CHIEF COMPLAINT: Fevers/Fatigue

PRESENT ILLNESS: 76 year old man with a history of mechanical aortic valve
replacement ([**2106**])on coumadin, who was transferred to the [**Hospital1 **] on
[**1-27**] from an OSH for further evaluation for recurrent fever,
flank pain, nausea, and vomiting. He was recently in El [**Country 19118**]
where he [**Doctor Last Name 6165**] and was seen in the [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] 2 occasions over past
6 weeks treated with abx for 4 days then 2 days for bacterial
illness. He returned to the US and saw his PCP that night
developed fever, rigors, myalgias, nausea and back pain. He
presented to [**Location (un) **] [**Location (un) 1459**] where a contrast CT done at the
OSH showed persistent right kidney subcapsular
fluid collecton and left non-obstructing urolithiasis. He was
febrile and started on vancomycin and pip/tazo and oseltamivir.
Blood cultures drawn at the OSH are now growing Group C Strep.
The patient was transferred to [**Hospital1 18**] for further management. A
TTE done here reveals mechanical aortic valve vegetation.

MEDICAL HISTORY: Past Medical History:
1. Hypertension
2. AAA s/p repair ([**2106**])-- per OMR but history unclear from
patient, no evidence of graft on CT
3. Right Kidney Stones s/p extracorporeal shockwave lithotripsy
at [**Hospital1 18**]
4. Retroperitoneal hemorrhage
5. CHF? *per patient he does not have this
6. R shoulder Bursitis
7. BPH

MEDICATION ON ADMISSION: FINASTERIDE - 5 mg Tablet - 1 Tablet(s) by mouth once a day
LISINOPRIL - 20 mg Tablet - 1 Tablet(s) by mouth once a day
METOPROLOL TARTRATE - 50 mg Tablet - 1 Tablet(s) by mouth twice
a
day
WARFARIN - 2.5 mg Tablet - [**12-25**] Tablet(s) by mouth daily as
directed

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Pulse: Resp:  O2 sat:
B/P  Right:    Left:
Height: 55 inches   Weight:147 lbs

FAMILY HISTORY: remarkable for multiple cancers in the family, including stomach
and liver cancer

SOCIAL HISTORY: Travels back and forth between El [**Country 19118**] and here. Wife lives
in El [**Country 19118**]. Has nine kids. Retired, used to be a farmer.
Tobacco - never
Alcohol - not in decades
Drugs - none past or present, no IVDU, no tattoos.
PCP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Hospital1 18**])
Infection and inflammatory reaction due to cardiac device, implant, and graft,Streptococcal septicemia,Sepsis,Acute and subacute bacterial endocarditis,Acute pyelonephritis without lesion of renal medullary necrosis,Calculus of kidney,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Iron deficiency anemia secondary to blood loss (chronic),Vascular disorders of kidney,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Heart valve replaced by other means,Long-term (current) use of anticoagulants,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Chronic kidney disease, unspecified
React-cardiac dev/graft,Streptococcal septicemia,Sepsis,Ac/subac bact endocard,Ac pyelonephritis NOS,Calculus of kidney,Hy kid NOS w cr kid I-IV,Chr blood loss anemia,Renal vascular disorder,Abn react-anastom/graft,Heart valve replac NEC,Long-term use anticoagul,BPH w/o urinary obs/LUTS,Chronic kidney dis NOS
Admission Date:  [**2113-1-27**]              Discharge Date:   [**2113-2-9**]

Date of Birth:  [**2036-6-26**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Fevers/Fatigue

Major Surgical or Invasive Procedure:
[**2113-2-3**]
Redo sternotomy, Redo Bentall aortic root replacement with a
size 21-mm homograft, Drainage of aortic root abscess.


History of Present Illness:
76 year old man with a history of mechanical aortic valve
replacement ([**2106**])on coumadin, who was transferred to the [**Hospital1 **] on
[**1-27**] from an OSH for further evaluation for recurrent fever,
flank pain, nausea, and vomiting. He was recently in El [**Country 19118**]
where he [**Doctor Last Name 6165**] and was seen in the [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] 2 occasions over past
6 weeks treated with abx for 4 days then 2 days for bacterial
illness. He returned to the US and saw his PCP that night
developed fever, rigors, myalgias, nausea and back pain. He
presented to [**Location (un) **] [**Location (un) 1459**] where a contrast CT done at the
OSH showed persistent right kidney subcapsular
fluid collecton and left non-obstructing urolithiasis. He was
febrile and started on vancomycin and pip/tazo and oseltamivir.
Blood cultures drawn at the OSH are now growing Group C Strep.
The patient was transferred to [**Hospital1 18**] for further management. A
TTE done here reveals mechanical aortic valve vegetation.



Past Medical History:
Past Medical History:
1. Hypertension
2. AAA s/p repair ([**2106**])-- per OMR but history unclear from
patient, no evidence of graft on CT
3. Right Kidney Stones s/p extracorporeal shockwave lithotripsy
at [**Hospital1 18**]
4. Retroperitoneal hemorrhage
5. CHF? *per patient he does not have this
6. R shoulder Bursitis
7. BPH

Past Surgical History:
1. Aortic valve replacement (mechanical) on coumadin since [**2106**]
2. Cholecystitis s/p cholecystectomy ([**2107**])


Social History:
Travels back and forth between El [**Country 19118**] and here. Wife lives
in El [**Country 19118**]. Has nine kids. Retired, used to be a farmer.
Tobacco - never
Alcohol - not in decades
Drugs - none past or present, no IVDU, no tattoos.
PCP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Hospital1 18**])


Family History:
remarkable for multiple cancers in the family, including stomach
and liver cancer

Physical Exam:
Pulse: Resp:  O2 sat:
B/P  Right:    Left:
Height: 55 inches   Weight:147 lbs

General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck:  Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x]  Irregular []  Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x]
bowel sounds + []; no costovertebral angle tenderness
Extremities: Warm [x], well-perfused [x]  no Edema
no Varicosities; no [**Last Name (un) **] lesions
Neuro: Grossly intact
Pulses:
Femoral      Right: 2+  Left: 2+
DP           Right: 2+  Left: 2+
PT           [**Name (NI) 167**]: 2+  Left: 2+
Radial       Right: 2+  Left: 2+
Carotid Bruit        Right: no   Left: no


Pertinent Results:
[**2113-2-8**] 04:08AM BLOOD WBC-7.2 RBC-3.20* Hgb-9.9* Hct-29.3*
MCV-92 MCH-31.0 MCHC-33.9 RDW-17.2* Plt Ct-228
[**2113-1-28**] 12:20AM BLOOD Neuts-88.2* Lymphs-7.9* Monos-2.5 Eos-1.0
Baso-0.5
[**2113-2-8**] 04:08AM BLOOD Albumin-3.3* Calcium-8.6 Phos-2.7 Mg-2.2
[**2113-2-8**] 04:08AM BLOOD ALT-12 AST-28 LD(LDH)-261* AlkPhos-101
Amylase-45 TotBili-0.7
[**2113-2-8**] 04:08AM BLOOD Glucose-101* UreaN-18 Creat-1.1 Na-136
K-4.5 Cl-96 HCO3-34* AnGap-11

[**2113-2-3**] TEE
PRE-BYPASS:
No spontaneous echo contrast is seen in the body of the left
atrium or left atrial appendage. No spontaneous echo contrast is
seen in the body of the right atrium. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%).
The right ventricular cavity is mildly dilated with borderline
normal free wall function. A bileaflet aortic valve prosthesis
is present. The transaortic gradient is normal for this
prosthesis. It appeared as though one of the leaflet was stuck
in the deep transgastric view but with no insufficiency and with
normal gradients. It was noted that previous TEE images from
cardiology had shown normal movements of the leaflets. The
imaging was suboptimal to elucidate further information and was
promptly conveyed to the surgeon. An aortic annular echodensity
of 4cm x 1.6 cm was seen posterior to the aortic root consistent
with abscess is see and was extending to the space between the
aorta and the right PA posteriorly. The abscess is outside the
ascending aortic graft and no cavity filling was seen unlike the
previous TEE images. This does not rule out communication. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. There
is no pericardial effusion.
POST-BYPASS:
Patient is on epinephrine 0.02 mcg/kg/min and levophed
0.03mcg/kg/min.
Intact thoracic aorta. There is a circumferential echodensity
with no filling is seen consistent with post surgical state of
aortic root abscesses. The homograft is in situ with functioning
aortic valve and a residual mean gradient of 12 mm of Hg. Mild
MR, TR. Preserved biventricular sytolic function, LVEF 55%

Brief Hospital Course:
This 76-year-old patient who has had a previous aortic root
replacement, Bentall procedure with mechanical composite graft
approximately 6 years ago, presented with signs of sepsis and a
transesophageal echocardiogram showed an aortic root abscess
placed posteriorly with communication into the aortic root. He
had positive blood cultures with group C Streptococci.
Initially he was given antibiotics but he developed signs of
worsening abscess with conduction abnormalities and was taken to
the operating room for urgent redo Bentall operation.
Preoperative coronary angiogram showed no occlusive disease, and
left ventricular function was well-preserved.  He was brought to
the operating room on [**2113-2-3**] where the patient underwent redo
sternotomy redo Bentall aortic root replacement with a size
21-mm
homograft and drainage of aortic root abscess. Overall the
patient tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring. POD 1 found the patient extubated, alert
and oriented and breathing comfortably.  The patient was
neurologically intact and hemodynamically stable on no inotropic
or vasopressor support.  Infectious disease was consulted and
recommended 6 weeks of PCN G from the date of surgery (aortic
valve gram stain was negative for microorganisms.) Beta blocker
was initiated and the patient was gently diuresed toward the
preoperative weight.  The patient was transferred to the
telemetry floor for further recovery. Chest tubes and pacing
wires were discontinued without complication.  The patient was
evaluated by the physical therapy service for assistance with
strength and mobility.  By the time of discharge on POD  the
patient was ambulating freely, the wound was healing and pain
was controlled with oral analgesics.  The patient was discharged
to [**Hospital 1459**] Nursing and Rehab Center in good condition on post
operative day 6 with appropriate follow up instructions for
appointments and labs.

Medications on Admission:
FINASTERIDE - 5 mg Tablet - 1 Tablet(s) by mouth once a day
LISINOPRIL - 20 mg Tablet - 1 Tablet(s) by mouth once a day
METOPROLOL TARTRATE - 50 mg Tablet - 1 Tablet(s) by mouth twice
a
day
WARFARIN - 2.5 mg Tablet - [**12-25**] Tablet(s) by mouth daily as
directed

NKDA

Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
6. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
7. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): x 1 week then decrease to 400 mg daily x 2 weeks then
200 mg daily x 1 month then as directed by cardiology.
8. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
10. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily).
13. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous every eight (8) hours as needed for line flush.
14. penicillin G potassium 20 million unit Recon Soln Sig: 4
million units  Injection every four (4) hours for 6 weeks:
Continue via PICC x 6 weeks from date of surgery.
15. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
16. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO DAILY (Daily) for 7
days.


Discharge Disposition:
Extended Care

Facility:
[**Location (un) 1459**] Care and Rehabilitation Center

Discharge Diagnosis:
Endocarditis


Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
1+ LE edema


Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart

No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**


Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**First Name (STitle) **] on [**2113-2-27**] at 2:00 PM
Cardiologist: Needs referral

[**Hospital **] clinic with Dr [**First Name4 (NamePattern1) 402**] [**Last Name (NamePattern1) 2688**] on [**2113-2-27**] at 10:00 AM
[**Hospital **] clinic with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9461**] on [**2113-3-15**] at 11:00 AM
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **] in [**3-28**] weeks [**Telephone/Fax (1) 1144**]

Please check weekly CBC with diff, Chem 7, LFT's ESR and CRP and
fax results to [**Hospital **] clinic [**Telephone/Fax (1) 1419**]

**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**



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

Completed by:[**2113-2-9**]
{'Infection and inflammatory reaction due to cardiac device, implant, and graft,Streptococcal septicemia,Sepsis,Acute and subacute bacterial endocarditis,Acute pyelonephritis without lesion of renal medullary necrosis,Calculus of kidney,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Iron deficiency anemia secondary to blood loss (chronic),Vascular disorders of kidney,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Heart valve replaced by other means,Long-term (current) use of anticoagulants,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Chronic kidney disease, unspecified'}


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: Fevers/Fatigue

PRESENT ILLNESS: 76 year old man with a history of mechanical aortic valve
replacement ([**2106**])on coumadin, who was transferred to the [**Hospital1 **] on
[**1-27**] from an OSH for further evaluation for recurrent fever,
flank pain, nausea, and vomiting. He was recently in El [**Country 19118**]
where he [**Doctor Last Name 6165**] and was seen in the [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] 2 occasions over past
6 weeks treated with abx for 4 days then 2 days for bacterial
illness. He returned to the US and saw his PCP that night
developed fever, rigors, myalgias, nausea and back pain. He
presented to [**Location (un) **] [**Location (un) 1459**] where a contrast CT done at the
OSH showed persistent right kidney subcapsular
fluid collecton and left non-obstructing urolithiasis. He was
febrile and started on vancomycin and pip/tazo and oseltamivir.
Blood cultures drawn at the OSH are now growing Group C Strep.
The patient was transferred to [**Hospital1 18**] for further management. A
TTE done here reveals mechanical aortic valve vegetation.

MEDICAL HISTORY: Past Medical History:
1. Hypertension
2. AAA s/p repair ([**2106**])-- per OMR but history unclear from
patient, no evidence of graft on CT
3. Right Kidney Stones s/p extracorporeal shockwave lithotripsy
at [**Hospital1 18**]
4. Retroperitoneal hemorrhage
5. CHF? *per patient he does not have this
6. R shoulder Bursitis
7. BPH

MEDICATION ON ADMISSION: FINASTERIDE - 5 mg Tablet - 1 Tablet(s) by mouth once a day
LISINOPRIL - 20 mg Tablet - 1 Tablet(s) by mouth once a day
METOPROLOL TARTRATE - 50 mg Tablet - 1 Tablet(s) by mouth twice
a
day
WARFARIN - 2.5 mg Tablet - [**12-25**] Tablet(s) by mouth daily as
directed

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Pulse: Resp:  O2 sat:
B/P  Right:    Left:
Height: 55 inches   Weight:147 lbs

FAMILY HISTORY: remarkable for multiple cancers in the family, including stomach
and liver cancer

SOCIAL HISTORY: Travels back and forth between El [**Country 19118**] and here. Wife lives
in El [**Country 19118**]. Has nine kids. Retired, used to be a farmer.
Tobacco - never
Alcohol - not in decades
Drugs - none past or present, no IVDU, no tattoos.
PCP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Hospital1 18**]) 

### Response:
{'Infection and inflammatory reaction due to cardiac device, implant, and graft,Streptococcal septicemia,Sepsis,Acute and subacute bacterial endocarditis,Acute pyelonephritis without lesion of renal medullary necrosis,Calculus of kidney,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Iron deficiency anemia secondary to blood loss (chronic),Vascular disorders of kidney,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Heart valve replaced by other means,Long-term (current) use of anticoagulants,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Chronic kidney disease, unspecified'}
