CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is a 59 year old
male with a past medical history of recent Streptococcal
bacteremia currently on Penicillin G, atrial valve
replacement secondary to bicuspid valve and aortic stenosis.
The patient was recently admitted on [**2190-2-2**] with fever
and back pain and was found to have at that time a hemolytic
Streptococcus bacteremia.  Initially, the patient was treated
with Vancomycin but changed to penicillin G once the
sensitivities were done.

MEDICAL HISTORY: 1.  Streptococcus bacteremia.
2.  Diabetes mellitus type 2 times 20 years.
3.  Aortic valve replacement; bicuspid valve and aortic
stenosis on [**2187-1-15**].
4.  Hypertension.
5.  High cholesterol.
6.  Hemorrhoids.
7.  Right knee surgery but without any hardware.

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Father died of a heart attack at 76 years
old and had prostate cancer.  Mother died of lung cancer in
her 70s.  There is a positive family history of diabetes
mellitus.

SOCIAL HISTORY: No tobacco, no ethanol.
Infection and inflammatory reaction due to cardiac device, implant, and graft,Acute and subacute bacterial endocarditis,Acute kidney failure with lesion of tubular necrosis,Bacteremia,Congestive heart failure, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Acidosis
React-cardiac dev/graft,Ac/subac bact endocard,Ac kidny fail, tubr necr,Bacteremia,CHF NOS,Hyp kid NOS w cr kid V,Acidosis
Admission Date:  [**2190-3-6**]       Discharge Date:  [**2190-4-18**]

Date of Birth:   [**2130-5-14**]       Sex:  M

Service:

HISTORY OF PRESENT ILLNESS:   The patient is a 59 year old
male with a past medical history of recent Streptococcal
bacteremia currently on Penicillin G, atrial valve
replacement secondary to bicuspid valve and aortic stenosis.
The patient was recently admitted on [**2190-2-2**] with fever
and back pain and was found to have at that time a hemolytic
Streptococcus bacteremia.  Initially, the patient was treated
with Vancomycin but changed to penicillin G once the
sensitivities were done.

A transesophageal echocardiogram then was performed which was
negative for endocarditis.  A MRA prior to discharge showed
increased ........  of single and rector spinal muscles at
T3-4 adjacent to facets and anterior within the right psoas.
There was no discitis or abscess.  Thallium scan on
[**2190-2-11**] corroborated the MRA findings.  The patient was
discharged home on [**2190-2-9**].

Since discharge, his pain has persisted and waxed and waned.
He had one temperature of 100.0 F., accompanied by mild
chills, but no higher temperatures or sweats.

The patient denies nausea or vomiting; no urinary symptoms.
MRI done yesterday for re-evaluation since his pain was so
severe, revealed an L2-3 discitis and osteomyelitis with
extension into the psoas anteriorly as well as the rector
spinal muscles posteriorly on the right.

PAST MEDICAL HISTORY:
1.  Streptococcus bacteremia.
2.  Diabetes mellitus type 2 times 20 years.
3.  Aortic valve replacement; bicuspid valve and aortic
stenosis on [**2187-1-15**].
4.  Hypertension.
5.  High cholesterol.
6.  Hemorrhoids.
7.  Right knee surgery but without any hardware.

MEDICATIONS AT HOME:
1.  Penicillin G 4 million units q. four hours.
2.  Avapro 75 mg q. day.
3.  Lantus 22 units q. a.m.
4.  Zestoretic 5/12.5.
5.  Celexa 20 mg q. day.
6.  Percocet q. four hours p.r.n.
7.  Atenolol 25 mg three times a day.
8.  Humalog sliding scale.
9.  Aspirin 325 mg q. day.
10. Lipitor 20 mg q. day.
11. Colace 100 mg twice a day.
12. Valium 10 mg.

ALLERGIES:   No known drug allergies.

SOCIAL HISTORY:   No tobacco, no ethanol.

FAMILY HISTORY:   Father died of a heart attack at 76 years
old and had prostate cancer.  Mother died of lung cancer in
her 70s.  There is a positive family history of diabetes
mellitus.

PHYSICAL EXAMINATION:   Temperature 97.6 F.; heart rate 62;
blood pressure 164/79; 98% on room air.  In general, the
patient is not in acute distress, alert and oriented times
three.  HEENT:  Moist oral mucosa.  Neck with no jugular
venous distention.  Cardiac:  Regular rate and rhythm, III/VI
systolic ejection murmur radiating to the carotid.  Lungs
clear to auscultation bilaterally.  Abdomen with positive
bowel sounds, soft, nontender.  Neurological:  Deferred as
patient just had sedation prior to biopsy of his discs.

LABORATORY:  White blood cell count was 6.0, hematocrit 27.2,
platelets 333.  Chem-7 was normal.

The patient was admitted on [**2190-3-6**] initially to the
Medicine Service.

HOSPITAL COURSE:   Upon admission, the patient received a
disc biopsy in an attempt to identify the organisms
responsible for the osteomyelitis.  He was started on
Vancomycin and Gentamicin as treatment.

Early in the patient's stay, he was found to have increasing
anemia.  His disc cultures came out negative although a set
of blood cultures indicated Gram positive cocci bacteremia.

The Infectious Disease service was involved early on.  They
agreed with the antibiotic choice.  They also requested that
another transesophageal echocardiogram be performed to rule
out endocarditis.  On the 3rd, the patient developed atrial
fibrillation.  The Electrophysiology Team was involved, who
also recommended a transesophageal echocardiogram to rule out
abscess.

The transesophageal echocardiogram was performed which was
concerning for endocarditis.  Cardiology performed a
transesophageal echocardiogram which did not show any obvious
vegetations, but there was valve dehiscence and mitral
regurgitation, which led them to believe that there probably
biosynthetic aortic valve replacement endocarditis.

The patient received one unit of packed red blood cells on
the 5th.  On [**2190-3-12**], the patient was taken to the
Operating Room by the Neurosurgery Team for bilateral L2, L3
diskectomy and right L3-L4 hemilaminectomy and medial
facetectomy performed.  The specimens were sent to
Microbiology.  There was no obvious osteomyelitis per
Neurosurgery although there was muscle necrosis surrounding
the facets.  No gross pus was seen.  A drain was left in for
one to two days.

On the 8th, the Cardiothoracic Surgery Team was involved with
the intention of doing a re-do aortic valve replacement.  The
CT Surgery Team was concerned about the patient's new onset
atrial fibrillation and requested that the patient be ruled
out for myocardial infarction which was done.  Amiodarone was
started per Electrophysiology and the patient was given
increasing doses of Lopressor.  Over the course of the next
few days, the patient continued to require blood transfusions
and manipulation of his blood pressure and heart rate control
medications.

Over the next several days, the patient was continued on
antibiotics although cultures from the Operating Room samples
remained negative.  Over these days, his creatinine started
to increase which was treated with intravenous fluids and
close monitoring of the Gentamicin levels.

With the intention of taking the patient to the Operating
Room for aortic valve replacement secondary to endocarditis a
cardiac catheterization was performed to insure that there
was not a need for coronary artery bypass graft during the
same procedure.

On the 13th, the patient was admitted to the Coronary Care
Unit for biventricular systolic hypertension requiring
nitroprusside treatment.


DICTATION ENDS.

                            [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D.  [**MD Number(1) 414**]

Dictated By:[**Last Name (NamePattern4) 8358**]
MEDQUIST36
D:  [**2190-4-19**]  18:16
T:  [**2190-4-19**]  23:25
JOB#:  [**Job Number **]


Name:  [**Known lastname 16142**], [**Known firstname 1500**]                  Unit No:  [**Numeric Identifier 16143**]

Admission Date:  [**2190-3-6**]     Discharge Date:  [**2190-4-20**]

Date of Birth:   [**2130-5-14**]     Sex:  M

Service:

ADDENDUM

CONTINUATION OF HOSPITAL COURSE:   Post coronary
catheterization, the patient's creatinine continued to rise
and his urine output dropped, presumably a combination of
both the catheterization dye as well as the gentamicin.

On the 14th, the Renal Service was consulted on the patient.
They requested the gentamicin be stopped.  It was restarted
by the Infectious Disease Team.  While in the Intensive Care
Unit, the patient became acutely decompensated mentally and
very confused.  He also had episodes of hyponatremia which
required fluid restriction.  Roughly in the middle of the
month, the patient's creatinine appeared to plateau around
4.0.  There was high hopes that the patient's renal function
would come back and the creatinine would start to come down.
It was decided to hold out on cardiac surgery with the hope
that the creatinine would come down and renal function would
improve prior to surgery.

The patient was allowed to go to the Floor for a brief time
although had to go back to the Coronary Care Unit secondary
to volume overload.  The patient was aggressively diuresed as
best as possible with Lasix.  While in the Intensive Care
Unit the patient's antibiotics were switched to Ceftriaxone
in an attempt to reduce the patient's volume challenge.  The
patient underwent dialysis also preoperatively.  CVVH was
initiated.

On [**3-27**], the patient had a positive Clostridium difficile
test.  He was started on Flagyl 500 q. 12. The patient was
started on Epogen secondary to his anemia.  Finally, on
[**2190-3-29**], the patient was taken to the Operating Room where
a redo Bentall with homograft was performed.  The patient
received perioperative Vancomycin.

Postoperatively, the patient required propofol and
Nitroglycerin drip.  The patient had pacing wires and
mediastinal tubes in place.  Postoperatively, the patient
developed a respiratory acidosis, possibly secondary to
reluctance to take deep breaths due to his pain.  The
patient's pacing wires and chest tubes were removed at the
appropriate time.  The patient was advanced on a diabetic
heart healthy diet.  He continued dialysis intermittently.
The patient had periods of time when he was confused and
difficult to manage, therefore, pain killers and sedatives
were used very reservedly.

While in the Cardiothoracic Intensive Care Unit the patient
started in with a new atrial fibrillation, for which beta
blockers were started.  Due to a question of nutritional
status, tube feeds were then started on the patient.

Neurosurgery once again was consulted regarding the patient's
confusion and somnolence.  It was their opinion that the
patient was a victim of toxic metabolic encephalopathy.
Neurology was also involved.  An MRI was done which showed
multiple micro-bleeds in the brain; although they still
believed that the patient suffered from toxic metabolic
encephalopathy.  They suggested that the patient be totally
restricted from all opiates and mood altering medications.

Pathology came back on the prosthetic valve showing active
poly-infiltrates and DMV stain with pockets of organisms.  A
six week course of antibiotic was requested by the Infectious
Disease Team.  Over the course of the next few days, the
patient was continued on Ceftriaxone.  His mental status
slowly began to improve.  He was continued on hemodialysis.

When the time was right, the patient was transferred to the
Regular Cardiothoracic Surgical Floor.  While there, the
patient continued to fall in and out of rapid atrial
fibrillation, however amiodarone could not be used secondary
to a negative hypertensive effects of previous usage.
Diltiazem was then started as a second line [**Doctor Last Name 932**] to help
control his atrial fibrillation.

Anti-coagulation was considered, however, decided against due
to the patient's question of micro-emboli to the brain and
micro-bleeds present in the brain.

While on the Floor, the patient had initially required a 24
hour sitter due to his confusion.  Slowly, his confusion
began to improve.  The patient was seen by Physical Therapy
with whom he did well and the patient was also seen by [**Last Name (un) 616**]
due to very poor glycemic control; however, the patient was
not amenable to their help.  He often refused his insulin
injections.

During this time, the patient's urine output and urinary
function remained poor; however, we continued to be
optimistic that the renal function would improve and the
patient's urine output slowly began to increase.

The patient was seen by Transplant Surgery for placement of a
Permacath so that he would be able to go home on intravenous
antibiotics.

Electrophysiology once again came to re-iterate their wishes
of using Lopressor and Diltiazem to control the patient's
rapid atrial fibrillation and requested that amiodarone not
be used due to previous increased QT intervals associated
with the drug.

On the [**10-18**], Infectious Disease had to be
reconsulted secondary to new onset of neutropenia.
Hematology and Infectious Disease were involved.  It was
Hematology's opinion that the cause of the neutropenia was
secondary to Ceftriaxone usage and Infectious Disease
proceeded to make new recommendations including Vancomycin
dosed per random levels drawn, as well as p.o. Levaquin.

Psychiatry was also consulted at that time due to the
patient's request that he be put back on his Celexa and the
fear that we may not be able to restart certain medications
secondary to his renal function.  It was however ultimately
decided that the Celexa could be used by Renal and
Psychiatry.

The Gastrointestinal Service was also consulted to check the
patient's vague complaint of gastrointestinal upset.  It was
their opinion that it was reflux associated and they
recommended Protonix.

It is now [**2190-4-19**], and the patient will likely be
discharged tomorrow if his white blood cell count continues
to improve post discontinuation of his Ceftriaxone.  He will
receive hemodialysis one last time tomorrow before discharge.
He has been set up with outpatient hemodialysis.  He has also
been set up with a home 24 hour nursing care.

DISCHARGE INSTRUCTIONS:
1.  He is to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in four
weeks.
2.  He is to follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in one to two
weeks.
3.  He is to follow-up in two to three weeks with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 86**].
4.  The patient should avoid strenuous activity.  He should
take showers but no baths.
5.  He should not drive while on pain medication.

DISCHARGE MEDICATIONS:
1.  Levofloxacin 250 mg p.o. q.o.d.
2.  Vancomycin one gram dosed when random levels fall below
15.
3.  Celexa 10 mg p.o. q. day.
4.  Protonix 40 mg p.o. q. day.
5.  Labetalol 400 mg p.o. three times a day.
6.  Percocet p.r.n.
7.  Insulin sliding scale.
8.  Diltiazem 30 mg p.o. four times a day.
9.  Hydralazine 50 mg p.o. q. eight.
10. Calcium acetate one tablet p.o. three times a day with
meals.
11. Trazodone 50 mg p.o. q. h.s. p.r.n.
12. Nephrocaps one capsule p.o. q. day.
13. Colace 100 mg p.o. twice a day p.r.n.
14. Enteric-coated aspirin 325 mg p.o. q. day.



                          [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D.  [**MD Number(1) 681**]

Dictated By:[**Last Name (NamePattern4) 1100**]

MEDQUIST36

D:  [**2190-4-19**]  19:09
T:  [**2190-4-20**]  00:01
JOB#:  [**Job Number 16144**]


Name:  [**Known lastname 16142**], [**Known firstname 1500**]                  Unit No:  [**Numeric Identifier 16143**]

Admission Date:  [**2163-3-7**]     Discharge Date:  [**2190-4-23**]

Date of Birth:   [**2130-5-14**]     Sex:  M

Service:

Patient's discharge was delayed due to a febrile episode just
before his previous discharge.  His fever reached 102.0
degrees.  The following day the patient was no longer febrile
nor was he febrile for the rest of his stay, although he was
pancultured and found to be positive for Clostridium
difficile infection.  The patient was started on Flagyl 500
mg tid.  His diarrhea has improved.  Patient's white count is
improving and reached normal range at 5.4.  He has remained
afebrile with vital signs stable.  He has been without
arrhythmias for a number of days.  He is now being
discharged.

Changes to his discharge medications include Flagyl 500 mg po
tid x17 days.  His Vancomycin duration will last another 17
days, and his levofloxacin duration will last another 17
days.

The patient is also in addition to previously mentioned
followup appointments, to followup with Dr. [**Last Name (STitle) 16145**] with
Infectious Disease.  Her office will call him with the
appropriate appointment time.



                          [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D.  [**MD Number(1) 681**]

Dictated By:[**Last Name (NamePattern4) 1100**]

MEDQUIST36

D:  [**2190-4-23**]  09:53
T:  [**2190-4-23**]  10:30
JOB#:  [**Job Number 16146**]
{'Infection and inflammatory reaction due to cardiac device, implant, and graft,Acute and subacute bacterial endocarditis,Acute kidney failure with lesion of tubular necrosis,Bacteremia,Congestive heart failure, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Acidosis'}


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: 

PRESENT ILLNESS: The patient is a 59 year old
male with a past medical history of recent Streptococcal
bacteremia currently on Penicillin G, atrial valve
replacement secondary to bicuspid valve and aortic stenosis.
The patient was recently admitted on [**2190-2-2**] with fever
and back pain and was found to have at that time a hemolytic
Streptococcus bacteremia.  Initially, the patient was treated
with Vancomycin but changed to penicillin G once the
sensitivities were done.

MEDICAL HISTORY: 1.  Streptococcus bacteremia.
2.  Diabetes mellitus type 2 times 20 years.
3.  Aortic valve replacement; bicuspid valve and aortic
stenosis on [**2187-1-15**].
4.  Hypertension.
5.  High cholesterol.
6.  Hemorrhoids.
7.  Right knee surgery but without any hardware.

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Father died of a heart attack at 76 years
old and had prostate cancer.  Mother died of lung cancer in
her 70s.  There is a positive family history of diabetes
mellitus.

SOCIAL HISTORY: No tobacco, no ethanol. 

### Response:
{'Infection and inflammatory reaction due to cardiac device, implant, and graft,Acute and subacute bacterial endocarditis,Acute kidney failure with lesion of tubular necrosis,Bacteremia,Congestive heart failure, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Acidosis'}
