CHIEF COMPLAINT: low grade fever and bacteremia

PRESENT ILLNESS: 76 yo Male with sCHF (EF 20-25% on TTE on [**11-28**]), CAD s/p CABG
(3 vs 4? vessel), HTN, NIDDM, A-fib on coagulation, s/p PPM, s/p
recent CCU stay for VF arrest requiring pressor support, h.o.
Pseudomonas + bld cultures admitted from cardiac rehab for
fevers, +GPC x 2 bottles 2 days ago.

MEDICAL HISTORY: CHF (EF 15-20% on ECHO in [**11/2194**])
CABG ([**2182**])
PPM ([**2189**]) s/p syncopal event
A-fib on Coumadin
h.o. VF Arrest [**11/2194**]
Left foot drop and weakness s/p gunshot wound in Korean War
s/p recent admission for sepsis ?[**1-19**] VAP vs line infection
requiring intubation/vasopressors
h.o.+ Pseudomonas on line cx
HL
HTN

MEDICATION ON ADMISSION: Amiodarone 400mg daily
ASA 81 mg daily
Coumadin 2mg qhs
Metoprolol 25mg daily
Spironolactone 25mg daily
Simvastatin 10mg qhs
Pantoprazole 40mg daily
Ascrobic Acid 500mg [**Hospital1 **]
Ferrous Sulfate 325mg daily
Folic Acid 1mg daily
ISS
Glargine 18u qhs
Metronidazole 500mg x 10 days (started [**2195-1-1**])
Polyetheline glycol daily
Pyridoxine 50mg daily
Vitamins/minerals 1 tab daily
Ambien 10mg qhs
Acetaminophen 650mg q6hr PRN
Biasacodyl 10mg PR PRN
miconazole PRN to groin

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T: BP:109/50 HR:75 RR:12 O2Sat:100%
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. No gait disturbance. No cerebellar dysfunction.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.

FAMILY HISTORY: NC

SOCIAL HISTORY: Pt denies any tobacco, Etoh or drug use. Pt usually lives at
home with his wife.
Bacteremia,Acute kidney failure, unspecified,Chronic systolic heart failure,Hyposmolality and/or hyponatremia,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Other specified forms of chronic ischemic heart disease,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Atrial fibrillation,Aortic valve disorders,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Other lesion of median nerve,Thrombocytopenia, unspecified,Long-term (current) use of anticoagulants,Aortocoronary bypass status,Cardiac pacemaker in situ
Bacteremia,Acute kidney failure NOS,Chr systolic hrt failure,Hyposmolality,Enterococcus group d,Chr ischemic hrt dis NEC,DMII wo cmp nt st uncntr,Atrial fibrillation,Aortic valve disorder,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Median nerve lesion NEC,Thrombocytopenia NOS,Long-term use anticoagul,Aortocoronary bypass,Status cardiac pacemaker
Admission Date:  [**2195-1-2**]              Discharge Date:   [**2195-1-12**]

Date of Birth:  [**2118-2-20**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 4028**]
Chief Complaint:
low grade fever and bacteremia

Major Surgical or Invasive Procedure:
None

History of Present Illness:
76 yo Male with sCHF (EF 20-25% on TTE on [**11-28**]), CAD s/p CABG
(3 vs 4? vessel), HTN, NIDDM, A-fib on coagulation, s/p PPM, s/p
recent CCU stay for VF arrest requiring pressor support, h.o.
Pseudomonas + bld cultures admitted from cardiac rehab for
fevers, +GPC x 2 bottles 2 days ago.

Per [**Hospital **] rehab records and pt noticed started feeling weak 2
days PTA, noted to have a low grade fever yesterday of 100.4.
Bld cultures and labs were drawn which grew GPC x1 bottle within
24hours and showed a leukocytosis of 15.0 (increased from 6.1 3
days prior). In the ED was noted to have SBP in the 90s-100s, pt
also noted to have a new holosystolic murmur. Pt received 4l
IVF, Vancomycin, Zosyn. R IJ was placed, CXR showed no
pneumonia, urine cultures and bld cultures were drawn from
central line.

ROS: The patient denies any fevers, chills, weight change,
nausea, vomiting, abdominal pain, diarrhea, constipation,
melena, hematochezia, chest pain, shortness of breath,
orthopnea, PND, lower extremity oedema, cough, urinary
frequency, urgency, dysuria, lightheadedness, gait unsteadiness,
focal weakness, vision changes, headache, rash or skin changes.


Past Medical History:
CHF (EF 15-20% on ECHO in [**11/2194**])
CABG ([**2182**])
PPM ([**2189**]) s/p syncopal event
A-fib on Coumadin
h.o. VF Arrest [**11/2194**]
Left foot drop and weakness s/p gunshot wound in Korean War
s/p recent admission for sepsis ?[**1-19**] VAP vs line infection
requiring intubation/vasopressors
h.o.+ Pseudomonas on line cx
HL
HTN


Social History:
Pt denies any tobacco, Etoh or drug use. Pt usually lives at
home with his wife.


Family History:
NC


Physical Exam:
Vitals: T: BP:109/50 HR:75 RR:12 O2Sat:100%
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. No gait disturbance. No cerebellar dysfunction.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.



Pertinent Results:
[**2195-1-2**] 11:50AM   GLUCOSE-157* UREA N-24* CREAT-1.3*
SODIUM-128* POTASSIUM-4.1 CHLORIDE-92* TOTAL CO2-24 ANION GAP-16
[**2195-1-2**] 11:50AM   WBC-11.2* RBC-3.02*# HGB-11.1*# HCT-31.3*#
MCV-104* MCH-36.9* MCHC-35.6* RDW-20.9*
[**2195-1-2**] 11:50AM   NEUTS-82.7* LYMPHS-14.0* MONOS-2.7 EOS-0.4
BASOS-0.3
[**2195-1-2**] 11:50AM   PLT COUNT-106*#
[**2195-1-2**] 12:08PM   LACTATE-1.7
[**2195-1-2**] 07:05PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2195-1-2**] 11:27PM   ALT(SGPT)-24 AST(SGOT)-21 LD(LDH)-128 ALK
PHOS-53 TOT BILI-1.1
[**2195-1-2**] 11:27PM   ALBUMIN-2.9* CALCIUM-7.3* PHOSPHATE-1.8*
MAGNESIUM-1.9
[**2195-1-2**] 11:59PM   LACTATE-1.5

ECG: Ventricular paced at 75 bpm.

CXR ([**1-2**]): No acute intrathoracic process.

[**2195-1-8**] 06:13AM BLOOD WBC-4.7 RBC-2.18* Hgb-8.1* Hct-22.4*
MCV-103* MCH-37.2* MCHC-36.2* RDW-20.3* Plt Ct-152
[**2195-1-7**] 06:37AM BLOOD Neuts-62.9 Lymphs-27.0 Monos-4.0 Eos-5.9*
Baso-0.2
[**2195-1-8**] 09:29AM BLOOD PT-19.5* PTT-29.1 INR(PT)-1.8*
[**2195-1-7**] 06:37AM BLOOD ESR-69*
[**2195-1-7**] 06:37AM BLOOD Ret Aut-2.3
[**2195-1-8**] 06:13AM BLOOD Glucose-69* UreaN-12 Creat-1.3* Na-138
K-3.3 Cl-104 HCO3-26 AnGap-11
[**2195-1-7**] 06:37AM BLOOD ALT-30 AST-29 LD(LDH)-134 AlkPhos-51
TotBili-0.7
[**2195-1-6**] 06:15AM BLOOD Calcium-8.6 Phos-3.3 Mg-2.0
[**2195-1-6**] 06:15AM BLOOD CRP-25.0*
[**2195-1-4**] 02:25AM BLOOD Lactate-1.0
[**2195-1-2**] 07:05PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG

Blood cultures
1/16
4/4 bottles positive for Enterococcus Faecalis
[**2195-1-2**] 11:50 am BLOOD CULTURE      SET # 1.

                            **FINAL REPORT [**2195-1-6**]**

   Blood Culture, Routine (Final [**2195-1-6**]):
      ENTEROCOCCUS FAECALIS.    FINAL SENSITIVITIES.
         HIGH LEVEL GENTAMICIN SCREEN: Resistant to 500 mcg/ml
of
         gentamicin. Screen predicts NO synergy with penicillins
or
         vancomycin. Consult ID for treatment options.
         HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to
1000mcg/ml of
         streptomycin.  Screen predicts possible synergy with
selected
         penicillins or vancomycin.  Consult ID for details..

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ENTEROCOCCUS FAECALIS
                             |
AMPICILLIN------------   <=2 S
PENICILLIN G----------     2 S
VANCOMYCIN------------   <=1 S

   Aerobic Bottle Gram Stain (Final [**2195-1-3**]):
      REPORTED BY PHONE TO [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 41713**], R.N. ON [**2195-1-3**] AT 0320.
      GRAM POSITIVE COCCI IN PAIRS AND CHAINS.

   Anaerobic Bottle Gram Stain (Final [**2195-1-3**]):
      GRAM POSITIVE COCCI IN PAIRS AND CHAINS.

Blood cultures
[**1-4**] x2 NGTD, [**1-5**] x2 NGTD, [**1-6**] NGTD

[**1-2**] Urine culture negative

Echo [**1-6**]
No atrial septal defect is seen by 2D or color Doppler. Left and
right ventricular systolic function appears depressed. There are
simple atheroma in the ascending aorta. There are simple
atheroma in the aortic arch. There are simple atheroma in the
descending thoracic aorta. The aortic valve leaflets are
moderately thickened with fusion of the right and left coronary
cusps. No masses or vegetations are seen on the aortic valve.
The study is inadequate to exclude significant aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. No mass or vegetation is seen on
the mitral valve. Trivial mitral regurgitation is seen. There is
no pericardial effusion.

Impression: Thickened aortic valve with fusion of left and right
cusps. No evidence of vegetation or mass to suggest
endocarditis. The pacing wire is without evidence of
vegetations. Biventricular systolic dysfunction.

[**1-6**] RUQ US
IMPRESSION:
1. No son[**Name (NI) 493**] evidence for acute cholecystitis.

2. Likely gallbladder polyp; recommend son[**Name (NI) 493**] followup in
[**5-29**] months.

[**1-7**] US of pacemaker site
IMPRESSION: No fluid collection or hyperemia involving the
pacemaker pocket.

Brief Hospital Course:
76 yo Male with sCHF (EF 20-25%), CAD s/p CABG, HTN, NIDDM,
A-fib on anticoagulation, s/p PPM, s/p recent CCU stay for VF
arrest requiring pressor support, admitted from cardiac rehab
with fevers and bacteremia.

1. Bacteremia/Hypotension: The patient was admitted with 2/2
Blood cultures from Cardiac rehab growing enterococcus on [**1-1**].
In the ED he had hypotension responsive to IVF.  After admission
to the ICU his SBPs dropped briefly, but were responsive to more
IVF fluids.  He was initally treated with ceftriaxone and
vancomycin empirically. [**3-21**] sets of BCx sent from the ED on [**1-2**]
grew GPCs within less then 24 hours and speciated to
enterococcus sensitive to vancomycin and ampicillin.
Antibiotics were narrowed to ampicillin 2 gm IV q4h when
sensitivities returned.  A TTE was ordered to evaluate for
endocarditis and showed no evidence of vegatations. Patient had
no stigmata of endocarditis on physical exam.  Surveillance
cultures on [**1-5**], 20th, and 21st were all NGTD on
discharge. The patient had a work up to evaluate for source of
enterococcus bacteremia. Infectious disease was consulted. Urine
culture was negative. Prostate exam negative for tenderness. RUQ
US negative. CT abdomen negative for intraabdominal process. The
patient has no decubitus ulcers. The patient received a 1 week
course of Ampicillin. VNA refused to administer Ampicillin q4
hours at home. Patient refused rehab. Though Vancomycin is
second line therapy, patient opted for 3 week course of
Vancomycin, so that he could go home.  He understood the risks
of Vancomycin over Ampicillin, and decided to proceed with this
course of therapy.
-Please follow up on final read of Blood cultures
-Please follow up on final read of CT scan
-follow up Vanc trough prior to 3rd dose of Vancomycin. Please
check weekly CBC, CRP, ESR, Chem 7. Fax results to [**Hospital **] clinic [**Telephone/Fax (1) 18871**]. Call [**Hospital **] clinic at [**Telephone/Fax (1) 11581**] with questions
regarding Vancomycin.

# CHF: The patient has an EF of 20-25% on Echo in [**2194-11-17**].
Outpatient regimen of Metoprolol 25mg daily and Spironolactone
25mg daily were held on admission secondary to hypotension.
These were restarted on discharge.

# A. Fib: Patient has history of A. fib on Coumadin and
Amiodarone for rhythm control. EKG showed a paced rhythm on
admission.  He was continued on amiodarone.  Coumadin was
continued with goal INR 2.0-3.0.
-INR will need to be checked 2 days after discharge.


# CRI: The patient's Creatinine on admission noted to be
elevated at 1.3, on review of [**Hospital 228**] rehab records show his
lowest Creatinine to be 1.2 from several days prior to
admission. Patient's Creatinine yesterday in rehab noted to be
1.6. Most likely [**1-19**] hypovolemia. On discharge Creatinine was
1.3.

# NIDDM: The patient was continued on Glargine, SSI and
underwent qid fingersticks for monitoring.

# h.o. V. fib: The patient was recently admitted to CCU
following a 6 minute episode of V. fib arrest. He currently has
a PPM, and was scheduled to have an ICD upgrade and possible LV
lead on [**1-9**] with Dr. [**Last Name (STitle) **].  The eletrophysiology service
postponed this procedure given bacteremia. They will follow up
with him in [**Month (only) 956**]. In the meantime, the patient was fitted
for a LifeVest.

# Macrocytic Anemia: HCT 22.4 on discharge.  31.3 on admission.
However looking at previous hospitalization, baseline HCT about
23-25.  No active signs of bleeding. Acute renal failure
resolved. No evidence of thrombocytopenia. Patient had elevated
B12 in [**2194-11-17**], elevated ferritin, and normal folate.
Stools were guaiac negative. No evidence of hemolysis.
-Please follow HCT as an outpatient
-consider outpatient Hematology follow up

# Gall bladder polyp incidentally seen on RUQ US: Recommend
son[**Name (NI) 493**] followup in [**5-29**] months.


Medications on Admission:
Amiodarone 400mg daily
ASA 81 mg daily
Coumadin 2mg qhs
Metoprolol 25mg daily
Spironolactone 25mg daily
Simvastatin 10mg qhs
Pantoprazole 40mg daily
Ascrobic Acid 500mg [**Hospital1 **]
Ferrous Sulfate 325mg daily
Folic Acid 1mg daily
ISS
Glargine 18u qhs
Metronidazole 500mg x 10 days (started [**2195-1-1**])
Polyetheline glycol daily
Pyridoxine 50mg daily
Vitamins/minerals 1 tab daily
Ambien 10mg qhs
Acetaminophen 650mg q6hr PRN
Biasacodyl 10mg PR PRN
miconazole PRN to groin

Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
3. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Insulin Glargine 100 unit/mL Solution Sig: Eighteen (18)
units Subcutaneous at bedtime.
7. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: as
directed units Subcutaneous qachs: Please follow sliding scale
as you were prior to admission.
8. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
Disp:*30 Capsule(s)* Refills:*2*
9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
10. Outpatient Lab Work
Please have INR checked 2 days after discharge and faxed to your
primary care doctor's office
11. BP cuff
Patient requires a blood pressure cuff
12. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Vancomycin 1,000 mg Recon Soln Sig: One (1) g Intravenous
once a day for 21 days.
Disp:*21 recon solns* Refills:*0*
14. Outpatient Lab Work
Please have Vancomycin trough drawn prior to 3rd dose of
Vancomycin. Fax results to Infectious disease clinic at [**Telephone/Fax (1) 18871**].
15. Outpatient Lab Work
Weekly CBC, CRP, ESR, Chem 7. Please have results faxed to
Infectious disease clinic at [**Telephone/Fax (1) 6313**].


Discharge Disposition:
Extended Care

Facility:
[**Doctor Last Name **] Green Nursing & Rehab Center - [**Hospital1 **]

Discharge Diagnosis:
Primary diagnosis:
1. Enterococcus bacteremia
2. Hypotension secondary to bacteremia
Secondary diagnosis:
1. Chronic systolic congestive heart failure
2. Atrial fibrillation
3. Hypertension
4. history of Ventricular fibrillation cardiac arrest


Discharge Condition:
 Afebrile, hemodynamically stable.


Discharge Instructions:
You were admitted with an infection in your blood. You were
treated with your antibiotics and your blood was closely
monitored. You were monitored in the ICU because your blood
pressure was running low. We looked for a source of infection,
but you CT scan of your abdomen, Ultrasound, and echo of your
heart showed no sources of infection. Your pacemaker is not
infected either. We are started you on Ampicillin for this
infection. However, you refused to complete the 4 week course of
Ampicillin because you would need to be in rehab for this.  You
agreed to 2nd line treatment with Vancomycin for the remaining 3
weeks of antibiotics.
Thereafter, cardiology will consider placing a defibrillator. In
the meantime, you will have a Lifevest fitted for your heart.

If you have chest pain, palpitations, shortness of breath,
fevers, chills, or any other symptoms that concern you please
see your primary doctor or go to the emergency room.

Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet

Please call Infectious disease clinic if you have questions
about Vancomycin at [**Telephone/Fax (1) 11581**]. Please fax lab results to them
at [**Telephone/Fax (1) 23413**].

Followup Instructions:
You have an appointment with Dr. [**Last Name (STitle) **] in Infectious disease
on [**2-3**] at 10am. The clinic phone number is [**Telephone/Fax (1) 10**].

You have an appointment with Dr. [**Last Name (STitle) **] in Cardiology on
[**2-4**] at 1pm. The clinic phone number is [**Telephone/Fax (1) 2037**].



Completed by:[**2195-1-9**]

Name:  [**Known lastname 7542**],[**Known firstname **]                     Unit No:   [**Numeric Identifier 7543**]

Admission Date:  [**2195-1-2**]              Discharge Date:   [**2195-1-12**]

Date of Birth:  [**2118-2-20**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 7544**]
Addendum:
Correction: After much discussion with the patient, family, and
consulting teams, patient agreed to go to rehab to complete the
recommended 4 week course of Ampicillin. He was discharged on
[**1-12**] to rehab, and will require Ampicilin until [**1-30**].
Thus, he was not started on Vancomycin.

Discharge Disposition:
Extended Care

Facility:
[**Doctor Last Name 7545**] Green Nursing & Rehab Center - [**Hospital1 1947**]

Discharge Diagnosis:
Primary diagnosis:
1. Enterococcus bacteremia
2. Hypotension secondary to bacteremia
Secondary diagnosis:
1. Chronic systolic congestive heart failure
2. Atrial fibrillation
3. Hypertension
4. history of Ventricular fibrillation cardiac arrest


Discharge Condition:
 Afebrile, hemodynamically stable.


Discharge Instructions:
You were admitted with an infection in your blood. You were
treated with your antibiotics and your blood was closely
monitored. You were monitored in the ICU because your blood
pressure was running low. We looked for a source of infection,
but you CT scan of your abdomen, Ultrasound, and echo of your
heart showed no sources of infection. Your pacemaker is not
infected either. We are started you on Ampicillin for this
infection. You will be kept on a 4 week course of Ampicillin to
treat this infection. Thereafter, cardiology will consider
placing a defibrillator. In the meantime, you will have a
Lifevest fitted for your heart.

If you have chest pain, palpitations, shortness of breath,
fevers, chills, or any other symptoms that concern you please
see your primary doctor or go to the emergency room.

Weigh yourself every morning, [**Name8 (MD) 233**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet

Please call Infectious disease clinic if you have questions
about Vancomycin at [**Telephone/Fax (1) 7546**]. Please fax lab results to them
at [**Telephone/Fax (1) 7547**].

Followup Instructions:
You have an appointment with Dr. [**Last Name (STitle) 3682**] in Infectious disease
on [**2-3**] at 10am. The clinic phone number is [**Telephone/Fax (1) 7548**].

You have an appointment with Dr. [**Last Name (STitle) **] in Cardiology on
[**2-4**] at 1pm. The clinic phone number is [**Telephone/Fax (1) 7549**].


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7550**] MD [**MD Number(2) 7551**]

Completed by:[**2195-1-12**]
{'Bacteremia,Acute kidney failure, unspecified,Chronic systolic heart failure,Hyposmolality and/or hyponatremia,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Other specified forms of chronic ischemic heart disease,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Atrial fibrillation,Aortic valve disorders,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Other lesion of median nerve,Thrombocytopenia, unspecified,Long-term (current) use of anticoagulants,Aortocoronary bypass status,Cardiac pacemaker in situ'}


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: low grade fever and bacteremia

PRESENT ILLNESS: 76 yo Male with sCHF (EF 20-25% on TTE on [**11-28**]), CAD s/p CABG
(3 vs 4? vessel), HTN, NIDDM, A-fib on coagulation, s/p PPM, s/p
recent CCU stay for VF arrest requiring pressor support, h.o.
Pseudomonas + bld cultures admitted from cardiac rehab for
fevers, +GPC x 2 bottles 2 days ago.

MEDICAL HISTORY: CHF (EF 15-20% on ECHO in [**11/2194**])
CABG ([**2182**])
PPM ([**2189**]) s/p syncopal event
A-fib on Coumadin
h.o. VF Arrest [**11/2194**]
Left foot drop and weakness s/p gunshot wound in Korean War
s/p recent admission for sepsis ?[**1-19**] VAP vs line infection
requiring intubation/vasopressors
h.o.+ Pseudomonas on line cx
HL
HTN

MEDICATION ON ADMISSION: Amiodarone 400mg daily
ASA 81 mg daily
Coumadin 2mg qhs
Metoprolol 25mg daily
Spironolactone 25mg daily
Simvastatin 10mg qhs
Pantoprazole 40mg daily
Ascrobic Acid 500mg [**Hospital1 **]
Ferrous Sulfate 325mg daily
Folic Acid 1mg daily
ISS
Glargine 18u qhs
Metronidazole 500mg x 10 days (started [**2195-1-1**])
Polyetheline glycol daily
Pyridoxine 50mg daily
Vitamins/minerals 1 tab daily
Ambien 10mg qhs
Acetaminophen 650mg q6hr PRN
Biasacodyl 10mg PR PRN
miconazole PRN to groin

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T: BP:109/50 HR:75 RR:12 O2Sat:100%
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. No gait disturbance. No cerebellar dysfunction.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.

FAMILY HISTORY: NC

SOCIAL HISTORY: Pt denies any tobacco, Etoh or drug use. Pt usually lives at
home with his wife. 

### Response:
{'Bacteremia,Acute kidney failure, unspecified,Chronic systolic heart failure,Hyposmolality and/or hyponatremia,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Other specified forms of chronic ischemic heart disease,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Atrial fibrillation,Aortic valve disorders,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Other lesion of median nerve,Thrombocytopenia, unspecified,Long-term (current) use of anticoagulants,Aortocoronary bypass status,Cardiac pacemaker in situ'}
