CHIEF COMPLAINT: Recurrent Endocarditis

PRESENT ILLNESS: Mr. [**Known lastname 57041**] is a 25 year old male with recurrent endocarditis.
Back in [**2137**], he underwent Bentall procedure utilizing homograft
along with VSD closure and debridement of aortic root abscess.
Unfortunately due to recurrent IVDA, he developed recurrent
endocarditis. Blood cultures were positive for MSSA. Following a
prolonged course of intravenous antibiotics and period of being
drug free/drug rehab, he presented to [**Hospital1 18**] for cardiac surgical
intervention. His last heroin abuse was back in [**2139-10-9**].

MEDICAL HISTORY: Recurrent Endocarditis, Aortic Root Abscess, Severe Aortic
Insufficiency, Congestive Heart Failue, Intravenous Drug Abuser,
Prior Homograft Root Replacement and VSD Closure in [**2137**],
History of Septic Emboli to Spleen, Kidney and Cerebrum in [**2137**],
History of Hepatic Pseudoaneurysm embolization in [**2137**], History
of Bicuspid Aortic Valve - s/p Aortic Valvuloplasty at age 15

MEDICATION ON ADMISSION: Atenolol 25 qd
Aspirin 81 qd
Lasix 40 qd
KCL 40 qd
Suboxone - discontinued 1 day prior to admission

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Admission:
Vitals: T 98.2, BP 124/75, HR 80, RR 18, SAT 97% on room air
General: well developed male in no acute distress
HEENT: oropharynx benign,
Neck: supple, no JVD,
Heart: regular rate, normal s1s2, [**5-13**] holosystolic murmur
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, 1+ edema bilaterally, no varicosities
Pulses: 2+ distally(bounding)
Neuro: nonfocal

FAMILY HISTORY: Denies premature coronary artery disease

SOCIAL HISTORY: Quit tobacco 2 weeks prior to admission. Admits to 8 pack year
history of tobacco. Denies ETOH over the last year. He currently
lives with his parents.
Congestive heart failure, unspecified,Complications of other specified transplanted organ,Aortic valve disorders,Opioid abuse, unspecified,Cerebral embolism without mention of cerebral infarction,Long-term (current) use of anticoagulants,Other specified cardiac dysrhythmias
CHF NOS,Comp oth organ transplnt,Aortic valve disorder,Opioid abuse-unspec,Crbl emblsm wo infrct,Long-term use anticoagul,Cardiac dysrhythmias NEC
Admission Date:  [**2140-3-7**]              Discharge Date:   [**2140-3-27**]

Date of Birth:  [**2114-4-25**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Recurrent Endocarditis

Major Surgical or Invasive Procedure:
[**2140-3-15**] Redo Sternotomy, Aortic Valve Replacement(27 millimeter
Onyx Mechanical Valve), Replacement of Ascending Aorta (24
millimeter Gelweave Dacron Graft)


History of Present Illness:
Mr. [**Known lastname 57041**] is a 25 year old male with recurrent endocarditis.
Back in [**2137**], he underwent Bentall procedure utilizing homograft
along with VSD closure and debridement of aortic root abscess.
Unfortunately due to recurrent IVDA, he developed recurrent
endocarditis. Blood cultures were positive for MSSA. Following a
prolonged course of intravenous antibiotics and period of being
drug free/drug rehab, he presented to [**Hospital1 18**] for cardiac surgical
intervention. His last heroin abuse was back in [**2139-10-9**].

Past Medical History:
Recurrent Endocarditis, Aortic Root Abscess, Severe Aortic
Insufficiency, Congestive Heart Failue, Intravenous Drug Abuser,
Prior Homograft Root Replacement and VSD Closure in [**2137**],
History of Septic Emboli to Spleen, Kidney and Cerebrum in [**2137**],
History of Hepatic Pseudoaneurysm embolization in [**2137**], History
of Bicuspid Aortic Valve - s/p Aortic Valvuloplasty at age 15

Social History:
Quit tobacco 2 weeks prior to admission. Admits to 8 pack year
history of tobacco. Denies ETOH over the last year. He currently
lives with his parents.

Family History:
Denies premature coronary artery disease

Physical Exam:
Admission:
Vitals: T 98.2, BP 124/75, HR 80, RR 18, SAT 97% on room air
General: well developed male in no acute distress
HEENT: oropharynx benign,
Neck: supple, no JVD,
Heart: regular rate, normal s1s2, [**5-13**] holosystolic murmur
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, 1+ edema bilaterally, no varicosities
Pulses: 2+ distally(bounding)
Neuro: nonfocal

Discharge:
VS T 97.5  HR 82 SR  BP 115/80  RR 18  O2sat 97% on room air
Gen NAD
Neuro A&Ox3, non focal exam
Pulm CTA- bilat
CV RRR, sternum stable, incision with steri strips-CDI
Abdm soft, NT/ND/NABS
Rt groin incision with steri strips-CDI
Ext warm, trace edema


Pertinent Results:
[**2140-3-7**] Admit chest x-ray: Diffuse enlargement of the cardiac
silhouette consistent with cardiomegaly and/or pericardial
effusion. This appears to have increased since the prior
examination. The lungs remain clear with no evidence of acute
infiltrate, pleural effusion, or pneumothorax.
[**2140-3-8**] Brain MRA: No enhancing lesions. Encephalomalacia of the
right parietal lobe from a prior infarct. Minimal chronic
microvascular ischemic changes. No acute infarct or evidence of
mycotic aneurysm.
[**2140-3-10**] Cardiac Catheterization: Selective coronary angiography
of this right dominant system demonstrated no significant
epicardial CAD.  The LMCA, LAD, LCX, RCA and their branches had
no angiographically apparent disease. Resting hemodynamics
revealed systemic arterial central normotension. Supraaortic
aortography revealed severe AI.

CHEST (PA & LAT)[**2140-3-16**]
Reason: evaluate pleural effusions
[**Hospital 93**] MEDICAL CONDITION:
25 year old man s/p avr, asc ao replacement
REASON FOR THIS EXAMINATION:
evaluate pleural effusions
STUDY: PA and lateral chest, [**2140-3-19**].
HISTORY: 25-year-old man status post aortic valve replacement.
Evaluate pleural effusions.
FINDINGS: Comparison is made to the previous study from [**3-19**], [**2140**] and [**2140-3-5**].
The cardiac silhouette is markedly enlarged but stable since the
previous studies. Median sternotomy wires are identified. There
is some streaky density seen at the left mid lung field
consistent with subsegmental atelectasis. There is blunting of
the left costophrenic angle consistent with a small pleural
effusion. Embolization coils are seen within the right upper
quadrant.
Impression:
Cardiomegaly with likely a small left-sided pleural effusion.
Cardiology Report ECHO Study Date of [**2140-3-15**]
PATIENT/TEST INFORMATION:
Indication: Intraoperative TEE for Re-do Bental Procedure
Status: Inpatient
Date/Time: [**2140-3-15**] at 13:55
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW1-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) 412**] [**Last Name (Prefixes) 413**]
MEASUREMENTS:
Left Ventricle - Inferolateral Thickness: 1.0 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: *9.2 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 20% (nl >=55%)
Aorta - Ascending: 2.8 cm (nl <= 3.4 cm)
Aorta - Descending Thoracic: 2.3 cm (nl <= 2.5 cm)
INTERPRETATION:
Findings:
LEFT ATRIUM: All four pulmonary veins identified and enter the
left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA  and extending into the RV. PFO is present.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D  images. Severely dilated LV cavity. Severe
global LV hypokinesis. Severely depressed LVEF.
LV WALL MOTION: Regional LV wall motion abnormalities include:
basal anterior  - hypo; mid anterior - hypo; basal anteroseptal
- hypo; mid anteroseptal -  hypo; basal inferoseptal - hypo; mid
inferoseptal - hypo; basal inferior - hypo; mid inferior - hypo;
basal inferolateral - hypo; mid inferolateral - hypo; basal
anterolateral - hypo; mid anterolateral - hypo; anterior apex -
hypo; septal apex - hypo; inferior apex - hypo; lateral apex -
hypo; apex - hypo;
RIGHT VENTRICLE: Dilated RV cavity. Severe global RV free wall
hypokinesis.
AORTA: Focal calcifications in aortic root. Focal calcifications
in ascending aorta. Normal descending aorta diameter.
AORTIC VALVE: ?# aortic valve leaflets. Mildly thickened aortic
valve
leaflets. Aortic valve homograft (AVR). Abnormal motion of AVR
leaflets/discs. Aortic valve vegetation/mass cannot be excluded.
Aortic root abscess. No AS. Severe (4+) AR. Eccentric AR jet
directed toward the anterior mitral leaflet.
MITRAL VALVE: Normal mitral valve leaflets. Mild mitral annular
calcification.  Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. No TEE related
complications. The patient was under general anesthesia
throughout the
procedure. The patient appears to be in sinus rhythm. Results
Conclusions:
PRE CPB A patent foramen ovale is present. The left ventricular
cavity is
severely dilated. There is severe global left ventricular
hypokinesis. Overall left ventricular systolic function is
severely depressed. The right ventricular cavity is dilated.
There is severe global right ventricular free wall hypokinesis.
The number of aortic valve leaflets cannot be determined.
Patient is s/p aortic homograft placement in past. The aortic
valve leaflets are mildly thickened. . Motion of the aortic
leaflets is abnormal. An aortic valve vegetation/mass cannot be
excluded. An aortic annular abscess is seen. The largest abscess
cavity is located along the non-coronary cusp. Flow is seen into
this cavity. There are other echolucencies consistent with
perivalvular abscess seen nera both coronary artery takeoffs.
There is no aortic valve stenosis. Severe (4+) aortic
regurgitation is seen. The aortic regurgitation jet is
eccentric, directed toward the anterior mitral leaflet. The
mitral valve leaflets are structurally normal. Trivial mitral
regurgitation is seen.

POST CPB The patient is receiving infusions of milrinone,
dobutamine, and
norepinephrine. LV systolic function remains severely globally
depressed.
However, the inferior wall appears to be worse. The EF is
perhaps 20%. RV
systolic function is somewhat improved from the pre-CPB study.
There is still at least moderate if not moderate to severe
global hypokinesis. There is a bileaflet prosthesis in the
aortic position. It is not well seen but it appears that both
leaflets are opening. It appears well seated. There are
fibrinous strands near the valve ring - ? signficance. There is
trace to mild valvular AI, normal for this prosthesis. Can not
rule out a small perivalvular leak. There is no AS. The abscess
cavity near the native non-coronary cusp is still visible. There
appears to still be flow into it. The PFO/ASD remains. No other
changes from pre-CPB.

Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD on [**2140-3-15**] 17:43


Brief Hospital Course:
In preperation for cardiac surgical intervention, Mr. [**Known lastname 57041**]
was admitted several days prior to undergo additional
evaluation. Brain MRI/MRA imaging was obtained which showed no
acute infarct or evidence of mycotic aneurysm. It was however
notable for encephalomalacia of the right parietal lobe from a
prior infarct, and minimal chronic microvascular ischemic
changes. Blood cultures were also taken which remained negative.
Transthoracic echocardiogram was also obtained which confirmed
severe aortic insufficiency. The left ventricle was severely
dilated with mildly depressed left ventricular function. Right
ventriclular systolic function was likely depressed but hard to
evaluate given the severity of tricuspid regurgitation which was
[**2-9**]+. There was 1+ mitral regurgitation and only trivial
pulmonic insufficiency.  On [**3-9**], he was taken to the
operating room. Prior to surgery, TEE was performed which
revealed severely dilated right and left ventricles with
severely depressed right and left ventricular function. Given
these new findings, surgery was postponed and additional
evaluation was performed, including potential cardiac
transplantation. Cardiac catheterization was obtained to exclude
a possibility of a coronary embolus. Angiography showed normal
coronary arteries. He returned to the operating room on [**3-15**] with contingency plan for RVAD. In the operating room, Dr.
[**Last Name (STitle) 1290**] performed redo sternotomy along with aortic valve
replacement and replacement of ascending aorta. Surgery was
successful and RVAD was not required. Following the operation,
he was brought to the CSRU in critical condition, on multiple
inotropes. For surgical details, please see seperate dictated
operative note. Within 24 hours, he awoke neurologically intact
and was extubated. He maintained stable hemodynamics and weaned
from inotropic support without difficulty. He was transfused
with packed red blood cells to maintain hematocrit near 30%. His
CSRU course was otherwise unremarkable and he transferred to the
SDU on postoperative day two. The pain service was consulted to
assist in the postoperative management of his incisional
discomfort. He remained in a normal sinus rhythm. His heart
failure regimen was optimized. Wafarin was dosed for a goal INR
between 2.0 - 2.5 given his mechanical aortic valve. He
temporarily required Heparin for a subtherapeutic prothrombin
time. He spiked a fever on postoperative day four for which pan
cultures were obtained and empiric antibiotics were given. He
continued to make clinical improvements and was eventually
cleared for discharge on postoperative day 12.


Medications on Admission:
Atenolol 25 qd
Aspirin 81 qd
Lasix 40 qd
KCL 40 qd
Suboxone - discontinued 1 day prior to admission

Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): while taking narcotics.
Disp:*30 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Buprenorphine-Naloxone  8-2 mg Tablet, Sublingual  Sig:  One
(1) Tablet Sublingual BREAKFAST (Breakfast).     Sig: 0.5 tablet
 Qbreakfast.
4. Buprenorphine-Naloxone 8-2 mg Tablet, Sublingual Sig: 0.5
Tablet Sublingual LUNCH (Lunch).
5. Buprenorphine-Naloxone 8-2 mg Tablet, Sublingual Sig: One (1)
Tablet Sublingual QHS (once a day (at bedtime)).
6. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q 2-3 hrs as
needed: script for 15 tabs given to father [**3-26**] .
8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
10. Warfarin 5 mg Tablet Sig: 2.5 Tablets PO once a day: please
take 12.5 mg [**3-27**] and [**3-28**] and have INR checked [**3-29**] for further
dosing.
Disp:*90 Tablet(s)* Refills:*0*
11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
13. Outpatient [**Name (NI) **] Work
PT/INR as needed
Results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Fax ([**2140**].
Goal INR 2.5-3.0 for AVR


Discharge Disposition:
Home

Discharge Diagnosis:
Recurrent Endocarditis, Aortic Root Abscess, Severe Aortic
Insufficiency, Congestive Heart Failue, Intravenous Drug Abuser,
Prior Homograft Root Replacement and VSD Closure in [**2137**],
History of Septic Emboli to Spleen, Kidney and Cerebrum, History
of Bicuspid Aortic Valve - s/p Aortic Valvuloplasty at age 15


Discharge Condition:
Good


Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.


Followup Instructions:
Cardiac surgeon, Dr. [**Last Name (STitle) 1290**] in [**5-12**] weeks.
Dr. [**First Name (STitle) **] in [**3-12**] weeks.
Dr. [**Last Name (STitle) 57046**] in [**3-12**] weeks.
Please call for appt with local PCP and cardiologist



Completed by:[**2140-3-29**]
{'Congestive heart failure, unspecified,Complications of other specified transplanted organ,Aortic valve disorders,Opioid abuse, unspecified,Cerebral embolism without mention of cerebral infarction,Long-term (current) use of anticoagulants,Other specified cardiac dysrhythmias'}


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: Recurrent Endocarditis

PRESENT ILLNESS: Mr. [**Known lastname 57041**] is a 25 year old male with recurrent endocarditis.
Back in [**2137**], he underwent Bentall procedure utilizing homograft
along with VSD closure and debridement of aortic root abscess.
Unfortunately due to recurrent IVDA, he developed recurrent
endocarditis. Blood cultures were positive for MSSA. Following a
prolonged course of intravenous antibiotics and period of being
drug free/drug rehab, he presented to [**Hospital1 18**] for cardiac surgical
intervention. His last heroin abuse was back in [**2139-10-9**].

MEDICAL HISTORY: Recurrent Endocarditis, Aortic Root Abscess, Severe Aortic
Insufficiency, Congestive Heart Failue, Intravenous Drug Abuser,
Prior Homograft Root Replacement and VSD Closure in [**2137**],
History of Septic Emboli to Spleen, Kidney and Cerebrum in [**2137**],
History of Hepatic Pseudoaneurysm embolization in [**2137**], History
of Bicuspid Aortic Valve - s/p Aortic Valvuloplasty at age 15

MEDICATION ON ADMISSION: Atenolol 25 qd
Aspirin 81 qd
Lasix 40 qd
KCL 40 qd
Suboxone - discontinued 1 day prior to admission

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Admission:
Vitals: T 98.2, BP 124/75, HR 80, RR 18, SAT 97% on room air
General: well developed male in no acute distress
HEENT: oropharynx benign,
Neck: supple, no JVD,
Heart: regular rate, normal s1s2, [**5-13**] holosystolic murmur
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, 1+ edema bilaterally, no varicosities
Pulses: 2+ distally(bounding)
Neuro: nonfocal

FAMILY HISTORY: Denies premature coronary artery disease

SOCIAL HISTORY: Quit tobacco 2 weeks prior to admission. Admits to 8 pack year
history of tobacco. Denies ETOH over the last year. He currently
lives with his parents. 

### Response:
{'Congestive heart failure, unspecified,Complications of other specified transplanted organ,Aortic valve disorders,Opioid abuse, unspecified,Cerebral embolism without mention of cerebral infarction,Long-term (current) use of anticoagulants,Other specified cardiac dysrhythmias'}
