CHIEF COMPLAINT: hemoptysis, dyspnea, chest pain

PRESENT ILLNESS: The pt is a 32yo man with a h/o IVDU who went to
[**Hospital1 **] ED for evaluation of hemoptysis, dyspnea, and
chest pain. The pt has had 3 days of cough with hemoptysis and
dyspnea, which has limited him substantially. He coughs up
"globs" of bright red blood, but denies any clots. He has had an
associated wheeze, and acknowledges bilateral sharp pleuritic
8/10 chest pain with coughing. He did have a fever as well, a
few days prior to the onset of these symptoms, but has continued
to have chills and sweats since then. He does acknowlege most
recent IVDU 10 days ago.
.
He went to OSH ED for evaluation, where he was noted to be
febrile to 104, diaphoretic, and hypoxic to 88% on RA. He was
given Tylenol, and blood Cx were drawn x3. CXR showed multiple
bilateral nonspecific rounded lung opacities, and CTA showed no
PE, but revealed patchy bilateral parenchymal opacities
throughout both lungs with suggestion of cavitation, most likely
due to septic emboli, with extensive mediastinal
lymphadenopathy. ECG was unremarkable. Labs revealed WBC 12.9
with neutrophilic predominance, and Na 123. He was given Zosyn
3.375mg IV, Vancomycin 1g IV, and 2L NS IVF, and transferred to
[**Hospital1 18**] ED. On arrival to the ED, VS - Temp 99.8F, BP 132/76, HR
98, R 18, SaO2 99% 4L NC. Blood Cx sent x2, Fungal Cx also sent.
UA negative. SBP decreased to 80s, so he received an additional
3L IVF, and a RIJ CVL sepsis line was placed. Labs were sent and
he is admitted to the MICU for further care.
.
On the floor, the pt also notes mild upper abdominal pain,
epigastric, without nausea, or vomiting. He does acknowledge
diarrhea, but denies any melena, hematochezia, or BRBPR. He also
has a right wrist fracture that he sustained after a fall [**2-12**]
days ago, which is currently casted.

MEDICAL HISTORY: Poly-substance abuse

MEDICATION ON ADMISSION: Suboxone 8mg PO BID

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: Temp 98.3F, HR 78, BP 122/89, R 18, SaO2 95% 2L NC
General: alert and oriented x 3, no acute distress
HEENT: NC/AT, PERRL/EOMI, sclera anicteric, moist mucous
membranes, oropharynx clear
Neck: supple, no JVD, no LAD
Lungs: diffuse bronchial breath sounds, no
wheezes/crackles/rhonchi
Heart: RRR, nl S1-S2, II-III/VI systolic murmur at LLSB
Abdomen: +BS, soft, nondistended, nontender, no masses or HSM,
no rebound/guarding
Extrem: warm, distal pulses intact
Skin: track marks noted on pt's right AC fossa and back of left
hand

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: - Lives with wife; works as electrician.
- Tobacco: 1.5 PPD x 15 years
- Alcohol: Denies
- Illicits: (+) IVDU with heroin, occasional cocaine. Last use
~10 days ago. (+) h/o marijuana, oxycodone, percocet, vicodin
abuse. Denies skin-popping, denies sharing needles. Reports
previously checked for hepatitis and HIV, last 4-6 months ago.
Acute respiratory failure,Septic shock,Opioid type dependence, continuous,Hepatitis, unspecified,Tobacco use disorder,Severe sepsis,Other chronic pulmonary heart diseases,Staphylococcal septicemia, unspecified,Acute and subacute bacterial endocarditis,Septic pulmonary embolism
Acute respiratry failure,Septic shock,Opioid dependence-contin,Hepatitis NOS,Tobacco use disorder,Severe sepsis,Chr pulmon heart dis NEC,Staphylcocc septicem NOS,Ac/subac bact endocard,Septic pulmonary embolsm
Admission Date:  [**2167-6-6**]              Discharge Date:   [**2167-6-17**]

Date of Birth:  [**2135-2-11**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
hemoptysis, dyspnea, chest pain


Major Surgical or Invasive Procedure:
None

History of Present Illness:
The pt is a 32yo man with a h/o IVDU who went to
[**Hospital1 **] ED for evaluation of hemoptysis, dyspnea, and
chest pain. The pt has had 3 days of cough with hemoptysis and
dyspnea, which has limited him substantially. He coughs up
"globs" of bright red blood, but denies any clots. He has had an
associated wheeze, and acknowledges bilateral sharp pleuritic
8/10 chest pain with coughing. He did have a fever as well, a
few days prior to the onset of these symptoms, but has continued
to have chills and sweats since then. He does acknowlege most
recent IVDU 10 days ago.
.
He went to OSH ED for evaluation, where he was noted to be
febrile to 104, diaphoretic, and hypoxic to 88% on RA. He was
given Tylenol, and blood Cx were drawn x3. CXR showed multiple
bilateral nonspecific rounded lung opacities, and CTA showed no
PE, but revealed patchy bilateral parenchymal opacities
throughout both lungs with suggestion of cavitation, most likely
due to septic emboli, with extensive mediastinal
lymphadenopathy. ECG was unremarkable. Labs revealed WBC 12.9
with neutrophilic predominance, and Na 123. He was given Zosyn
3.375mg IV, Vancomycin 1g IV, and 2L NS IVF, and transferred to
[**Hospital1 18**] ED. On arrival to the ED, VS - Temp 99.8F, BP 132/76, HR
98, R 18, SaO2 99% 4L NC. Blood Cx sent x2, Fungal Cx also sent.
UA negative. SBP decreased to 80s, so he received an additional
3L IVF, and a RIJ CVL sepsis line was placed. Labs were sent and
he is admitted to the MICU for further care.
.
On the floor, the pt also notes mild upper abdominal pain,
epigastric, without nausea, or vomiting. He does acknowledge
diarrhea, but denies any melena, hematochezia, or BRBPR. He also
has a right wrist fracture that he sustained after a fall [**2-12**]
days ago, which is currently casted.


Past Medical History:
Poly-substance abuse


Social History:
- Lives with wife; works as electrician.
- Tobacco: 1.5 PPD x 15 years
- Alcohol: Denies
- Illicits: (+) IVDU with heroin, occasional cocaine. Last use
~10 days ago. (+) h/o marijuana, oxycodone, percocet, vicodin
abuse. Denies skin-popping, denies sharing needles. Reports
previously checked for hepatitis and HIV, last 4-6 months ago.


Family History:
Non-contributory


Physical Exam:
VS: Temp 98.3F, HR 78, BP 122/89, R 18, SaO2 95% 2L NC
General: alert and oriented x 3, no acute distress
HEENT: NC/AT, PERRL/EOMI, sclera anicteric, moist mucous
membranes, oropharynx clear
Neck: supple, no JVD, no LAD
Lungs: diffuse bronchial breath sounds, no
wheezes/crackles/rhonchi
Heart: RRR, nl S1-S2, II-III/VI systolic murmur at LLSB
Abdomen: +BS, soft, nondistended, nontender, no masses or HSM,
no rebound/guarding
Extrem: warm, distal pulses intact
Skin: track marks noted on pt's right AC fossa and back of left
hand


Pertinent Results:
On admission:
[**2167-6-6**] 08:30PM BLOOD WBC-8.7 RBC-3.07* Hgb-8.7* Hct-28.3*
MCV-92 MCH-28.3 MCHC-30.7* RDW-13.7 Plt Ct-118*
[**2167-6-6**] 08:30PM BLOOD Neuts-89* Bands-4 Lymphs-4* Monos-2 Eos-0
Baso-0 Atyps-1* Metas-0 Myelos-0
[**2167-6-6**] 08:30PM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-NORMAL
Macrocy-OCCASIONAL Microcy-NORMAL Polychr-NORMAL
[**2167-6-6**] 08:30PM BLOOD PT-17.6* PTT-42.3* INR(PT)-1.6*
[**2167-6-6**] 08:30PM BLOOD Glucose-830* UreaN-10 Creat-0.8 Na-107*
K-2.9* Cl-77* HCO3-22 AnGap-11
[**2167-6-6**] 11:32PM BLOOD ALT-48* AST-52* CK(CPK)-24* AlkPhos-162*
Amylase-28 TotBili-1.1
[**2167-6-6**] 11:32PM BLOOD Lipase-18
[**2167-6-6**] 08:30PM BLOOD cTropnT-<0.01
[**2167-6-6**] 11:32PM BLOOD CK-MB-<1 cTropnT-<0.01
[**2167-6-6**] 08:30PM BLOOD Calcium-5.9* Phos-2.6* Mg-1.7
[**2167-6-10**] 03:15AM BLOOD Cortsol-5.6
[**2167-6-7**] 05:02AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2167-6-7**] 06:31AM BLOOD HIV Ab-NEGATIVE
[**2167-6-7**] 05:02AM BLOOD HCV Ab-NEGATIVE
[**2167-6-7**] 05:47AM BLOOD Type-MIX pO2-37* pCO2-43 pH-7.42
calTCO2-29 Base XS-2 Intubat-NOT INTUBA
[**2167-6-6**] 07:45PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.013
[**2167-6-6**] 07:45PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-6.5 Leuks-NEG
[**2167-6-6**] 07:45PM URINE RBC-0-2 WBC-0-2 Bacteri-NONE Yeast-NONE
Epi-0-2
[**2167-6-12**] 04:45PM PLEURAL WBC-2444* RBC-[**Numeric Identifier 82586**]* Polys-89*
Lymphs-1* Monos-9* Meso-1*
[**2167-6-12**] 04:45PM PLEURAL TotProt-2.4 Glucose-101 LD(LDH)-458
Amylase-46 Albumin-1.0
[**2167-6-6**]   Blood Culture, Routine (Final [**2167-6-12**]):    NO
GROWTH.
[**2167-6-6**]   BLOOD/FUNGAL CULTURE (Preliminary):    NO FUNGUS
ISOLATED.
[**2167-6-6**]   BLOOD/AFB CULTURE (Preliminary):    NO MYCOBACTERIA
ISOLATED.
[**2167-6-7**]   GRAM STAIN (Final [**2167-6-7**]):
      >25 PMNs and >10 epithelial cells/100X field.
      Gram stain indicates extensive contamination with upper
respiratory
      secretions. Bacterial culture results are invalid.
      PLEASE SUBMIT ANOTHER SPECIMEN.
.

On discharge:
[**2167-6-12**]   Fluid Culture (CSF) in Bottles (Preliminary):    NO
GROWTH.
[**2167-6-12**]   Blood Culture, Routine: PENDING
[**2167-6-16**] 03:22PM BLOOD WBC-9.6 RBC-3.04* Hgb-8.1* Hct-25.5*
MCV-84 MCH-26.8* MCHC-31.9 RDW-17.4* Plt Ct-666*
[**2167-6-16**] 03:22PM BLOOD Glucose-100 UreaN-6 Creat-0.7 Na-141
K-3.7 Cl-105 HCO3-28 AnGap-12
[**2167-6-15**] 06:50AM BLOOD ALT-18 AST-19
[**2167-6-16**] 03:22PM BLOOD Calcium-8.3* Phos-4.5 Mg-1.9
HCT [**2167-6-17**] HCT 24.4,  plt 650, creatinine 0.8
.
OSH CTA CHEST: FINDINGS: No evidence of PE. Multiple bilateral
rounded opacities throughout both lungs, soome of which appear
slightly cavitary, could represent septic emboli. Neoplastic
process difficult to exclude. Right lung base infiltrate. Trace
right pleural effusion. Heart and great vessels normal.
Extensive mediastinal adenopathy. Visualized abdomen normal.
Soft tissues and bones are normal. IMPRESSION: No evidence of
PE. Patchy bilateral parenchymal opacities throughout both lungs
with suggestion of cavitation. Most likely due to septic emboli.
Extensive mediastinal lymphadenopathy.
.
OSH CXR: FINDINGS: Multiple bilateral rounded opacities.
Nonspecific, could relate to infectious, inflammatory, or
neoplastic process. No cardiomegaly. Mediastinal silhouette
normal. No fractures. IMPRESSION: Multiple bilateral nonspecific
rounded lung opacities.
.
TEE [**2167-6-10**]:
The esophagus was intubated on the third attempt due to a
prominent gag reflex. The patient was dry retching during the
majority of the procedure. The TEE was performed and five
minutes after the procedure ended the cardiology fellow and MICU
team noticed that he was hypoxic with O2 sats between 80-90,
tachycardiac, hypertensive and wheezing on examination. He
responded to 100% O2 face mask. Methemoglobinemia was ruled out
on the basis of an ABG with birght red blood and a METHgb level
of 0. He responded to the oxygen, IV morphine, and 10 mg IV
lasix. We felt that he most likely had an aspiration event given
prominent gagging during the procedure.
.
Overall left ventricular systolic function is normal (LVEF>55%).
The right ventricular cavity is moderately dilated with normal
free wall contractility. There is abnormal septal
motion/position consistent with right ventricular
pressure/volume overload. 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. Trivial mitral
regurgitation is seen. There is a large, multilobulated
vegetation on the tricuspid valve (measuring 0.6 x 2.9 cm in
largest dimensions) with associated flail tricuspid valve
leaflet and torn chordae. No definite tricuspid valve abcess is
seen (can not be fully exlcuded). Severe [4+] tricuspid
regurgitation is seen. No vegetation/mass is seen on the
pulmonic valve. There is no pericardial effusion. A TEE
procedure related complication occurred (see comments for
details).
.
IMPRESSION: Large tricuspid valve vegetation with associated
anterior leaflet flail and severe tricuspid valve regurgitation.
No definite tricuspid valve abcess.
.
CXR (portable) [**2167-6-14**]:
FINDINGS: In comparison with the study of [**6-13**], there is little
interval
change. Right IJ line again extends to the region of the
cavoatrial junction. Retrocardiac opacification persists,
consistent with volume loss and bilateral pleural effusions.
There again are vague areas of patchy opacification throughout
both lungs.
.
MRI Spine [**2167-6-12**]:
FINDINGS: In the cervical region, no evidence of epidural
abscess seen or
evidence of fluid collection seen within the spinal canal.
Vertebral
alignment is normal. The spinal cord shows normal signal
intensities.
.
In the thoracic region, there is no evidence of abnormal signal
seen within the spinal cord or evidence of fluid collection
seen. There is no epidural abscess. The areas of low signal in
the posterior portion of the spinal cord in the thoracic region
are due to pulsation artifacts, a normal finding.
.
In the lumbar region, there is no evidence of epidural abscess
identified.  There is no evidence of fluid collection seen.
Degenerative disc disease and bulging seen at L5-S1 level. There
is mild increased signal identified in the posterior soft
tissues in the lumbar region which could be secondary to edema.
.
The paraspinal soft tissues are unremarkable otherwise without
fluid
collection or abscess.
.
Note is made of diffuse low signal in the visualized bony
structures which could be secondary to marrow hyperplasia or
given patient's young age could be secondary to persistent red
marrow.
.
IMPRESSION: No evidence of epidural abscess seen. No evidence of
intraspinal fluid collection or spinal cord compression
identified.
.
COMMENT: There are bilateral large pleural effusions identified.
Correlation with patient's chest film and chest CT recommended.
.
Right Wrist 3 View [**2167-6-11**];
IMPRESSION: No radiographic evidence of fracture. Given the
close interval followup, a repeat film in one week can be
performed if there is continued clinical concern for scaphoid
fracture.
.
Abdominal Ultrasound [**2167-6-8**]:
FINDINGS: Bilateral pleural effusions and a small amount of
ascites are
present. The liver echotexture is normal. There is no focal
intrahepatic
lesion or intrahepatic biliary ductal dilatation. The
gallbladder is
unremarkable. The CBD is not dilated, measuring 4 mm. The right
kidney
measures 13.8 cm and the left kidney measures 10.0 cm, with no
evidence of stones or hydronephrosis. Included views of the
pancreas are unremarkable.  The aorta is normal. The spleen
measures 11.8 cm.
.
IMPRESSION: 1) Small amount of ascites. 2) No hepatic or splenic
abscesses or lesions detected.
.
ECG [**2167-6-6**]:
Sinus rhythm. Non-specific ST-T wave changes, probably normal
variant.
No previous tracing available for comparison.


Brief Hospital Course:
32-year-old male with recent hx of IV drug use who presented
with hemoptysis, dyspnea, and pleuritic chest pain and was found
to have bacterial endocarditis (tricuspid vegetation) with
septic emboli to lungs.
.
#. Hypotension - The patient's hypotension was likely secondary
to sepsis and insensible fluid losses. The pt presented w/
septic emboli on chest CP and insensible fluid losses from
fevers/ chills/ sweats over the last several days. The patient
was treated with aggressive fluid hydration for length of stay
in ICU w/ intermittant levophed drip to keep MAP above 65.  The
CVP is likely difficult to interpret in setting of tricuspid
endocarditis and regurgitant valvular disease with significant
preload requirement given right-sided valvular disease. As the
patient was having difficulty maintaining pressures and was
becoming significantly volume overloaded, a TTE and TEE were
ordered demonstrating 4+ TR, a flail tricuspid valve with
ruptured chordae, and 2.9 cm in diameter vegetation on the TV.
On [**6-10**] after the TEE the patient became tachypneic,
hypertensive, hypoxic, rigoring (ABG 7.43/37/57). The patient
was given NRB, morphine, and lasix, and the episode resolved. A
CXR at the time was negative for flash pulmonary edema. Etiology
of episode unclear, it may be bacteremia because of vegetation
spray during the TEE or aspiration. He had repeated episodes
like this one until 2 days prior to transfer, usually in the
morning, all treated successfully with Lasix, Morphine, NRB, and
bair hugger.  At the time of discharge, he had sbp's of 110-130s
and had no further episodes of hypotension.
.
#. Endocarditis and Septic emboli to lung- The patient had
pulmonary septic emboli identified on OSH CT from right-sided
endocarditis in setting of IVDA. Trans-thoracic echos on [**6-8**]
and [**6-7**] revealed moderate to severe tricuspid regurgitation
with mild pulmonary artery hypertension. A TEE on [**6-10**]
demonstrated a large tricuspid vegetation and could not rule out
a valvular abscess although one was not visualized. The patient
was initiated on Vancomycin q8hrs and Zosyn and switched to
Vancomycin on [**6-8**] after blood cx from an outside hospital grew
GPC. The patient was switched to Nafcillin on [**6-9**] after
confirmation from outside hospital of MSSA infection. Daily
blood cultures from the MICU have been negative to date, but
several were still pending on discharge. ID has recommended a
6-wk course of nafcillin, due to end on [**2167-7-22**]. The patient
needs weekly Chem 10, LFTS and CBC for surveillance which should
be faxed to the Infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**].  He
has follow up with ID Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2167-7-1**] at 10:30am.

Spine MRI was negative for septic emboli and abscesses.
Abdominal ultrasound was also negative for abscesses in liver
and spleen.  CT surgery said that the patient is not a surgical
candidate at this time since he is relatively stable and still
infected.  He will have follow-up with CT surgery Dr. [**Last Name (STitle) **] on
[**2167-7-1**] at 01:00p at [**Hospital1 **] Cardiac Surgery.
.
#. Volume overload - Pt initially became volume overloaded due
to aggressive rehydration for hypotension and chest x-rays have
shown bilateral pulmonary edema. Pt also has some splinting due
to pleuritic chest pain upon deep inspiration, probably from the
peripheral septic emboli in the lungs. He has had a
supplementary O2 requirement ranging from 2-6 L nasal cannula
with good saturations at time of discharge.  By time of
discharge, he had oxygen saturations in the mid 90s on 2-3L
oxygen by nasal cannula.
.
#. Elevated LFTs - On admission, patient was noted to have
elevated transaminases and epigastric pain, which were thought
to be likely [**1-13**] hepatic congestion from R heart dysfunction.
Hepatitis and HIV serologies were negative, and liver ultrasound
was negative for abscess. His LFTs trended to normal and were
ALT/AST 18/19 at discharge.
.
#. Right wrist fracture - The patient was casted for a suspected
right wrist fracture at an outside hospital. Communication with
the OSH revealed final radiologic read of no acute fx, but need
for repeat imaging.  The cast was removed in the MICU and repeat
xrays demonstrated no apparent fracture. A repeat xray with
scaphoid view confirmed that there was no scaphoid fx under the
soft tissue swelling. By discharge, patient no longer complained
of wrist pain or swelling.  He was advised to follow up with a
repeat xray in 1 week if he began to experience discomfort in
that wrist again.
.
#. Nutrition:  The patient's albumin has been low since
admission, probably due to his decreased PO intake.  His diet
was supplemented with Ensure shakes.

#. IVDU: Patient has history of heroin use and had been on
suboxone until his recent relapse.  He reported that his most
recent abuse occurred 10 days prior to presentation at OSH.  His
home dose suboxone was continued throughout his hospital stay
without problems.

#. Pain control: Patient has had abdominal and pleuritic chest
pain during this admission. In the setting of opioid abuse, pain
management was more difficult and the pain Team was consulted.
He received a 3-day course of Ketorolac with tizanidine.  By
discharge, he was no longer complaining of pain and was
discharged on tizanidine, ibuprofen, and acetaminophen as needed
for pain.
.

Medications on Admission:
Suboxone 8mg PO BID

Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
2. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
3. Buprenorphine-Naloxone 8-2 mg Tablet, Sublingual Sig: One (1)
Tablet Sublingual [**Hospital1 **] (2 times a day).
4. Nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily): Please remove patch if you start
smoking again.
5. Tizanidine 2 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day) as needed for pain.
6. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: One (1)
Intravenous Q4H (every 4 hours) for 6 weeks: Continue for 6
weeks total ([**2167-6-9**] to [**2167-7-22**]).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q6H (every 6 hours) as
needed for Wheezing.
13. Sodium Chloride 0.9%  Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
14. Surveillance labs
Chem 10, LFTS, and CBC weekly
15. Labs and abx questions
All Surveillance laboratory results should be faxed to
Infectious disease
R.Ns. at ([**Telephone/Fax (1) 1353**]
All questions regarding outpatient antibiotics should be
directed to the infectious disease R.Ns. at ([**Telephone/Fax (1) 1354**]


Discharge Disposition:
Extended Care

Discharge Diagnosis:
Primary:
Bacterial endocarditis
Septic emboli to lungs
.
Secondary:
Polysubstance abuse


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
It was a pleasure taking care of you at the hospital.  You were
admitted for fever, coughing up blood, and chest pain when
breathing.  You underwent several lab tests and imaging tests
both at [**Hospital1 **] and at an outside hospital that
showed that you have an infection of one of the heart valves.
This occurs due to infection secondary to IV drug use. The
bacteria on your heart valve also occasionally get released to
your lungs, which likely caused your symptoms of shortness of
breath and coughing up blood.  We started you on antibiotics for
this infection and you will need to continue this antibiotic
through your PICC line for a total of 6 weeks (from [**2167-6-9**] to
[**2167-7-22**]).
.
You were given a nicotine patch during your hospital stay.  It
is dangerous for you to smoke cigarettes while you on the
nicotine patch.  If you do decide to smoke again, please remove
the patch.  We strongly encourage you to no longer smoke.
.
The following medications were added:
1) Nafcillin IV 2g every 4 hours for a total of 6 weeks
2) Ibuprofen 600mg every 8hours as needed for pain pls take
with food
3) acetaminophen 500mg; 1-2 tablets every 6 hrs as needed for
fever and pain. Do not take more than 4 grams in 24 hrs or it
can be toxic to your liver.
4) nicotine patch daily
5) docusate sodium 100mg twice a day
6) senna 8.6 mg tablets twice a day as needed for constipation
7) tizanidine 4mg three times a day as needed for pain
8) bisacodyl 10mg as needed for constipation
9) Heparin shots while at the [**Hospital1 **]
10) Albuterol as needed for shortness  of breath or wheeze
.
The following medications were continued:
1) suboxone (buprenophine-naloxone 8-2mg); one tablet sublingual
twice a day

All Surveillance laboratory results should be faxed to
Infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**] All questions
regarding outpatient antibiotics should be directed to the
when clinic is closed

Followup Instructions:
-You need to follow up with infectious disease and cardivascular
surgery as below.  However, it is VERY IMPORTANT THAT YOU FIND A
PCP.
[**Name10 (NameIs) 21421**] register insurance if you have any. Otherwise your
appointments will be self-pay. IT IS ESSENTIAL THAT YOU FOLLOW
UP WITH ID.
.
Department: CARDIAC SURGERY
When: WEDNESDAY [**2167-7-1**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8583**], MD [**Telephone/Fax (1) 170**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 551**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage
.
Department: INFECTIOUS DISEASE
When: WEDNESDAY [**2167-7-1**] at 10:30 AM
With: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

.
Department: INFECTIOUS DISEASE
When: THURSDAY [**2167-7-30**] at 10:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10000**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage
{'Acute respiratory failure,Septic shock,Opioid type dependence, continuous,Hepatitis, unspecified,Tobacco use disorder,Severe sepsis,Other chronic pulmonary heart diseases,Staphylococcal septicemia, unspecified,Acute and subacute bacterial endocarditis,Septic pulmonary 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: hemoptysis, dyspnea, chest pain

PRESENT ILLNESS: The pt is a 32yo man with a h/o IVDU who went to
[**Hospital1 **] ED for evaluation of hemoptysis, dyspnea, and
chest pain. The pt has had 3 days of cough with hemoptysis and
dyspnea, which has limited him substantially. He coughs up
"globs" of bright red blood, but denies any clots. He has had an
associated wheeze, and acknowledges bilateral sharp pleuritic
8/10 chest pain with coughing. He did have a fever as well, a
few days prior to the onset of these symptoms, but has continued
to have chills and sweats since then. He does acknowlege most
recent IVDU 10 days ago.
.
He went to OSH ED for evaluation, where he was noted to be
febrile to 104, diaphoretic, and hypoxic to 88% on RA. He was
given Tylenol, and blood Cx were drawn x3. CXR showed multiple
bilateral nonspecific rounded lung opacities, and CTA showed no
PE, but revealed patchy bilateral parenchymal opacities
throughout both lungs with suggestion of cavitation, most likely
due to septic emboli, with extensive mediastinal
lymphadenopathy. ECG was unremarkable. Labs revealed WBC 12.9
with neutrophilic predominance, and Na 123. He was given Zosyn
3.375mg IV, Vancomycin 1g IV, and 2L NS IVF, and transferred to
[**Hospital1 18**] ED. On arrival to the ED, VS - Temp 99.8F, BP 132/76, HR
98, R 18, SaO2 99% 4L NC. Blood Cx sent x2, Fungal Cx also sent.
UA negative. SBP decreased to 80s, so he received an additional
3L IVF, and a RIJ CVL sepsis line was placed. Labs were sent and
he is admitted to the MICU for further care.
.
On the floor, the pt also notes mild upper abdominal pain,
epigastric, without nausea, or vomiting. He does acknowledge
diarrhea, but denies any melena, hematochezia, or BRBPR. He also
has a right wrist fracture that he sustained after a fall [**2-12**]
days ago, which is currently casted.

MEDICAL HISTORY: Poly-substance abuse

MEDICATION ON ADMISSION: Suboxone 8mg PO BID

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: Temp 98.3F, HR 78, BP 122/89, R 18, SaO2 95% 2L NC
General: alert and oriented x 3, no acute distress
HEENT: NC/AT, PERRL/EOMI, sclera anicteric, moist mucous
membranes, oropharynx clear
Neck: supple, no JVD, no LAD
Lungs: diffuse bronchial breath sounds, no
wheezes/crackles/rhonchi
Heart: RRR, nl S1-S2, II-III/VI systolic murmur at LLSB
Abdomen: +BS, soft, nondistended, nontender, no masses or HSM,
no rebound/guarding
Extrem: warm, distal pulses intact
Skin: track marks noted on pt's right AC fossa and back of left
hand

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: - Lives with wife; works as electrician.
- Tobacco: 1.5 PPD x 15 years
- Alcohol: Denies
- Illicits: (+) IVDU with heroin, occasional cocaine. Last use
~10 days ago. (+) h/o marijuana, oxycodone, percocet, vicodin
abuse. Denies skin-popping, denies sharing needles. Reports
previously checked for hepatitis and HIV, last 4-6 months ago. 

### Response:
{'Acute respiratory failure,Septic shock,Opioid type dependence, continuous,Hepatitis, unspecified,Tobacco use disorder,Severe sepsis,Other chronic pulmonary heart diseases,Staphylococcal septicemia, unspecified,Acute and subacute bacterial endocarditis,Septic pulmonary embolism'}
