CHIEF COMPLAINT: Fatigue, shortness of breath

PRESENT ILLNESS: Mr. [**Known lastname 76674**] is a 44 year old male who was diagnosed with rectal
abscess and alpha hemolytic Streptococcus aortic valve
endocarditis on [**2151-10-15**]. He completed a course of Flagyl and
Ceftriaxone. Serial echocardiograms showed severe AI with a L->R
shunt from the sinus of valsalva to right ventricle. At time of
admission, he reported worsening fatigue associated with
shortness of breath with minimal activity and frequent
palpitations. He was admitted for further evaluation and
treatment.

MEDICAL HISTORY: Aortic Valve Endocarditis(Alpha Hemolytic Streptococcus)
Aortic Insufficiency
Rectal Abscess
History of Pancreatic Pseudocyst - s/p Percutaneous Drainage
History of Gallstone Pancreatitis
History of Lap Chole
History of Duodenal Stricture - s/p Gastrojejunostomy
History of Renal Cell Carcinoma - s/p Cryoablation
Prior Toe Surgery

MEDICATION ON ADMISSION: Omeprazole 40 [**Hospital1 **], Atorvastatin 40 qd, Zyrtec 10 qd, Klor con 20
qd, Lasix 120 qam, Lorazepam 2 [**Hospital1 **], Ambien 12.5 qhs, Ceftriaxone

ALLERGIES: Penicillins

PHYSICAL EXAM: Blood pressure was 113-133/31-41 mm Hg while seated.  Pulse was
109 beats/min and regular, respiratory rate was 16 breaths/min.
Generally the patient was well developed, well nourished and
well
groomed. The patient was oriented to person, place and time. The
patient's mood and affect were not inappropriate.

FAMILY HISTORY: Denies any family history of premature CAD. States his father
had an MI in his 70s, still living. Possible CAD on his mother's
side of the family. No history of known sudden death.

SOCIAL HISTORY: Married works as a project manager and has been working from
home over the past few weeks. No children. He denies any alcohol
use or IVDU.  He reports smoking 1/2ppd x 20 years, quit on
[**2151-10-15**].
Acute and subacute bacterial endocarditis,Pneumonia, organism unspecified,Other aneurysm of heart,Cardiac complications, not elsewhere classified,Atrioventricular block, complete,Unspecified pleural effusion,Streptococcus infection in conditions classified elsewhere and of unspecified site, other streptococcus,Aortic valve disorders,Anemia, unspecified,Unspecified essential hypertension,Pure hypercholesterolemia
Ac/subac bact endocard,Pneumonia, organism NOS,Aneurysm of heart NEC,Surg compl-heart,Atriovent block complete,Pleural effusion NOS,Other streptococcus,Aortic valve disorder,Anemia NOS,Hypertension NOS,Pure hypercholesterolem
Admission Date:  [**2151-11-17**]              Discharge Date:   [**2151-11-27**]

Date of Birth:  [**2107-10-14**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
Penicillins

Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Fatigue, shortness of breath

Major Surgical or Invasive Procedure:
[**2151-11-17**] Cardiac Catheterization
[**2151-11-19**] Bentall Procedure utilizing a 23mm Homograft with Repair
of a Sinus Valsalva Fistula
[**2151-11-24**] Placement of Dual Chamber Permanent Pacemaker(Guidant
Insignia Ultra DR)


History of Present Illness:
Mr. [**Known lastname 76674**] is a 44 year old male who was diagnosed with rectal
abscess and alpha hemolytic Streptococcus aortic valve
endocarditis on [**2151-10-15**]. He completed a course of Flagyl and
Ceftriaxone. Serial echocardiograms showed severe AI with a L->R
shunt from the sinus of valsalva to right ventricle. At time of
admission, he reported worsening fatigue associated with
shortness of breath with minimal activity and frequent
palpitations. He was admitted for further evaluation and
treatment.

Past Medical History:
Aortic Valve Endocarditis(Alpha Hemolytic Streptococcus)
Aortic Insufficiency
Rectal Abscess
History of Pancreatic Pseudocyst - s/p Percutaneous Drainage
History of Gallstone Pancreatitis
History of Lap Chole
History of Duodenal Stricture - s/p Gastrojejunostomy
History of Renal Cell Carcinoma - s/p Cryoablation
Prior Toe Surgery

Social History:
Married works as a project manager and has been working from
home over the past few weeks. No children. He denies any alcohol
use or IVDU.  He reports smoking 1/2ppd x 20 years, quit on
[**2151-10-15**].

Family History:
Denies any family history of premature CAD. States his father
had an MI in his 70s, still living. Possible CAD on his mother's
side of the family. No history of known sudden death.


Physical Exam:
Blood pressure was 113-133/31-41 mm Hg while seated.  Pulse was
109 beats/min and regular, respiratory rate was 16 breaths/min.
Generally the patient was well developed, well nourished and
well
groomed. The patient was oriented to person, place and time. The
patient's mood and affect were not inappropriate.

There was pale conjunctiva without cyanosis of the oral mucosa.
The neck was supple with JVP of 8 cm.  The carotid waveform was
normal.  There was no thyromegaly. The were no chest wall
deformities, scoliosis or kyphosis.  The respirations were not
labored and there were no use of accessory muscles. The lungs
has
bibasilar rales.

Palpation of the heart revealed a prominent PMI.  There were no
thrills, lifts or palpable S3 or S4.  He is tachycardic with a
[**1-20**] holosystolic murmur best appreciated at LUSB. The abdominal
aorta was not enlarged by palpation. There was no
hepatosplenomegaly or tenderness. The abdomen was soft nontender
and nondistended. The extremities had no pallor, cyanosis,
clubbing or edema. There were no abdominal, femoral or carotid
bruits. Inspection and/or palpation of skin and subcutaneous
tissue showed no stasis dermatitis, ulcers, scars, or xanthomas.


Pertinent Results:
Hematology
  COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2151-11-27**] 05:44AM    5.5 3.31* 9.3* 28.0* 85 27.9 33.0 15.9*
264
Chemistry
  RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2151-11-27**] 05:44AM    101 15 1.1 137 4.4 100 31 10

[**2151-11-17**] Cardiac Catheterization:
1. Coronary angiography in this right dominant system revealed
no angiographically apparent coronary artery disease in the
LMCA, LAD, LCx, and RCA (although coronaries could not be well
opacified due to severe aortic regurgitation).
2. Resting hemodynamics revealed markedly elevated left and
right sided filling pressures with mean PCW of 21 mmHg and RVEDP
of 25 mmHg. There was severe pulmonary arterial hypertension
with PASP of 66 mmHg. The cardiac index was preserved at 3.2
L/min/m2. There was normal systemic arterial pressure with SBP
of 114 mmHg and DBP of 56 mmHg. There was a left-to right shunt
with oxygen step-up at RV flow and a possible fistula from sinus
of Valsalva to RV demonstrated by selective injection and
supravalvular aortography.
[**2151-11-17**] TEE:
Right ventricular systolic function is normal. Overall left
ventricular function is normal. The ascending, transverse and
descending thoracic aorta are normal in diameter and free of
atherosclerotic plaque to 45 cm from the incisors. There are
three aortic valve leaflets. There is a moderate to large sized
vegetation on the aortic valve involving the right and
non-coronary cusps. The vegetation measures 0.4cm x 1.5cm. The
left coronary cusp is moderately thickened. There is no aortic
root abcess cavity seen. Severe (4+) aortic regurgitation is
seen with reversal of flow in the descending thoracic aorta.
There is prominent color flow in the area of the right coronary
cusp which may represent a sinus of valsalva fistula (aortic
root to RA/RVOT). The mitral valve leaflets are structurally
normal. Mild (1+) mitral regurgitation is seen. There is no
pericardial effusion.
[**2151-11-18**] Abdominal CT Scan:
1. No retroperitoneal hematoma.
2. Right upper quadrant pericolonic and peripancreatic
induration at least some of which may be secondary to known
previous procedures. This may represent recurrent or acute
pancreatitis and as patient cannot receive contrast, MRI may
also be informative. Note also higher density contents of right
colon (question intraluminal blood) compared to the remainder
bowel. Is patient guaiac positive?
3. Persistent contrast opacification kidneys, now greater than
24 hours past contrast administration indicative of ATN. Note
additional density abnormality right lateral kidney. ?is this
site of patient's previous known RF ablation for renal cell
cancer?
4. Small amount of free intraperitoneal fluid and
small-to-moderate size right pleural effusion, neither of which
measure blood density.
5. Mildly enlarged spleen.
6. Diverticulosis.
[**2151-11-21**] Chest/Abdominal CT Scan:
1. Large areas of consolidation seen within the lungs
bilaterally, with air bronchograms, concerning for infection.
2. New diffuse patchy ground-glass airspace opacities seen
bilaterally, right greater than the left. 3. No evidence of
retroperitoneal hematoma. Small amount of nonspecific free fluid
in pelvis. Stranding in pelvic soft tissues possibly represent
small amount of interstitial hemorrhage.
4. Post-operative changes seen within the chest, with multiple
lines and tubes. Pneumomediastinum and small bilateral
pneumothoraces seen, consistent with post-operative changes.
[**2151-11-22**] TTE:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve appears to be a homograft. The
aortic valve prosthesis appears well seated, with normal leaflet
motion and transvalvular gradients. No aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. There is moderate pulmonary artery
systolic hypertension.
   RADIOLOGY  Final Report

CHEST (PA & LAT)  [**2151-11-27**] 10:46 AM

CHEST (PA & LAT)

Reason: check atel

[**Hospital 93**] MEDICAL CONDITION:
44 year old man with
REASON FOR THIS EXAMINATION:
check atel
CLINICAL HISTORY: Pacer placed, check for pneumothorax, unable
to raise left arm.

CHEST: The position of the pacemaker is unchanged. No
pneumothorax is present. The left lung appears clear.

Patchy opacities are again noted within the right lung, not
significantly changed since the prior chest x-ray of [**11-25**]. These probably represent areas of pneumonia.

IMPRESSION: No significant change since [**11-25**].

DR. [**First Name11 (Name Pattern1) 3347**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 5034**]






Brief Hospital Course:
Mr. [**Known lastname 76674**] was admitted and underwent cardiac catheterization
and transesophageal echocardiogram which confirmed aortic valve
endocarditis, severe aortic insufficiency and a sinus of
Valsalva fistula. Coronary angiography showed normal coronary
arteries. His creatinine on admission was noted to be 1.8. He
remained on intravenous Ceftriaxone per ID recommendations.
Based on the above, cardiac surgery was consulted and further
evaluation was performed. He was cleared for surgery by dental,
but will require extractions after he recovers from surgery. His
acute renal insufficiency was attributed to hypoperfusion given
his severe aortic insufficiency. He was also noted to be anemic
which required several blood transfusions. An abdominal CT scan
was performed which ruled out a retroperitoneal bleed. He
otherwise remained stable on medical therapy and was eventually
cleared for surgery.

On [**11-19**], Dr. [**First Name (STitle) **] performed a Bentall procedure with a
homograft along with repair of sinus of Valsalva fistula. Given
that his hospital stay was greater than 24 hours prior to
surgery, he was given Vancomycin for perioperative coverage. For
surgical details, please see seperate dictated operative note.
Following the operation, he was brought to the CVICU for
invasive monitoring. Within 24 hours, he awoke neurologically
intact and was extubated. He remained anemic and continued to
require intermittent blood transfusions. There was no evidence
of active bleeding. Following extubation, he experienced poor
oxygenation along with some hemoptysis. Chest x-rays were
notable for extensive bilateral consolidations and bilateral
pleural effusions. Right sided chest tube was placed and
diagnostic/therapeutic bronchoscopy was performed. Blood tinged
secretions were noted in the lower lobes along with an occlued
right middle lobe by mucosal edema. Bronchoalveolar lavage was
performed and sent for culture. Antibiotic coverage was
temporarily broadend for nosocomial pneumonia. Cultures
eventually grew out MRSA and antibiotics were titrated
accordingly per ID recommendations. Over several days, his
oxygenation gradually improved. All chest tubes were eventually
removed without complication. Since the operation, he was noted
to have complete heart block and remained entirely pacer
dependent. The EP service was consulted and recommended
permananent pacemaker which was successfully placed on [**11-24**] without complication. He continued to make clinical
improvements and eventually transferred to the SDU for further
care and recovery. His renal function normalized, and he
continued to respond well to antibitioc therapy. Per ID
recommendation, he will need to remain on Levofloxacin until
[**2151-11-28**] and Vancomycin until [**2151-12-5**]. The remainder of his
postoperative course was uneventful and he was medically cleared
for discharge on postoperative day 8.


Medications on Admission:
Omeprazole 40 [**Hospital1 **], Atorvastatin 40 qd, Zyrtec 10 qd, Klor con 20
qd, Lasix 120 qam, Lorazepam 2 [**Hospital1 **], Ambien 12.5 qhs, Ceftriaxone

Discharge Disposition:
Home With Service

Facility:
Critical Care Systems

Discharge Diagnosis:
AV endocarditis(Strep viridans) and Aortic Insufficiency
Postoperative Complete Heart Block
Postoperative MRSA Pneumonia
Postoperative Pleural Effusions
Anemia
Acute Renal Insufficiency
Hypertension
Hyperlipidemia
Rectal Abscess


Discharge Condition:
Good.


Discharge Instructions:
1)Please shower daily. No baths. Pat dry incisions, do not rub.
2)Avoid creams and lotions to surgical incisions.
3)Call cardiac surgeon if there is concern for wound infection.
4)No lifting more than 10 lbs for at least 10 weeks from
surgical date.
5)No driving for at least one month.
6)Complete course on antbiotics as directed


Followup Instructions:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**12-19**] weeks(cardiologist) - call for appt
Dr. [**Last Name (STitle) 76675**] in [**12-19**] weeks(PCP) - call for appt
Dr. [**Last Name (STitle) **] in [**2-19**] weeks(cardiac surgeon)- call for appt
EP Device Clinic in 1 week - call for [**Telephone/Fax (1) 76676**]
Dr. [**First Name (STitle) 1075**] in Infectious Disease Clinic - call for appt. @
[**Telephone/Fax (1) **]


                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]

Completed by:[**2151-11-27**]
{'Acute and subacute bacterial endocarditis,Pneumonia, organism unspecified,Other aneurysm of heart,Cardiac complications, not elsewhere classified,Atrioventricular block, complete,Unspecified pleural effusion,Streptococcus infection in conditions classified elsewhere and of unspecified site, other streptococcus,Aortic valve disorders,Anemia, unspecified,Unspecified essential hypertension,Pure hypercholesterolemia'}


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: Fatigue, shortness of breath

PRESENT ILLNESS: Mr. [**Known lastname 76674**] is a 44 year old male who was diagnosed with rectal
abscess and alpha hemolytic Streptococcus aortic valve
endocarditis on [**2151-10-15**]. He completed a course of Flagyl and
Ceftriaxone. Serial echocardiograms showed severe AI with a L->R
shunt from the sinus of valsalva to right ventricle. At time of
admission, he reported worsening fatigue associated with
shortness of breath with minimal activity and frequent
palpitations. He was admitted for further evaluation and
treatment.

MEDICAL HISTORY: Aortic Valve Endocarditis(Alpha Hemolytic Streptococcus)
Aortic Insufficiency
Rectal Abscess
History of Pancreatic Pseudocyst - s/p Percutaneous Drainage
History of Gallstone Pancreatitis
History of Lap Chole
History of Duodenal Stricture - s/p Gastrojejunostomy
History of Renal Cell Carcinoma - s/p Cryoablation
Prior Toe Surgery

MEDICATION ON ADMISSION: Omeprazole 40 [**Hospital1 **], Atorvastatin 40 qd, Zyrtec 10 qd, Klor con 20
qd, Lasix 120 qam, Lorazepam 2 [**Hospital1 **], Ambien 12.5 qhs, Ceftriaxone

ALLERGIES: Penicillins

PHYSICAL EXAM: Blood pressure was 113-133/31-41 mm Hg while seated.  Pulse was
109 beats/min and regular, respiratory rate was 16 breaths/min.
Generally the patient was well developed, well nourished and
well
groomed. The patient was oriented to person, place and time. The
patient's mood and affect were not inappropriate.

FAMILY HISTORY: Denies any family history of premature CAD. States his father
had an MI in his 70s, still living. Possible CAD on his mother's
side of the family. No history of known sudden death.

SOCIAL HISTORY: Married works as a project manager and has been working from
home over the past few weeks. No children. He denies any alcohol
use or IVDU.  He reports smoking 1/2ppd x 20 years, quit on
[**2151-10-15**]. 

### Response:
{'Acute and subacute bacterial endocarditis,Pneumonia, organism unspecified,Other aneurysm of heart,Cardiac complications, not elsewhere classified,Atrioventricular block, complete,Unspecified pleural effusion,Streptococcus infection in conditions classified elsewhere and of unspecified site, other streptococcus,Aortic valve disorders,Anemia, unspecified,Unspecified essential hypertension,Pure hypercholesterolemia'}
