GAP-14

[**2105-12-14**] 02:25PM

CK(CPK)-45*

[**2105-12-14**] 02:25PM

CK-MB-2 cTropnT-<0.01

[**2105-12-14**] 02:25PM

WBC-5.3# RBC-3.90* HGB-12.0* HCT-36.3* MCV-93 MCH-30.7 MCHC-33.0
RDW-22.7*
NEUTS-58 BANDS-1 LYMPHS-25 MONOS-9 EOS-0 BASOS-0 ATYPS-1*
METAS-3* MYELOS-2* PROMYELO-1*

STOOL     CONSISTENCY: LOOSE      Source: Stool.

CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2106-2-6**]):
Feces negative for C.difficile toxin A & B by EIA.

[**2105-12-14**] 02:25PM

HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL

[**2105-12-14**] 02:25PM

PLT COUNT-219#

[**2105-12-14**] 02:25PM   PT-14.8* PTT-27.6 INR(PT)-1.3*

RECENT STUDIES:

[**2105-12-29**] ECHO:

The left atrium is mildly dilated. The left ventricular cavity
size is normal. There is moderate to severe regional left
ventricular systolic dysfunction with
inferior/inferolateral/septal hypokinesis with milder
hypokinesis elsewhere. Right ventricular chamber size is normal.
with probably mild global free wall hypokinesis. The aortic root
is mildly dilated at the sinus level. The aortic valve leaflets
(3) are mildly thickened. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is mild mitral valve prolapse. An
eccentric, posteriorly directed jet of mild to moderate ([**1-24**]+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. The pulmonary artery systolic pressure could
not be determined. There is no pericardial effusion.

No vegetation seen (cannot definitively exclude).

Compared with the prior study (images reviewed) of [**2105-12-15**],
left ventricular systolic function is now much worse. Mitral
regurgitation appears similar.
.
CXRAY [**2105-12-28**]:

In comparison with the study of [**12-20**], there is continued
relatively low lung volumes. Enlargement of the cardiac
silhouette in a patient with intact midline sternal wires.
Continued diffuse prominence of interstitial markings that could
reflect chronic lung disease, elevated pulmonary venous
pressure, or both. Central catheter remains in place. There is
some haziness at the bases with blunting of the costophrenic
angle suggesting some pleural effusion.
.
CT OF HEAD W/ CONTRAST ON [**2105-12-28**]:

FINDINGS: There is a stable area of right occipital
encephalomalacia, with ex vacuo dilatation of the occipital [**Doctor Last Name 534**]
of the right lateral ventricle. There is no evidence, for an
acute major [**Doctor Last Name 1106**] territorial infarct or acute hemorrhage.
There is mild prominence of ventricles and sulci, as before.

There is mild mucosal thickening in the right sphenoid sinus
with a possible air-fluid level. The bones are unremarkable.
There is calcification of bilateral carotid siphons.

Apparent hyperdensity projecting over the posterior right globe
likely represents motion artifact.

IMPRESSION:
1. No evidence of acute intracranial abnormalities.
2. Stable right occipital encephalomalacia.
3. Apparent hyperdensity projecting over the posterior right
globe likely represents motion artifact. Please correlate with
eye exam.

[**2106-1-14**]

FINDINGS:

CHEST: An endotracheal tube terminates just beyond the thoracic
inlet, 8 cm above the carina. Retained mucus is noted in the
proximal trachea. There is no pneumothorax. Diffuse irregular
bronchial wall thickening may be consistent with small airways
disease, although the airways are patent to the segmental
levels.

There is severe, apical-predominant centriacinar and paraseptal
emphysema.  Diffuse ground-glass opacities are present
throughout the lungs, consistent with combined pulmonary edema
and atelectasis, although superimposed infection cannot be
excluded. Moderate bilateral pleural effusions persist, with
adjacent compressive atelectasis.

A left internal jugular line again terminates in the distal left

brachiocephalic vein. Dense calcifications are noted in the
aortic root,
coronary arteries, and thoracic aorta. Within the limits of
contrast bolus
timing, there is no main or lobar pulmonary embolus, and no
evidence of acute aortic syndrome. The heart is normal in size,
without pericardial effusion.

Multiple prominent mediastinal and hilar lymph nodes are
present, likely
reactive, and measuring up to 10 mm in the right paratracheal
region.

ABDOMEN: Nasogastric tube terminates in the stomach. The small
bowel is
normal.

There is mild fatty infiltration of the liver. The gallbladder
is partially collapsed. The pancreas is slightly atrophic. The
spleen is normal.

The adrenals are normal. The kidneys are mildly atrophic, but
enhance and
excrete contrast promptly and symmetrically. Extensive
calcifications are
noted in the renal arteries.

Fat-containing umbilical and right parasagittal ventral hernias
are present.

PELVIS: The appendix is normal. Scattered descending colonic and
sigmoid
diverticula are present, without acute inflammation. Note is
made of a
patulous, fluid-filled rectum. A Foley catheter is present
within the
bladder.

An aortobifemoral graft is present, with contrast opacifying
both limbs.
Dense calcifications are noted in the abdominal aorta, iliac,
and femoral
arteries, with moderate stenosis of branch vessel origins. Soft
plaques are present along the posterior wall of the infrarenal
aorta, resulting in mild luminal stenosis. A rim-calcified,
nonenhancing 1.6 x 1.1 cm collection posterior to the proximal
left iliac artery likely represents a thrombosed pseudoaneurysm.
Within the abdomen, there is no evidence of contrast
extravasation, fat stranding, lymphadenopathy, or fluid
collections to suggest endoleak, infection, or other
complications.

Changes of debridement are again noted in the right thigh. There
are two
heteregeneously enhancing, lobulated soft tissue and fluid
collections
surrounding the proximal and distal ends of the right
femoropopliteal graft.  These were incompletely imaged on the
most recent examination, but appear decreased in size from CT on
[**2106-1-10**]. The collection surrounding the proximal limb is
located in the right infrainguinal region (2:136) and
measures 6.1 x 2.8 cm, previously 6.1 x 3.7 cm. The collection
surrounding
the distal limb (2:146) is located in the medial proximal thigh
and measures 3 x 2.1 cm, previously 3.6 x 2.5 cm. Prominent
reactive inguinal lymph nodes are present, along with mild
subcuatenous edema and fascial thickening. There is no evidence
of intrapelvic extension.

No suspicious osseous lesions are identified. Moderate
degenerative changes are noted in the thoracolumbar spine.

IMPRESSION:

1. Decrease in fluid collections surrounding the ends of the
right
femoropopliteal graft. The appearance is nonspecific, but may
reflect
hematoma or phlegmon. No evidence of intra-abdominal extension;
if follow-up imaging is desired, please selectively image the
right thigh.
2. Patent aortobifemoral graft, without evidence of
complications.
3. Severe emphysema with diffuse pulmonary edema, effusions, and
atelectasis. Superimposed infection cannot be excluded.
4. ET tube just beyond thoracic inlet, please advance 3-5 cm.

The study and the report were reviewed by the staff radiologist

[**2106-2-1**]:

INDICATION: Status post PICC placement, assess position.

COMPARISON: Chest radiograph from [**2106-1-29**].

FINDINGS: The left PICC ends in the high SVC. The right lateral
lung is not included on this radiograph. There is unchanged mild
cardiomegaly. The
mediastinal contours are normal. There is no pneumothorax
identified. The
right mid-lower lung opacities are unchanged while the left
mid-lower lung
opacities have improved.

IMPRESSION:
1. Unchanged right mid-lower lung opacities and improved left
mid-lower lung opacities, may be secondary to pulmonary edema
and/or pneumonia. Recommend followup imaging to distinguish
between these entities.
2. Unchanged mild cardiomegaly.
3. Left PICC ending in high SVC.

ECHO:

[**2106-1-12**]

The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is moderately
depressed (LVEF= 35 %). Right ventricular chamber size and free
wall motion are normal. The aortic root is mildly dilated at the
sinus level. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. No masses or vegetations are
seen on the aortic valve, but cannot be fully excluded due to
suboptimal image quality. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is
borderline/mild posterior leaflet mitral valve prolapse. No
masses or vegetations are seen on the mitral valve, but cannot
be fully excluded due to suboptimal image quality. Mild (1+)
mitral regurgitation is seen. No masses or vegetations are seen
on the tricuspid valve, but cannot be fully excluded due to
suboptimal image quality. The pulmonary artery systolic pressure
could not be determined. No masses or vegetations are seen on
the pulmonic valve, but cannot be fully excluded due to
suboptimal image quality. There is no pericardial effusion.

Compared with the findings of the prior study (images reviewed)
of [**2105-12-29**], the findings are similar.

If clinically indicated, a transesophageal echocardiographic
examination is recommended.

IMPRESSION: no definite vegetations seen (suboptimal study)

[**2106-1-19**] 9:21 am PLEURAL FLUID

GRAM STAIN (Final [**2106-1-19**]):
1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR LEUKOCYTES.
NO MICROORGANISMS SEEN.

FLUID CULTURE (Final [**2106-1-22**]):    NO GROWTH.

ANAEROBIC CULTURE (Final [**2106-1-25**]):    NO GROWTH.

ACID FAST CULTURE (Preliminary):    NO MYCOBACTERIA ISOLATED.

ACID FAST SMEAR (Final [**2106-1-20**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.

[**2-12**]:

WBC   RBC   Hgb   Hct   MCV MCH  MCHC RDW   Plt Ct
11.1* 3.21* 10.0* 30.6* 95  31.1 32.6 20.2* 130*

[**2-12**]:

Glucose UreaN Creat  Na   K Cl HCO3
194*1   22*   0.6    132* 3.7  99

Test Name Value Reference Range Units
[**2106-1-28**] 08:45

Report Comment:
Source: Catheter
GENERAL URINE INFORMATION
Urine Color Yellow
Urine Appearance Clear
Specific Gravity 1.016 1.001 - 1.035
DIPSTICK URINALYSIS
Blood SM
Nitrite NEG
Protein 25   mg/dL
Glucose NEG   mg/dL
Ketone NEG   mg/dL
Bilirubin NEG   mg/dL
Urobilinogen NEG 0.2 - 1 mg/dL
pH 5.0 5 - 8 units
Leukocytes NEG
MICROSCOPIC URINE EXAMINATION
RBC 0-2 0 - 2 #/hpf
WBC 0-2 0 - 5 #/hpf
Bacteria NONE
Yeast NONE
Epithelial Cells 0-2   #/hpf
URINE CASTS
Hyaline Casts 0-2 0 - 0 #/lpf
OTHER URINE FINDINGS
Urine Mucous FEW

[**2106-1-31**] 4:09 am CATHETER TIP-IV      Source: central line.

WOUND CULTURE (Final [**2106-2-2**]):    No significant growth.

[**2106-1-15**] 9:12 am SWAB      Source: Right Groin.

GRAM STAIN (Final [**2106-1-15**]):

1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2106-1-17**]):    NO GROWTH.

[**2106-1-28**] 11:05 am BLOOD CULTURE
Blood Culture, Routine (Final [**2106-2-3**]):    NO GROWTH.

Pertinent images:

#CXRAY [**2106-1-4**]:
In comparison with the study of [**1-1**], there is little overall
change. The Dobbhoff tube is uncoiled and in the upper stomach.
Bibasilar opacification with pleural calcification on the right
is essentially unchanged. Mild indistinctness of pulmonary
vessels could reflect some elevated pulmonary venous pressure.
.
#CT PELVIS ON [**2106-1-4**]:

in comparison to [**12-22**], fluid collections in the right groin
about the bypass grafts are slightly smaller in size -- a more
superior portion of the collection previously measured 2.5 x 3.2
cm is now 2.5 x 2.8 cm axially. a more inferior component
previously measured 2.3 x 4.1 cm is now 1.8 x 2.7 cm axially.
the craniocaudad extent is similar. while the collections about
the graft are smaller, the walls appear thicker and there is
increased overlying inflammatory change. this is deep to the
surgical staples, and may be post- operative, though clinical
correlation woudl be required to exclude infection. also noted
is a new superficial collection more laterally, not present on
prior study. this is of higher attenuation and may represent
evolving post-operative hematoma.

on the left, there is stranding consistent with recent
catheterization, but no large hematoma is identified.

the intrapelvic contents remain unremarkable. no deep fluid
collection or abscess is identified.

this study is not optimized for evaluation of the vessels,
however, no new vessel occlusion is identified. partial thrombus
of the right fem-[**Doctor Last Name **] graft is noted.

# US OF RIGHT FOOT ON [**2106-1-4**]:
Prelim report- no abscess or fluid collection. + subcutaneous
tissue edema

MRI: There has been little change compared to the [**2105-12-20**]
MRI. Again demonstrated is encephalomalacia in the right
parietal region and scattered FLAIR/T2 hyperintensities within
the cerebral white matter. There is no evidence of interval
hemorrhage, infarct, or mass. The post-gadolinium images are
unremarkable. Abnormal appearance to the right globe is similar
to prior with T2 hypointense material present within the
posterior globe. The major intracranial flow voids are
preserved. Ventricles, cisterns, and sulci are otherwise
significant for symmetric, age-related prominence.



Brief Hospital Course:
Mr. [**Known lastname 9250**] is a 71yo man with history of MDS on Dacogen (last
dose 5 weeks prior to admission), CAD, PAD, and DM who presented
with sudden vision loss and eye pain and was found to have
endocarditis with endophthalmitis.

# Endocarditis: His endophthalmitis was felt to be secondary to
endogenous source, and bacteremia was suspected.  Patient
underwent TEE on [**12-16**] which showed a small vegetation on his
aortic valve consistent with endocarditis.  His blood cultures
were persistently negative and either culture negative
endocarditis or fungal source was suspected.  He was empirically
treated with vancomycin and ceftaz for bacterial coverage and
ambisome and doxycycline for fungal and atypical coverage.
Numerous serologies including mycoplasma, brucella, bartonella,
Q-fever and chlamydia were sent and which are negative to date.
Fungal workup included beta glucan and galactomannan serologies
and fungal cultures were are negative. Pt was on a variety IV
antibiotics per ID. See below brief hosptal course out line.

# ID: Mr. [**Known lastname 9250**] is a 71 year old man with a history of MDS,
[**Known lastname 1106**] disease who was admitted [**2105-12-14**] with 3-4 days of
vision loss in the right eye, which occurred acutely at his home
in [**State 108**]. A few weeks prior to this incident, he was treatedas
an outpatient with Levofloxacin for an "URI" during which he had
fevers to 103-104.

There has been no positive culture data during this
hospitalization, except for two universal PCR's done on [**12-14**]
vitreous fluid and [**12-25**] groin pus - Streptococcus agalactiae was
isolated both times.

He is currently on the floor and antibiotics were briefly
narrowed to Daptomycin only on [**2106-1-26**] (Vancomycin was changed to
Daptomycin over family's concern that Vancomycin may have been
contributing to drug fever). He continued to have fever to
101-102 on Daptomycin alone and upon the family's request on
[**2106-1-28**], a three drug regimen to cover other nocosomial organisms
(Aztreonam, Ciprofloxacin, and Metronidazole) was re-started.

Currently, the patient's last low grade fever was on [**2106-2-2**].
Even if he continues to have higher fevers on this regimen, the
antibiotic plan will be the same, unless there is new culture
data to change therapy.

On discharge pt is on Daptomycin IV untill [**2-18**], then keflex 500
[**Hospital1 **] for life, for supression therapy.

# Pururic skin lesions: Patient was noted to have a right medial
malleolar palpable purpuric skin lesion on admission.  Over the
next couple days, he developed scattered discrete skin lesions
and one was biopsied by dermatology. The biopsy showed acute
necrotizing vasculitis and dermal abscess formation and noted
"Although an immune-mediated vasculitis may be present, the
dermal abscess formation is concerning for an infectious
process." He was evaluated for possible vasculitis by
rheumatology and serologies where negative. Rheumatology signed
off.

# Endophthalmitis:  He was evaluated by ophthamology in the ER
and underwent urgent vitrectomy on [**12-14**] which produced pus.
This fluid was sent for gram stain which showed numerous polys
but no microorgansims.  He received intraocular
Vanc/Ceftaz/Amphotericin.  As mentioned above, this was felt to
be an endogenous infection.  He was followed by ophthomology and
treated with numerous drops. Pt currently on drops as per med
list.

# Right shoulder pain: Patient complained of right shoulder pain
which he had for approximately a week prior to admission.  MRI
of the shoulder was poor quality but found supraspinatous
rotator cuff tear.  There was no evidence of infection.  Rest
and anti-inflammatories were recommended by orthopedics with
agreement from rheumatology.  His pain was treated with
oxycontin and oxycodone. This was DC'd when patient had
delerium. Once stable he should follow up with a orthopedist.

Other Info R shoulder pain: R shoulder pain and new left elbow
pain: MRI of R shoulder poor quality but no clear signs of
infection and rotator cuff tear. Films of R shoulder and L elbow
unremarkable. Ortho feels these pains are MSK related and
suggested rest with pain control/anti-inflammatories and
eventual PT.  Rheum recommends consideration of AC joint tap to
rule out infection; ortho has deferred on this and does not feel
exam is c/w infxn. Overall symptoms are improving and feeling sl
better today with some improvement in ROM.

# MDS:  He follows with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**Location (un) 27087**] [**State 108**].
Patient s/p 5 cycles of Dacogen (started [**8-1**]) with last chemo
approximately 5 weeks prior to [**Hospital1 18**] admission.  Patient usually
takes a week of Neupogen as needed for neutropenia after the 5
days of dacogen.  Last BM bx in [**Month (only) 205**] showed some blast
proliferation concerning for MDS conversion to leukemia. A heme
Onc consult was obtained, for further management and
recommendations. Final Consult below.

Mr. [**Known lastname 9250**] has a history of MDS and was treated in [**10/2105**] with
decitabine.  On presentation, he has anemia and thrombocytopenia
that are less severe than previous.  Review of peripheral smear
showed modest dysplastic changes but not blasts
concerning for transformation to leukemia.  MDS may results in
functional or absolute neutropenia and leukopenia that can
result in infection and thereby fevers.  In the absense of this,
MDS itself should not be a cause of fever.  We favor ongoing
infection or drug fever as the cause of Mr. [**Known lastname 27088**] fever.
With regard to his MDS, he should receive PRBC and platelet
transfusions as needed.  No further therapy is available or
indicated for his myelodysplasia.

# CAD, Chest Pain: Patient does not take aspirin at home given
recent ASA induced gastritis but was started on this medication
when his plavix was held in the hospital per his cardiologist's
recommendation.  Pt did have a NSTEMI. His was restarted on
plavix  He was continued on vytorin, and metoprolol. He did have
a cardiac cath as outlined below.

Selective coronary angiography in this right dominant system
demonstrated native three vessel disease.  The LMCA was patent.
The LAD was 100% occluded in the mid vessel.  The LCx had a hazy
area of thrombosis/in-stent restenosis.  The RCA was totally
occluded.

Arterial conduit angiography revealed the LIMA to LAD to be
widely  patent.  Venous conduit angiography revealed the SVG-RCA
and SVG-OM to be widely patent and without change.

Limited resting hemodynamics revealed normotension 118/56 mmHg.

Successful PTCA/stenting of proximal LCX with 3.0 X 15 mm VISION
BMS  at 20 atms. Final angiogram showed 0% residual stenosis, no
dissection and normal flow in the distal vessel.

FINAL DIAGNOSIS:

1. Three vessel native coronary artery disease.
2. Patent LIMA to LAD.
3. Patent SVG to OM and SVG to RCA.
4. Successful placement of Vision bare metal stent in proximal
LCX.

Other Cardiac: Elevated Troponins/Cardiac ischemia: Pt has
significant hx of CAD with  coronary angioplasty and stenting
[**2103**], CABG (LIMA to LAD, SVG to diagonal, SVG to OM, sequential.
Followed by Dr. [**Last Name (STitle) **]. On [**12-25**] in the setting of being hypotensive
in the PACU after his I&D, he had troponins checked which were
elevated. His troponins peaked at 0.88 on [**12-30**] and his CK/MB
peaked at 353/39 on [**12-26**]. EKG remains unchanged from prior. He
was tx as NSTEMI w/ hep gtt, ASA, Plavix.  His repeat Echo on
[**12-29**] showed significant worsening LVF with EF decreasing from
50% to 30%. He went for cardiac cath on [**12-31**] which showed 100%
mid LAD occlusion, Lcx hazy thrombus in stent restenosis. He had
ballon angio and had BMS placed on PTCA, Plavix was changed from
Qday to 75mg [**Hospital1 **] x 1 week, then QD on ([**1-7**]), Cont ASA 325mg,
Cont simvastatin.

# DM: His blood sugars were initially elevated but improved with
sliding scale Humalog and evening Lantus. This was eventually
switched to SSI. Pt blood sugars stable on DC

# [**Month/Year (2) **] Brief: Incision and drainage of right groin abscess,
radical debridement of right groin and sartorius muscle flap
closure of groin wound [**12-25**] and Debridement and drainage of
groin; removal of distal end of aortobifemoral graft and
replacement with rifampin-soaked 8-mm interposition Dacron graft
segment, complete removal of femoropopliteal graft, and
oversewing of popliteal artery on [**1-7**]. Currenly patient has
minimal bllod flow to foot. [**Month (only) 116**] need future amp. Does  have
collaterals. Pt did have ischemic leg. Was on IV heperin. This
was DC'd because of multiple GI blled. On Dc pt on asa, plavix.
We are now watching leg.

# Vision loss: Patient with most likely diagnosis of
endophthalmitis. Optho team concerned for endogenous source,
especially given his immunocompromised status. They recommend
vanc/ceftaz until cultures can confirm a pathogen. No pathogen
detected. On DC current eye drops per med list.

# Hypoxemia: Blood gas confirms hypoxemia. Concominant
respiratory alkalosis with hypocarbia points away from
narcotic-induced hypoventilation as etiology. Patient also with
interstitial changes c/w interstitial fibrosis versus emphysema.
Pt was intubated x 2. Weaned from ventalator. Each time
transfered to the VICU
.
# Hyponatremia: Most likely secondary to hypovolemia given
patient's history of very poor PO intake, dry MM, NS bolus 500cc
x 1, Maintanaince fluids, Urine lytes. On DC na is normalized.


# Elevated creatinine: Improving after IV fluids, back to
baseline.  Could be related to ambisome or other medications.
Given IV fluids prior to IV contrast today
Continue to monitor lytes and creatine, thougt to be contrast
induced. Hydrated. On Dc creatinine is stable

# Pain management: Stopped all narcotics this AM given that pt
has AMS likely due to delusion- with hallucinations and
inattention which per family seems worse after receiving pain
meds, continue to close monitor MS and pain management, Cont on
tylenol PRN, Lidocaine patch

# Altered Mental Status: Pt alert and oriented x person. Having
hallucinations seen peopele in the room. He was previously
evaluated by neuro for AMS and was found to be due to metabolic
causes. He does not have a neuro defecit. He had head CT on
[**12-28**] and head MRI on [**12-30**] that showed no acute process or
changes when compared to prior MRI done on [**12-20**]. This was
likely due to combination of medications, poor sleep, pain. This
does not appear to be infectious since he has no other
menigitides symptoms. On DC mental staus has cleared, still
alittle confused at night. Neurology was consulted Neurolgoy
believes his change in MS is due to metabolic delerium. There is
also concern about septic emboli from ? endocarditis and
arterial graft infection, so ID recommended MRI of head for
evaluation of septic emboli.

MRI: There has been little change compared to the [**2105-12-20**]
MRI. Again demonstrated is encephalomalacia in the right
parietal region and scattered FLAIR/T2 hyperintensities within
the cerebral white matter. There is no evidence of interval
hemorrhage, infarct, or mass. The post-gadolinium images are
unremarkable. Abnormal appearance to the right globe is similar
to prior with T2 hypointense material present within the
posterior globe. The major intracranial flow voids are
preserved. Ventricles, cisterns, and sulci are otherwise
significant for symmetric, age-related prominence.

IMPRESSION:
1. No significant change compared to [**2105-12-20**].
2. Abnormal appearance of the right globe, compatible with the
patient's
known history of staphylococcal infection of his right globe.

#Thrombocytopenia/Coags:  Pt was on hep drip which started on
[**12-25**] and had decrease in platelets which have trended down over
the last several days.  This could be due to bone marrow
supression from the antibiotics, infection or MDS. His MDS
initial presentation was thromcytopenia and his last chemo dose
was 7 weeks ago, which he could be having bone marrow
transformation of abnormal cells. Doxi was stopped [**12-30**];
however he still on vancomycin. HIT was also in the
differential, but less likely given the rate of plalet decline.
His calculated pre-test prob for HIT is low-intermediate. So
anti-hep antibody was sent, this was negative.

# Anemia: pt has Hct trended down from low 30s->upper 20s, this
is stable. He has small hematoma at site of cath that is
unchanged, Pt transfused multiple times, Pt put on IV protonix.
Pt did have scope showed GI bleed. Gi was consulted,  PPI
started, HCT followed. Did get a EGD [**1-14**].

Grade 3 esophagitis in the gastroesophageal junction In the
second part of the duodenum there was an adherent clot with
blood extruding under the clot. There was fresh blood in this
area. On injection of this area with 1/10,000 epi patient's
heart rate and BP increased. A clip was placed one cm. proximal
to the clot towards the stomach from this clot. This was to
allow an angiographer to know the location.
Otherwise normal EGD to third part of the duodenum.

Pt c/w drop in HCT. Transfused again. Another EGD was performed.

A single bleeding spot (? visible vessel) was noted in the
second part of the duodenum, at the same location as the
previously noted adherent clot, just distal to the bend where
the duodenal bulb meets the second part of the duodenum. The
area was washed and oozing was noted from the spot.  One
endoclip was successfully applied for the purpose of hemostasis.
There was no further oozing from the spot. It was at a location
that was very difficult to identify and treat endoscopically.

Recommendations:

The findings account for the symptoms.
Continue IV PPI gtt, chanfged to IV BID.
Hold heparin gtt, this was done. pt on IV heperin for leg
ischemia. This was eventually DC'd.

# FEN: IVF, replete lytes prn. Pt was on tube feeds given poor
po intake. He pulled dobhoff tube off today while confused. Will
hold off in place tube back on since remains confused and was
difficult to place. It was eventually decided to place PEG. Pt
did have mutiple failed attempts at speech and swallow. On DC pt
getting TF's.

# Prophylaxis: hep SQ ppx, plavix, asa, IV protonix

Medications on Admission:
1) Glimipremide 2mg PO daily
2) Genuvia 100mg PO daily
3) Plavix 75mg PO Daily
4) nitro SL PRN chest pain
5) Lopressor 50mg PO daily
6) nortryptaline 25mg PO HS
7) Vytorin 10-40mg PO daily


Discharge Medications:
1. bacitracin-polymyxin B 500-10,000 unit/g Ointment Sig: One
(1) Appl Ophthalmic HS (at bedtime).
2. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain/fever: prn for pain.
3. fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
4. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. scopolamine HBr 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
9. quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q6H (every 6 hours) as
needed for wheezes.
11. Insulin
Sliding Scale

Insulin SC Sliding Scale

Q6H

Humalog

Glucose Insulin Dose

0-70     mg/dL Proceed with hypoglycemia protocol
71-119   mg/dL 0   Units
120-159   mg/dL 2   Units
160-199   mg/dL 4   Units
200-239   mg/dL 6   Units
240-279   mg/dL 8   Units
280-319   mg/dL 10   Units
> 320     mg/dL Notify M.D.

12. PICC CARE
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.
13. daptomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours): DC ON [**2106-2-18**].
14. Keflex 500 mg Capsule Sig: One (1) Capsule PO twice a day:
Please start on [**2-18**] after daptomycin is complete. life long AB.

15. pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours).
16. haloperidol lactate 5 mg/mL Solution Sig: One (1)  Injection
Q4H (every 4 hours) as needed for aggitation.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 700**] - [**Location (un) 701**]

Discharge Diagnosis:
Infected R [**Doctor Last Name 27089**] PTFE graft (strep agalactiae)
c/b UGIB
persistent fevers
FTT - poor nutritional status
Delerium
endopthalmitis
Possible AV vegetation and peri-graft abscess
Melena, anemia - requuiring multiple blood transfusions
Active oozing at juncture of duodenal bulb and 2nd part of
duodenum
Hypotension / Hypoxia requiring intubation
DM
CAD
PAD
HTN
Septic emboli
NSTEMI
Hyponatremia
Complete R supraspinatus tear
ARF


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound, progress to ambulation


Discharge Instructions:
Please follow the course of antibiotics as scheduled for ID:
Daptomycin to continue until [**2106-2-18**]. After which the patient
will be placed on suppressive Keflex 500mg [**Hospital1 **]

PEG CARE

Foley to gravity, DC when ambulatory

Pt may need flex seal in future for loose stools

Vac to Right groin, change everry three days

Moniter RLE for signs of ischemia, Pt may need amputaton in
future

Moniter CK weekly while on Daptomycin. FAX: [**Telephone/Fax (1) 432**], ATTN:
OPAT

Moniter for fever and or chills, signs of septcemia,
neurological deficits, Loose stools / check for C - Diff

Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2106-2-25**] 1:00

Provider: [**Name10 (NameIs) 2323**] [**Name11 (NameIs) 2324**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2106-3-26**] 11:30



Completed by:[**2106-2-12**]
{'Streptococcal septicemia,Subendocardial infarction, initial episode of care,Acute endocarditis, unspecified,Duodenitis, with hemorrhage,Toxic encephalopathy,Acute respiratory failure,Acute endophthalmitis,Septic arterial embolism,Arterial embolism and thrombosis of lower extremity,Cellulitis and abscess of trunk,Infection and inflammatory reaction due to other vascular device, implant, and graft,Alkalosis,Hematoma complicating a procedure,Acute kidney failure, unspecified,Severe sepsis,Myelodysplastic syndrome, unspecified,Acute lymphadenitis,Disorders of bursae and tendons in shoulder region, unspecified,Thrombocytopenia, unspecified,Other esophagitis,Aortocoronary bypass status,Coronary atherosclerosis of native coronary artery,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}


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: Orinal complaint - R eye vision loss

PRESENT ILLNESS: 71yo man h/o MDS, CAD, PAD, and DM who presents with sudden
vision loss and eye pain. He was driving in [**State 108**] when he
noticed these symptoms 3 days prior to presentation. He was on a
trip visiting [**Location (un) 86**] and was feeling progressively worse with
associated fevers, chills, malaise, arthralgias, and myalgias
and decided to come to the ED for further evaluation.
.
In the ED, initial vs were: 96.4 66 102/59 18 96% RA. Patient
was given percocet 5/325 x 2. Last set of vitals were 70 118/62
16 95%RA. Opthalmology was consulted who recommended urgent
vitrectomy. Patient was sent to [**Hospital Ward Name 23**] OR where he underwent
diagnostic and therapeutic vitrectomy and [**Hospital Ward Name **] pus was
expressed from the vitreous fluid. They injected tetracaine
2gtt, intraocular vancomycin 0.1ml (1mg), ceftazidime 0.1ml
(2mg), amphotericine 0.1ml (5mcg), and amphotericin, and
recommended work up for systemic sources of infection. They also
gave 200cc of LR and patient was given remifentanil 50mcg IV
ONCE at 2245. Last set of vitals were 120/55 80 16 90%RA.
.
On the floor, the patient complains of right shoulder and right
sided chest pain. He describes it as sharp, radiating to the
back and down his right arm and right chest. He says he's never
had this pain before. He says the pain gets worse with movement
althouth he has not been moving much. His anginal equivalent is
dyspnea, and this is different that angina. He says he has no
history of arthritis in his shoulder, but was given cortisol
injections in his shoulder which did not help. Percocets in the
ED did help with the pain. He denies any associated SOB, nausea,
vomitting, diaphoresis, dizziness. There is no association with
coughing or taking deep breaths. He did go on a long car ride on
Sunday (12 hours), denies calf pain, swelling, cough,
hemoptysis. He denies abdominal pain, diarrhea, constipation. He
does report flu-like symptoms with rhinorrhea, fevers to 104,
chills, sore throat, arthralgias and myalgias. His arthralgias
and myalgias seem to persist into his current R shoulder, R
chest, and left arm pain.
.
Review of systems:
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denied
cough, shortness of breath. Denied chest tightness,
palpitations. Denied nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.

MEDICAL HISTORY: AAA with illiac artery aneurysms treated with an aortobifemoral
graft [**2089**].
Bilat carotid endarterectomies
CAD - coronary angioplasty and stenting [**2103**]
CABG (LIMA to LAD, SVG to diagonal, SVG to OM, sequential
SVG to AM/PDA)[**2089**]
Hyperlipidemia
HTN
AODM
Cerebral hemorrhage mid [**2085**]??????s
Prior CVA
Asbestos exposure

MEDICATION ON ADMISSION: 1) Glimipremide 2mg PO daily
2) Genuvia 100mg PO daily
3) Plavix 75mg PO Daily
4) nitro SL PRN chest pain
5) Lopressor 50mg PO daily
6) nortryptaline 25mg PO HS
7) Vytorin 10-40mg PO daily

ALLERGIES: Penicillins

PHYSICAL EXAM: Vitals: T: 98.1 BP: 133/87 P: 93 R: 24 SaO2: 97% 3L

FAMILY HISTORY: non contributory

SOCIAL HISTORY: married, large family w/ many kids and grandkids.
Pt & wife spend most of the year living in [**State 108**].
-Occupation/Hobbies: pt is a retired pipe fitter & manager. He
enjoys hunting and has a new gun that he has been looking
forward
to using per his family
-Sources of Support: tight-knit family
-Religion/Spirituality: not explored
-Coping: family is struggling to cope w/ patient's decline
-Health-care [**Doctor Last Name 360**]/proxy: wife 

### Response:
{'Streptococcal septicemia,Subendocardial infarction, initial episode of care,Acute endocarditis, unspecified,Duodenitis, with hemorrhage,Toxic encephalopathy,Acute respiratory failure,Acute endophthalmitis,Septic arterial embolism,Arterial embolism and thrombosis of lower extremity,Cellulitis and abscess of trunk,Infection and inflammatory reaction due to other vascular device, implant, and graft,Alkalosis,Hematoma complicating a procedure,Acute kidney failure, unspecified,Severe sepsis,Myelodysplastic syndrome, unspecified,Acute lymphadenitis,Disorders of bursae and tendons in shoulder region, unspecified,Thrombocytopenia, unspecified,Other esophagitis,Aortocoronary bypass status,Coronary atherosclerosis of native coronary artery,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}
