CHIEF COMPLAINT: Hip Pain

PRESENT ILLNESS: 57M w hx of IVDU, endocarditis, recent diagnosis of cutaneous
lupus treated only with cream, presenting w/ severe left hip
pain. Approx 5 days ago, had 3 days of nausea, vomiting,
diahrrea which he claims was secondary to eating bad steak tips,
these symptoms have resoved. resolved. Nausea was consistency of
coffee grounds per patient. No gross blood, No blood in his
stool. He also reported general malaise which persisted. Approx
2 days ago, developed severe left hip pain, worse with walking
and movement, and worsened despite taking ibuprofen and tylenol.
Hip ROM severely limited with flexion and extension [**1-29**] pain,
ABduction and ADduction more or less preserved. No obvious
erythema or deformity. Denied fevers, night sweats, chills. he
is unsure when he last used IV heroin, reporting it may have
been 1 week or several months ago.
.
In the ED, initial vs were: T97.6 P101 BP 107/65 R 17 O2 sat 98%
RA. The patient had a CXR which showed right lung opacity
concerning for pneumonia. Multiple lab abnormalities were also
present, including hyponatremia, hypokalemia, elevated
creatinine to 2.2, thrombocytopenia with plts of 21, bandemia of
24, elevated LFTs. Also, INR 1.5 and PTT 100. Patient was given
vancomycin, levaquin, ceftriaxone, and 3.5 liters of fluid.
Orhopedics saw patient and recommended pelvis CT, which was
unrevealing, though limited because it was without contrast.
RUQUS was also done which was negative for cholecystitis,
negative son[**Name (NI) 493**] [**Name2 (NI) **]. However, multiple hyperechoic
splenic lesions were identified. After 3.5l of fluid the
patient's heart rate increased to 130's, RR increased to 40's. A
right EJ and left IJ were placed. Also received 40mEq Potassium,
ativan 1mg IV x1, morphine 4mg IV X2.
.

MEDICAL HISTORY: -Cutaneous lupus, diagnosed last year at [**Hospital1 2177**] and treated
topically
-MRSA TV endocarditis, treated at [**Hospital1 112**] ([**4-5**]) with daptomycin
complicated by multiple septic pulmonary emboli and splenic
abscess
-Hepatitis B
-Hepatitis C, negative viral load

MEDICATION ON ADMISSION: None

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: At Admission

FAMILY HISTORY: Mother alive at 88 with hypertension.

SOCIAL HISTORY: no tobacco, no alcohol, IV heroin use 2-3 months ago or
potentially sooner.
Acute and subacute bacterial endocarditis,Septic pulmonary embolism,Methicillin resistant Staphylococcus aureus septicemia,Septic shock,Severe sepsis,Acute respiratory failure,Pneumonia, organism unspecified,Abscess of lung,Intraspinal abscess,Acute kidney failure, unspecified,Viral hepatitis B without mention of hepatic coma, acute or unspecified, without mention of hepatitis delta,Unspecified pleural effusion,Septic arterial embolism,Hyposmolality and/or hyponatremia,Critical illness myopathy,Lupus erythematosus,Tricuspid valve disorders, specified as nonrheumatic,Thrombocytopenia, unspecified,Opioid abuse, continuous,Enthesopathy of hip region,Other specified cardiac dysrhythmias,Other and unspecified disc disorder, cervical region,Other nonspecific abnormal serum enzyme levels,Other chronic pulmonary heart diseases,Anemia of other chronic disease,Iron deficiency anemia, unspecified,Fever, unspecified,Aphonia,Constipation, unspecified,Unspecified essential hypertension,Personal history of Methicillin resistant Staphylococcus aureus,Personal history of venous thrombosis and embolism
Ac/subac bact endocard,Septic pulmonary embolsm,MRSA septicemia,Septic shock,Severe sepsis,Acute respiratry failure,Pneumonia, organism NOS,Abscess of lung,Intraspinal abscess,Acute kidney failure NOS,Hpt B acte wo cm wo dlta,Pleural effusion NOS,Septic arterial embolism,Hyposmolality,Critical illness myopthy,Lupus erythematosus,Nonrheum tricusp val dis,Thrombocytopenia NOS,Opioid abuse-continuous,Enthesopathy of hip,Cardiac dysrhythmias NEC,Disc dis NEC/NOS-cerv,Abn serum enzy level NEC,Chr pulmon heart dis NEC,Anemia-other chronic dis,Iron defic anemia NOS,Fever NOS,Aphonia,Constipation NOS,Hypertension NOS,Hx Methicln resist Staph,Hx-ven thrombosis/embols
Admission Date:  [**2131-9-17**]              Discharge Date:   [**2131-10-25**]

Date of Birth:  [**2074-3-2**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Hip Pain

Major Surgical or Invasive Procedure:
- Endotracheal Intubation
- Central Venous Line
- Arterial Line
- Peripherally Inserted Central Catheter


History of Present Illness:
57M w hx of IVDU, endocarditis, recent diagnosis of cutaneous
lupus treated only with cream, presenting w/ severe left hip
pain. Approx 5 days ago, had 3 days of nausea, vomiting,
diahrrea which he claims was secondary to eating bad steak tips,
these symptoms have resoved. resolved. Nausea was consistency of
coffee grounds per patient. No gross blood, No blood in his
stool. He also reported general malaise which persisted. Approx
2 days ago, developed severe left hip pain, worse with walking
and movement, and worsened despite taking ibuprofen and tylenol.
Hip ROM severely limited with flexion and extension [**1-29**] pain,
ABduction and ADduction more or less preserved. No obvious
erythema or deformity. Denied fevers, night sweats, chills. he
is unsure when he last used IV heroin, reporting it may have
been 1 week or several months ago.
.
In the ED, initial vs were: T97.6 P101 BP 107/65 R 17 O2 sat 98%
RA. The patient had a CXR which showed right lung opacity
concerning for pneumonia. Multiple lab abnormalities were also
present, including hyponatremia, hypokalemia, elevated
creatinine to 2.2, thrombocytopenia with plts of 21, bandemia of
24, elevated LFTs. Also, INR 1.5 and PTT 100. Patient was given
vancomycin, levaquin, ceftriaxone, and 3.5 liters of fluid.
Orhopedics saw patient and recommended pelvis CT, which was
unrevealing, though limited because it was without contrast.
RUQUS was also done which was negative for cholecystitis,
negative son[**Name (NI) 493**] [**Name2 (NI) **]. However, multiple hyperechoic
splenic lesions were identified. After 3.5l of fluid the
patient's heart rate increased to 130's, RR increased to 40's. A
right EJ and left IJ were placed. Also received 40mEq Potassium,
ativan 1mg IV x1, morphine 4mg IV X2.
.


Past Medical History:
-Cutaneous lupus, diagnosed last year at [**Hospital1 2177**] and treated
topically
-MRSA TV endocarditis, treated at [**Hospital1 112**] ([**4-5**]) with daptomycin
complicated by multiple septic pulmonary emboli and splenic
abscess
-Hepatitis B
-Hepatitis C, negative viral load


Social History:
no tobacco, no alcohol, IV heroin use 2-3 months ago or
potentially sooner.

Family History:
Mother alive at 88 with hypertension.

Physical Exam:
At Admission

Vitals: T:99.4 axillary BP:129/64 P:149 R:35 O2: 97% 5LNC
General: tachypneic, cachectic, dyspneic
HEENT: Sclera anicteric, dry mucous membranes
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: tachycardic, no m/g/r
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: no clubbing, cyanosis or edema
MSK: tenderness to palpation over lateral hip and anterior hip.
tenderness with passive extension, passive internal and external
rotation. patient does not actively move his hip joint.
Skin: multiple scars and excoriations on arms.

Pertinent Results:
LABS ON ADMISSION:
[**2131-9-16**] 09:45PM BLOOD WBC-8.6 RBC-6.08 Hgb-14.6 Hct-44.5
MCV-73* MCH-24.1* MCHC-32.9 RDW-16.0* Plt Ct-21*
[**2131-9-16**] 09:45PM BLOOD Neuts-64 Bands-24* Lymphs-4* Monos-5
Eos-0 Baso-0 Atyps-3* Metas-0 Myelos-0
[**2131-9-16**] 09:45PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-3+
Macrocy-NORMAL Microcy-2+ Polychr-NORMAL Ovalocy-2+ Burr-3+
Acantho-OCCASIONAL
[**2131-9-16**] 09:45PM BLOOD Plt Smr-VERY LOW Plt Ct-21*
[**2131-9-17**] 06:44AM BLOOD Fibrino-159 Thrombn-12.3
[**2131-9-16**] 09:45PM BLOOD Glucose-130* UreaN-76* Creat-2.2* Na-125*
K-2.8* Cl-88* HCO3-16* AnGap-24*
[**2131-9-16**] 09:45PM BLOOD ALT-68* AST-92* CK(CPK)-52 AlkPhos-136*
TotBili-2.9* DirBili-2.2* IndBili-0.7
[**2131-9-16**] 09:45PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2131-9-17**] 04:30AM BLOOD Calcium-7.6* Phos-1.9* Mg-2.6
[**2131-9-17**] 06:44AM BLOOD calTIBC-230* Hapto-168 Ferritn-443*
TRF-177*
[**2131-9-16**] 09:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-25.9*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2131-9-17**] 02:00AM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
[**2131-9-17**] 02:00AM URINE RBC-0-2 WBC-[**6-6**]* Bacteri-MOD Yeast-NONE
Epi-0-2 TransE-[**3-1**]
[**2131-9-17**] 02:00AM URINE Blood-LG Nitrite-POS Protein-30
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-1 pH-6.5 Leuks-TR

--------------------

RUQ US [**10-22**]: No intra- or extra-hepatic biliary dilatation.
Small gallbladder polyp. Otherwise unremarkable study.

WBC SCAN [**10-17**]: Focal areas of increased radiotracer uptake
projecting over site of known cavitary lesions on recent chest
CT involving the posterior aspect of the right lower lobe most
compatible with lung abscesses.

CT-TORSO [**10-16**]: 1. New right pneumothorax. In a patient with
risk of lung necrosis from complicating infection, differential
diagnosis includes possibility of bronchopleural fistula,
although less likely. Correlate with history of recent
instrumentation. 2. Innumerable cavitary lesions within the
lungs for which the differential diagnosis includes septic
emboli, cavitary pneumonia such as staphylococcus, or less
likely metastasis or acute presentation of Wegner's
granulomatosis. There is interval improvement of air
opacification in the lungs. Interval improvement of appearance
of the pleural effusion, with remaining small right pleural
effusion. 3. Splenic hypodense lesions some could be
hemangiomas; however in keeping with lung findings cannot
exclude septic emboli. 4. Lytic small iliac lesions bilaterally,
incompletely characterized on this study. 5. Multiple bilateral
cystic lesions in the kidneys, likely simple cysts.

MR HEAD [**10-10**]: 1. Multiple small lesions scattered throughout
the bilateral frontal and parietal lobes with varying degrees of
restricted diffusion representing infarcts of varying ages, very
likely embolic and related to known bacterial endocarditis.
There is no hemorrhage.
2. Series of lesions within the paramedian right frontal and
temporo-occipital regions, which appear more acute and may
represent watershed infarcts, in the appropriate clinical
setting (ie. acute [relative] hypotensive event]; there is no
evidence of vascular territorial infarction. 3. Scattered
punctate lesions in the posterior frontal lobes, bilaterally,
corresponding to some of the older foci of resolving restricted
diffusion, above, and likely representing septic emboli. There
is no evidence of microabscess or pathologic leptomeningeal
enhancement. 4. There is no evidence of cerebral venous
thrombosis.

MR [**Name13 (STitle) **] [**10-10**]: 1. C6-7: Findings involving the contiguous
endplates, intervening disc and annuloligamentous complexes,
characteristic of vertebral osteomyelitis/discitis, in this
clinical setting. Though there is no epidural phlegmon or
discrete abscess, there is a likely focal phlegmon in the left
anterolateral prevertebral space, subjacent to that longus [**Last Name (un) **]
muscle, at the C6 level. 2. C5-6: Contiguous findings, though
less marked, are suspicious for a second level of involvement
with discitis/vertebral osteomyelitis; again, no discrete
epidural phlegmon or abscess is seen. 3. No non-contiguous
vertebral involvement, elsewhere in the imaged spine. 4. Normal
cervical spinal cord caliber and intrinsic signal intensity,
with no pathologic leptomeningeal or intramedullary enhancement.


CT HEAD [**9-22**]: Since the CT head of four days prior, there is
increased
conspicuity of subcortical white matter hypodensities which are
bilateral but slightly more prominent on the right. Etiology is
indeterminate. MRI with diffusion-weighted imaging and
post-contrast imaging is recommended for further assessment.

TEE [**9-18**]: The left atrium and right atrium are normal in cavity
size. No atrial septal defect is seen by 2D or color Doppler.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. No masses or vegetations are seen on the
aortic valve. No aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. No mass or vegetation is seen
on the mitral valve. No mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is likely
partial flail of the anterior tricuspid valve leaflet with
possible leaflet perforation without evidence of a tricuspid
valve abscess. There is a large vegetation measuring 2.8 cm by
1.7 cm in largest dimension on the atrial side of the anterior
leaflet of the tricuspid valve. Severe [4+] tricuspid
regurgitation is seen. There is a small pericardial effusion.
IMPRESSION: Large tricuspid valve vegetation with partial flail
and likely perforation of the anterior tricuspid valve leaflet
in the setting of severe tricuspid regurgitation. Small
pericardial effusion.

MRI HIPS [**9-17**]: IMPRESSION:
1. Fluid tracking along the gluteal muscles bilaterally, left
more than right extending to the greater trochanter likely
represents bursitis.
2. Mild intramuscular edema may be inflammatory or reactive in
nature.
3. Diffuse signal abnormality of the visualized osseous
structures signifying anemia or chronic disease.

CT TORSO [**9-17**]: IMPRESSION:
1. Innumerable cavitatory lesions within the lungs, for which
the
differential includes septic emboli (favored given the lesions
in the spleen), cavitatory pneumonia (such as Staph aureus) or
less likely metastases or acute presentation of Wegener's
granulomatosis.
2. Splenic lesions likely represent septic emboli less likely in
this
clinical context of neoplasm/metastases.
3. Bilateral pleural effusions and associated relaxation
atelectasis.
4. Lytic lesions in the iliacs bilaterally are incompletely
characterized onthis study. In the absence of prior imaging
stability/acutity cannot be
assessed. Recommend bone scan and/or MR are for further
characterization.
5. Multiple bilateral renal hypodensities, simple in attenuation
and
structure, likely simple cysts.

MICROBIOLOGY:

[**2131-9-17**] 06:44AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-POSITIVE IgM HAV-NEGATIVE
[**2131-9-17**] 11:10AM BLOOD AMA-NEGATIVE Smooth-POSITIVE *
[**2131-9-17**] 03:05PM BLOOD HIV Ab-NEGATIVE
[**2131-9-17**] 06:44AM BLOOD HCV Ab-POSITIVE*, HCV VIRAL LOAD NEGATIVE

[**2131-9-17**] Urine culture: STAPH AUREUS COAG +.    >100,000
ORGANISMS/ML..
         PREDOMINATING ORGANISM INTERPRET RESULTS WITH CAUTION.
         Oxacillin RESISTANT Staphylococci MUST be reported as
also
         RESISTANT to other penicillins, cephalosporins,
carbacephems,
         carbapenems, and beta-lactamase inhibitor combinations.

         Staphylococcus species may develop resistance during
prolonged
         therapy with quinolones.   Therefore, isolates that are
initially
         susceptible may become resistant within three to four
days after
         initiation of therapy.  Testing of repeat isolates may
be
         warranted.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------  0.25 S
NITROFURANTOIN--------    32 S
OXACILLIN-------------   =>4 R
TETRACYCLINE----------   <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------   <=1 S

  BLOOD CULTURE

   Blood Culture, Routine (Preliminary):
      GRAM POSITIVE COCCUS(COCCI).    IN CLUSTERS.

   Anaerobic Bottle Gram Stain (Final [**2131-9-19**]):
      GRAM POSITIVE COCCI IN CLUSTERS.
      REPORTED BY PHONE TO [**First Name8 (NamePattern2) 26976**] [**Last Name (NamePattern1) **] AT 10:50PM ON
[**2131-9-19**].
   GRAM STAIN (Final [**2131-9-18**]):
      >25 PMNs and <10 epithelial cells/100X field.
      3+  (5-10 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND CLUSTERS.

   RESPIRATORY CULTURE (Final [**2131-9-20**]):
      Commensal Respiratory Flora Absent.
      STAPH AUREUS COAG +.    SPARSE GROWTH.
         Oxacillin RESISTANT Staphylococci MUST be reported as
also
         RESISTANT to other penicillins, cephalosporins,
carbacephems,
         carbapenems, and beta-lactamase inhibitor combinations.

         Rifampin should not be used alone for therapy.
         Staphylococcus species may develop resistance during
prolonged
         therapy with quinolones.   Therefore, isolates that are
initially
         susceptible may become resistant within three to four
days after
         initiation of therapy.  Testing of repeat isolates may
be
         warranted.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------   =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------   <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------   <=1 S


Brief Hospital Course:
This is a 57 year old man with pmh IV drug use, cutaneous SLE,
endocarditis, presenting with three days of gastrointestinal
symptoms, followed by intense left hip pain, along with multiple
lab abnormalities including bandemia, thrombocytopenia, elevated
transaminases, and coagulopathy found to have a large MRSA
vegetation on tricuspid valve.

# Sepsis / Endocarditis: patient intially presented with sepsis
was intubated and started on pressors. Initial TTE showed a TV
vegetation and mild TR with moderate pulmonary HTN and systolic
HTN. A follow up TEE showed large TCV vegetation with partial
flail and possible perforation of anterior tricuspid valve
leaflet with severe TR, small pericardial and complex pleural
effusions.  Blood cultures were also possitive for MRSA. ID was
consulted and patient was started on IV Vancomycin.  Additional
imaging was performed which showed multifocal lung lesions and
splenic lesions consistent with septic emboli. Imaging was also
performed for his initial complaint of hip pain which was only
significant for bursitis. Cardiac surgery was consulted and felt
the patient was an extremely poor surgical candidate given the
severity of his condition. Patient remained persistently
tachycardic throughout his stay. Cardiology was consulted and
felt his persistent sinus tachycardia was a physiologic response
to TR in an effort to maintain adequate cardiac output. They
initially advised diuresis as appropriate as the only potential
medical therapy to help reduce RV strain. A repeat TTE was
performed on [**9-21**] which showed worsening TR and RV strain. On
[**9-22**] a CT head was performed to evaluate altered mental status
(patient remained unresponsive despite no sedation) and concerns
for ICH given setting of multiple septic emboli which showed
foci of subcortical white matter hypodensities in bifrontal
lobes extending from the superior convexity to the inferior
frontal lobes. Gentle diuresis with lasix gtt was continued and
then stopped for increased pressor requirements. On [**9-24**] a
repeat TTE was performed which showed mild interval improvement.
 Clinical exam began to change with improving mental status and
decreased ventilation requirements. On [**9-27**] a power PICC line
was placed in hopes of decreasing the line burden. On [**9-28**] the
patient was successfully extubated. He remained alert,
interactive, able to follow commands but appeared very weak
overall. At the time of transfer to the floor, he continued to
have daily fever spikes and tachycardia, to be expected with his
underlying endocarditis.  On the floor he had an episode of
hypoxia and tachycardia and was transferred back to the ICU.
With each progressing day he gained strength in his upper and
lower extremties as well as his voice.  His fevers were less
frequent and his white count decreased. An abdominal u/s was
done due to rising AP which was negative for obstruction.

He was transferred to the medical floor for further management.
The patient remained in sinus tachycardia throughout his stay,
near the 130's, likely a hyperdynamic response to severe TR and
underlying infection. He required around the clock alternating
Acetaminophen and Motrin for fever control. His fever curve was
periodically checked off the anti-inflammatories but
persistently returned, associated with rigors. ID felt this will
be his prolonged clinical picture in the setting of multiple
pulmonary abscesses [**1-29**] the endocarditis. Additional fever
workup was also performed including an opthomology consult which
ruled out endopthalmitis, a WBC scan which targetted the lungs,
and a MRI which showed a C5-6 and C6-7 discitis and possible
osteomyelitis. Cardiac surgery followed patient as well and felt
that no surgical intervention was appropriate at this time. This
may be revisted after the course of antibiotic therapy is
complete.

Also of note, the patient began to have large urine outputs
while on the floor in the setting of known septic emboli to his
brain. The pituitary looked unaffected on MRI but there is some
suspicion that he may be suffering from central DI.  A water
deprivation test was performed which was inconclusive.  Patient
was able to keep up with his urine output as long as he has
access to adequate PO fluids.

Also of note, liver was consulted regarding an isolated alkaline
phosphatase elevation that progressed throughout his
hospitalization. [**Doctor First Name **], AMA, [**Last Name (un) 15412**] and IgG were all sent and
pending at the time of discharge. Initial differential for
possible etiologies included infiltrative process vs. drug
induced process. The patient will require an outpatient
ultrasound guided percutaneous liver biopsy to rule out
infiltrative process. He should also follow up with Liver at
[**Hospital1 18**] for further evaluation. They are aware and expecting
patient.

Infectious Disease followed throughout the hospitalization and
recommended continued INTRAVENOUS VANCOMYCIN (no substitutions)
with goal trough of 20 through [**11-18**]. They will be
following his labs and appointments have been made for follow
up. They will evaluate if patient will require additional
antibiotcs after complete of this 2 month course.

Patient was advised never to use drugs again.

# Respiratory status/sedation: Patient was intubated for
respiratory distress (intially presented with RR to 50's).
Imaging showed a multifocal PNA c/w septic emboli from his TCV
endocarditis. He was initially started on an ardsnet protocol
but was later switched to PSV.  His ventilator requirements
gradually improved throughout his MICU stay and he was
successfully extubated on [**9-28**]. He now is saturating well on RA.
Throughout his stay on the medical floor, his respiratory exam
substantially improved. Repeat CT-chest imaging showed marked
interval improvements in lung infection; however, it did reveal
a small, stable retrocardiac pneumothorax. IP felt no
interventions were required. The patient continued to have
fevers throughout his stay and interventional pulmonology were
consulted to evaluate for possible drainage; after additional
imaging was obtained, they recommended persistent medical
management.

# Tachycardia: Pt was found to have worsening tachycardia
several days into his MICU stay. Repeat TTE showed worsening TR.
Cardiology was consulted and felt that this was a physiologic
response to poor forward flow. They also noted that B-blockade
would be dentrimental. They also recommended gentle lasix gtt to
help offload the RV which was attempted and limited by pressor
requirements.  The episodes of worsening tachycardia were also
noted to correlate with fever spikes. The patients tachycardia
persists at discharge and likely represents a hyperdynamic
response to poor forward flow [**1-29**] TR. This is exacerbated by
fevers which is responsive to Tylenol, Motrin and gentle fluid
boluses

# Weakness: Pt initially slow to recover s/p extubation. Initial
differential included myopathy of chronic disease vs. central
process. MR of the head and C-spine showed areas of likely
septic embolization.  Neuro exam and strength gradually
increased throughout hospital stay and patient was near baseline
and non-focal at time of discharge.

# Microcytic anemia: Fe studies showed low Fe with elevated
Ferritin (likely [**Month (only) **]).  Hemolysis labs were unremarkable. The
anemia is likely multifactorial with possible component of Fe
deficiency and anemia of chronic disease. HCT were reoutinely
monitored throughout his stay and remained stable.

# Liver abnormalities: transaminases were noted to be slightly
elevated throughout his admission.  AP also noted to gradually
rise in the setting of a normal BR. A GGT level was tested which
verified the AP was a biliary source. Hepatitis serologies were
performed which showed no active disease. There were no findings
on abdominal u/s to suggest liver abnormalties or obstruction.
Liver was consulted regarding the isolated alkaline phosphatase
elevation (it progressed throughout hospitalization). [**Doctor First Name **], AMA,
[**Last Name (un) 15412**] and IgG were all sent and pending at the time of discharge.
Initial differential for possible etiologies included
infiltrative process vs. drug induced process. Unsuccessful
attempts were made to obtain an in-patient liver biopsy. The
patient will require an outpatient ultrasound guided
percutaneous liver biopsy to rule out infiltrative process. He
should also follow up with Liver at [**Hospital1 18**] for further
evaluation. They are aware and expecting patient.


Medications on Admission:
None

Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours. Tablet(s)
3. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours as needed for fever. Tablet(s)
4. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
5. Vancomycin 1,000 mg Recon Soln Sig: One (1)  Intravenous
every twelve (12) hours for 1 months: This Medication Should Be
continued until [**11-18**].


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 2222**] - [**Location (un) 538**]

Discharge Diagnosis:
Primary Dx
- Tricuspid Valve Endocarditis

Secondary Dx
- severe Triscuspid Regurgitation with persistent sinus
tachycardia
- septic emboli to lung, spleen, brain
- C [**5-2**] and C [**6-3**] discitis with extra-epidural phlegmon
- trochanteric bursitis
- anemia of chronic disease
- retrocardiac pneumothorax - stable
- isolated alkaline phosphatase elevation


Discharge Condition:
Improved
- sinus tachycardia to 130's at baseline
- persistent fevers (likely from pulmonary abscesses) suppressed
by around the clock Tylenol and Advil


Discharge Instructions:
Mr. [**Known lastname 66673**],

You were admitted to the hospital for a serious infection
involving your heart. This infection is caused by bacteria. This
bacteria was introduced into your body most likely from your
intravenous drug use. Parts of this heart infection broke off
and spread throughout your body, also infecting your lungs,
spine and potentially your brain and spleen. This was a very
serious infection which almost took your life. You will require
an extensive course of IV antibiotics (NOT ORAL) for this
infection and close follow up with the Infection sepcialists at
[**Hospital1 18**]. Please stay at the rehab facility and complete your
entire course of IV antibiotics. This infection is very serious,
and any pause in your treatment may cause you to become very
very sick.

Once you leave the rehab facility, please call your primary care
doctor listed below or return to the emergency department for
any of the following:
- increased fevers, shaking chills
- chest pain, shortness of breath
- increasing weakness, confusion
- nausea, vomiting, abdominal pain
- any other symptoms which concern you

Please note the follow-up appointments we have made for you

Infectious Diseases - [**Hospital1 18**]
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13896**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2131-11-13**] 9:00

Liver Center - [**Hospital1 18**] [**Hospital Unit Name **]
Provider: [**Name10 (NameIs) **] [**Doctor Last Name **] / [**Name6 (MD) 1382**] [**Name8 (MD) 1383**], MD
Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2131-11-19**] 8:10


Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13896**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2131-11-13**] 9:00

Provider: [**Name10 (NameIs) **] [**Doctor Last Name **] / [**Name6 (MD) 1382**] [**Name8 (MD) 1383**], MD
Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2131-11-19**] 8:10

Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2131-11-15**] 3:15

Patient should also be re-evaluated by cardiology or cardiac
surgery after completion of his medical management to evaluate
for any surgical interventio





Name:  [**Known lastname 15116**],[**Known firstname **]                   Unit No:   [**Numeric Identifier 15962**]

Admission Date:  [**2131-9-17**]              Discharge Date:   [**2131-10-25**]

Date of Birth:  [**2074-3-2**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1775**]
Addendum:
Please note that liver believe isolated AP elevation may also be
cause by cholestatsis of sepsis.

Discharge Disposition:
Extended Care

Facility:
[**Hospital6 4356**] - [**Location (un) 164**]

                             [**First Name11 (Name Pattern1) 1034**] [**Last Name (NamePattern1) 1778**] MD [**MD Number(2) 1779**]

Completed by:[**2131-10-25**]
{'Acute and subacute bacterial endocarditis,Septic pulmonary embolism,Methicillin resistant Staphylococcus aureus septicemia,Septic shock,Severe sepsis,Acute respiratory failure,Pneumonia, organism unspecified,Abscess of lung,Intraspinal abscess,Acute kidney failure, unspecified,Viral hepatitis B without mention of hepatic coma, acute or unspecified, without mention of hepatitis delta,Unspecified pleural effusion,Septic arterial embolism,Hyposmolality and/or hyponatremia,Critical illness myopathy,Lupus erythematosus,Tricuspid valve disorders, specified as nonrheumatic,Thrombocytopenia, unspecified,Opioid abuse, continuous,Enthesopathy of hip region,Other specified cardiac dysrhythmias,Other and unspecified disc disorder, cervical region,Other nonspecific abnormal serum enzyme levels,Other chronic pulmonary heart diseases,Anemia of other chronic disease,Iron deficiency anemia, unspecified,Fever, unspecified,Aphonia,Constipation, unspecified,Unspecified essential hypertension,Personal history of Methicillin resistant Staphylococcus aureus,Personal history of venous thrombosis and embolism'}


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: Hip Pain

PRESENT ILLNESS: 57M w hx of IVDU, endocarditis, recent diagnosis of cutaneous
lupus treated only with cream, presenting w/ severe left hip
pain. Approx 5 days ago, had 3 days of nausea, vomiting,
diahrrea which he claims was secondary to eating bad steak tips,
these symptoms have resoved. resolved. Nausea was consistency of
coffee grounds per patient. No gross blood, No blood in his
stool. He also reported general malaise which persisted. Approx
2 days ago, developed severe left hip pain, worse with walking
and movement, and worsened despite taking ibuprofen and tylenol.
Hip ROM severely limited with flexion and extension [**1-29**] pain,
ABduction and ADduction more or less preserved. No obvious
erythema or deformity. Denied fevers, night sweats, chills. he
is unsure when he last used IV heroin, reporting it may have
been 1 week or several months ago.
.
In the ED, initial vs were: T97.6 P101 BP 107/65 R 17 O2 sat 98%
RA. The patient had a CXR which showed right lung opacity
concerning for pneumonia. Multiple lab abnormalities were also
present, including hyponatremia, hypokalemia, elevated
creatinine to 2.2, thrombocytopenia with plts of 21, bandemia of
24, elevated LFTs. Also, INR 1.5 and PTT 100. Patient was given
vancomycin, levaquin, ceftriaxone, and 3.5 liters of fluid.
Orhopedics saw patient and recommended pelvis CT, which was
unrevealing, though limited because it was without contrast.
RUQUS was also done which was negative for cholecystitis,
negative son[**Name (NI) 493**] [**Name2 (NI) **]. However, multiple hyperechoic
splenic lesions were identified. After 3.5l of fluid the
patient's heart rate increased to 130's, RR increased to 40's. A
right EJ and left IJ were placed. Also received 40mEq Potassium,
ativan 1mg IV x1, morphine 4mg IV X2.
.

MEDICAL HISTORY: -Cutaneous lupus, diagnosed last year at [**Hospital1 2177**] and treated
topically
-MRSA TV endocarditis, treated at [**Hospital1 112**] ([**4-5**]) with daptomycin
complicated by multiple septic pulmonary emboli and splenic
abscess
-Hepatitis B
-Hepatitis C, negative viral load

MEDICATION ON ADMISSION: None

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: At Admission

FAMILY HISTORY: Mother alive at 88 with hypertension.

SOCIAL HISTORY: no tobacco, no alcohol, IV heroin use 2-3 months ago or
potentially sooner. 

### Response:
{'Acute and subacute bacterial endocarditis,Septic pulmonary embolism,Methicillin resistant Staphylococcus aureus septicemia,Septic shock,Severe sepsis,Acute respiratory failure,Pneumonia, organism unspecified,Abscess of lung,Intraspinal abscess,Acute kidney failure, unspecified,Viral hepatitis B without mention of hepatic coma, acute or unspecified, without mention of hepatitis delta,Unspecified pleural effusion,Septic arterial embolism,Hyposmolality and/or hyponatremia,Critical illness myopathy,Lupus erythematosus,Tricuspid valve disorders, specified as nonrheumatic,Thrombocytopenia, unspecified,Opioid abuse, continuous,Enthesopathy of hip region,Other specified cardiac dysrhythmias,Other and unspecified disc disorder, cervical region,Other nonspecific abnormal serum enzyme levels,Other chronic pulmonary heart diseases,Anemia of other chronic disease,Iron deficiency anemia, unspecified,Fever, unspecified,Aphonia,Constipation, unspecified,Unspecified essential hypertension,Personal history of Methicillin resistant Staphylococcus aureus,Personal history of venous thrombosis and embolism'}
