CHIEF COMPLAINT: Intermittent bradycardia, hypoxia, chest pain with TWI and trop
leak in setting of infective endocarditis

PRESENT ILLNESS: 28 yo M with PMH of IVDU, and aortic valve infective
endocarditis admitted with infective endocarditis.  He is
transferred to the CCU for more monitoring in setting of
worsened hypoxia, altered mental status and intermittent
hypotension/bradycardia thought to be vagal in nature.
.
He was admitted here on [**6-26**] after a 3 day stay at an OSH.  The
day prior to that he presented to his PCP and found to have a 7
point hct drop 31--->24 and was referred to an OSH ED. There, he
has no elevation if WBC but had a 7% bandemia and blood cultures
grew out strep.  He was positive for cocain as well. After his
blood cultures turned positive, he was transferred here for
further care as there had been plan for valve replacement with
Dr. [**Last Name (STitle) 65483**].
.
Of note, his last episode of infective endocarditis was in the
fall of [**2123**] and was treated with 3 months of iv antibiotics
(unknown type). He had previously been on IV abx (unclear which
kind for 3 months
.
Since admission here, he has been doing well and had been
treated with ceftriaxone and gentamycin.  ID has been following.
 Blood cultures here have been negative.
.
He has been continued on his cardiac medications and received
diuresis for fluid overload with lasix thought to be from his
severe MR.  Repeat echo here showed 4+ MR, 4+ AI, EF 65% with
1cm vegetations on both the aoritic and mitral valves.  There
was also a likely vegetation attached to the left atrial wall in
the region of the warfarin ridge.  Finally, the aortic root
appeared thickened concerning for an abscess/phlegmon.
.
CT surgery was consulted given wide open MV and AV on echo.
Though there is CT surgery note from this admission, per intern
notes, recommendation was antibiotics, out pt drug rehab and
goal of being drug free for 6 months prior to consideration for
valve replacement.
.
He had been doing well since admission until last night at 10pm
when he became anxious, reported chest pain. Also had 2 episodes
of bradycardia to high 30's which resolved without intervention
and tele showed ? junctional rhythm. EKG showed TWI in the
precordial leads.  The overnight team spoke with the cardiology
fellow who felt that this was unlikely to be heart block as it
resolved with no intervention.  Felt to be vagal and likely
related to anxiety and he received ativan 1mg iv and he felt
better. Cardiac enzymes were sent and trop was 0.37 and CK/MB
were normal.  Felt to likely be a coronary septic emboli and
systemic anticoagulation is not favored given high risk of CNS
emboli and converstion to hemorrhage.  CT head was negative
though MRI was recommended for complete rule out of emboli.
.
At 6am this morning, he triggered for tachypnia, hypoxia to mid
80's on room air.  He noted to be diaphoretic and with chest
pain.  See trigger note for full details.  He was again
bradycardic, with BP's in the 100's, hypoxia to mid 80's on room
air which reoslved to 2L nc.  EKG showed deeper TWI in
precordial leads and TWI in inferior leads. Repeat trop down
trended to 0.32 and CK/MB normal.  Cr increased to 1.6 and Na
down to 130.  Lactate was 3. There was concern that he had
friends visiting the evening before and that he could have used
an illicit drug.  A room search was done and suboxone/naloxone
combo pills were found.  Pill count showed an appropriate number
of pills.  Urine and serum tox were negative.

MEDICAL HISTORY: Aortic and mitral valve endocarditis s/p Aortic and Mitral valve
replacement

MEDICATION ON ADMISSION: Buprenorphine-nalaxone 8 mg-2mg sublingually [**Hospital1 **]
Klonoprin 0.25 mg Daily
Furosemide 80 mg daily
Lisinopril 10 mg daily
Potassium 20 mEq daily

ALLERGIES: Advil / Aspirin

PHYSICAL EXAM: VS: Tc 99.2 BP 96/53 HR 65 RR 18 100% RA
GENERAL: diaphoretic male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: Eyebrown ring above left eyebrow. No evidence of focal
hemmorage. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink

FAMILY HISTORY: Father died at age 57 of an abdominal aortic aneurysm (heavy
smoker). Mother had [**Name2 (NI) 499**] cancer with a colectomy, GF died of
asbestos

SOCIAL HISTORY: -Tobacco: 1 ppd
-ETOH:  Denies
-Illicit drugs:  Denies, but cocaine postive at OSH
Acute and subacute bacterial endocarditis,Acute systolic heart failure,Acute kidney failure, unspecified,Atrioventricular block, complete,Other and unspecified infection due to central venous catheter,Other chronic pulmonary heart diseases,Hyposmolality and/or hyponatremia,Bacteremia,Streptococcus infection in conditions classified elsewhere and of unspecified site, other streptococcus,Aortic valve disorders,Cocaine dependence, unspecified,Dysthymic disorder,Anemia of other chronic disease,Pilonidal cyst without mention of abscess,Asthma, unspecified type, unspecified,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus,Family history of malignant neoplasm of gastrointestinal tract,Other postprocedural status
Ac/subac bact endocard,Ac systolic hrt failure,Acute kidney failure NOS,Atriovent block complete,Oth/uns inf-cen ven cath,Chr pulmon heart dis NEC,Hyposmolality,Bacteremia,Other streptococcus,Aortic valve disorder,Cocaine depend-unspec,Dysthymic disorder,Anemia-other chronic dis,Pilonidal cyst w/o absc,Asthma NOS,Abn react-procedure NEC,Meth resis Staph carrier,Family hx-gi malignancy,Post-proc states NEC
Admission Date:  [**2124-6-26**]              Discharge Date:   [**2124-7-9**]

Date of Birth:  [**2096-2-3**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
Advil / Aspirin

Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Intermittent bradycardia, hypoxia, chest pain with TWI and trop
leak in setting of infective endocarditis


Major Surgical or Invasive Procedure:
[**2124-7-2**]
1. Aortic valve replacement with a size 23-mm St. [**Male First Name (un) 923**]
mechanical valve.
2. Mitral valve replacement with a size 31 St. [**Male First Name (un) 923**] mechanical
valve.


History of Present Illness:
28 yo M with PMH of IVDU, and aortic valve infective
endocarditis admitted with infective endocarditis.  He is
transferred to the CCU for more monitoring in setting of
worsened hypoxia, altered mental status and intermittent
hypotension/bradycardia thought to be vagal in nature.
.
He was admitted here on [**6-26**] after a 3 day stay at an OSH.  The
day prior to that he presented to his PCP and found to have a 7
point hct drop 31--->24 and was referred to an OSH ED. There, he
has no elevation if WBC but had a 7% bandemia and blood cultures
grew out strep.  He was positive for cocain as well. After his
blood cultures turned positive, he was transferred here for
further care as there had been plan for valve replacement with
Dr. [**Last Name (STitle) 65483**].
.
Of note, his last episode of infective endocarditis was in the
fall of [**2123**] and was treated with 3 months of iv antibiotics
(unknown type). He had previously been on IV abx (unclear which
kind for 3 months
.
Since admission here, he has been doing well and had been
treated with ceftriaxone and gentamycin.  ID has been following.
 Blood cultures here have been negative.
.
He has been continued on his cardiac medications and received
diuresis for fluid overload with lasix thought to be from his
severe MR.  Repeat echo here showed 4+ MR, 4+ AI, EF 65% with
1cm vegetations on both the aoritic and mitral valves.  There
was also a likely vegetation attached to the left atrial wall in
the region of the warfarin ridge.  Finally, the aortic root
appeared thickened concerning for an abscess/phlegmon.
.
CT surgery was consulted given wide open MV and AV on echo.
Though there is CT surgery note from this admission, per intern
notes, recommendation was antibiotics, out pt drug rehab and
goal of being drug free for 6 months prior to consideration for
valve replacement.
.
He had been doing well since admission until last night at 10pm
when he became anxious, reported chest pain. Also had 2 episodes
of bradycardia to high 30's which resolved without intervention
and tele showed ? junctional rhythm. EKG showed TWI in the
precordial leads.  The overnight team spoke with the cardiology
fellow who felt that this was unlikely to be heart block as it
resolved with no intervention.  Felt to be vagal and likely
related to anxiety and he received ativan 1mg iv and he felt
better. Cardiac enzymes were sent and trop was 0.37 and CK/MB
were normal.  Felt to likely be a coronary septic emboli and
systemic anticoagulation is not favored given high risk of CNS
emboli and converstion to hemorrhage.  CT head was negative
though MRI was recommended for complete rule out of emboli.
.
At 6am this morning, he triggered for tachypnia, hypoxia to mid
80's on room air.  He noted to be diaphoretic and with chest
pain.  See trigger note for full details.  He was again
bradycardic, with BP's in the 100's, hypoxia to mid 80's on room
air which reoslved to 2L nc.  EKG showed deeper TWI in
precordial leads and TWI in inferior leads. Repeat trop down
trended to 0.32 and CK/MB normal.  Cr increased to 1.6 and Na
down to 130.  Lactate was 3. There was concern that he had
friends visiting the evening before and that he could have used
an illicit drug.  A room search was done and suboxone/naloxone
combo pills were found.  Pill count showed an appropriate number
of pills.  Urine and serum tox were negative.

Cardiac surgery consulted for urgent surgical correction.

Past Medical History:
Aortic and mitral valve endocarditis s/p Aortic and Mitral valve
replacement

Past medical history:
Viridin streptococcal endocarditis
PICC line infection - Stenotrophomonas/Enterobacter cloacae
Anxiety
Depression
Asthma
surgery for pilonidal cyst
s/p Hernia repair


Social History:
 -Tobacco: 1 ppd
-ETOH:  Denies
-Illicit drugs:  Denies, but cocaine postive at OSH

Family History:
Father died at age 57 of an abdominal aortic aneurysm (heavy
smoker). Mother had [**Name2 (NI) 499**] cancer with a colectomy, GF died of
asbestos

Physical Exam:
VS: Tc 99.2 BP 96/53 HR 65 RR 18 100% RA
GENERAL: diaphoretic male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: Eyebrown ring above left eyebrow. No evidence of focal
hemmorage. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink

NECK: Supple without JVD
CARDIAC: [**3-12**] soft systolic murmur best heart at the mitral
position,
LUNGS: CTAB
ABDOMEN: Soft, NTND. No HSM or tenderness
EXTREMITIES: 2+ lower extremity edema, non-pitting. Left toe
between digits 4 and 5 is torn with scab formation.
SKIN: Multiple tattos, but no signs of osler's nodes or [**Last Name (un) **]
lesions.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+


Pertinent Results:
[**2124-6-26**] 11:44PM BLOOD WBC-13.0* RBC-3.77* Hgb-9.6* Hct-30.1*
MCV-80* MCH-25.5* MCHC-31.9 RDW-18.0* Plt Ct-460*
[**2124-6-26**] 11:44PM BLOOD Neuts-83.2* Lymphs-9.2* Monos-3.5 Eos-3.1
Baso-0.9
[**2124-6-26**] 11:44PM BLOOD PT-14.9* PTT-22.9 INR(PT)-1.3*
[**2124-6-26**] 11:44PM BLOOD Glucose-129* UreaN-26* Creat-1.5* Na-130*
K-4.1 Cl-90* HCO3-28 AnGap-16
[**2124-6-27**] 05:49AM BLOOD ALT-16 AST-24 LD(LDH)-208 AlkPhos-112
TotBili-0.5 DirBili-0.3 IndBili-0.2
[**2124-6-26**] 11:44PM BLOOD Calcium-8.4 Phos-5.0* Mg-2.2
[**2124-6-27**] 05:49AM BLOOD calTIBC-268 Hapto-309* Ferritn-282
TRF-206
[**2124-6-27**] 05:49AM BLOOD CRP-50.9*
[**2124-6-26**] 11:45PM BLOOD HIV Ab-NEGATIVE
.
Echo [**6-30**]: The left atrium is dilated. Left ventricular wall
thicknesses are normal. The right ventricular cavity is dilated
with depressed free wall contractility. There is abnormal septal
motion/position consistent with right ventricular
pressure/volume overload. The aortic root is mildly dilated at
the sinus level. The aortic valve leaflets are mildly thickened
with probable vegetation (~1cm diameter). The aortic root is
irregularly thickened consistent with aortic phelgmon/abscess.
Severe (4+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened with large perforation of the
anterior leaflet. There is a large (~1.7 cm) vegetation on the
mitral valve attached to the anterior leaflet in the region of
the perforation. Severe (4+) mitral regurgitation is seen. There
is a moderate sized vegetation (~1.2 cm) attached to the left
atrial wall in the region of the warfarin ridge. The tricuspid
valve leaflets are mildly thickened. There is severe pulmonary
artery systolic hypertension. The pulmonic valve leaflets are
thickened. There is a very small pericardial effusion.

In addition to the above vegetations, at least one additional
vegetation (~0.6 cm diameter) is noted attached to the anterior
mitral valve leaflet.

Compared with the prior report (images unavailable) of
[**2124-6-27**], findings are similar. The mitral valve vegetation
appears slightly larger.

[**2124-7-2**] TEE
Conclusions
Prebypass

No spontaneous echo contrast is seen in the body of the left
atrium or left atrial appendage. There is a small vegetation
seen on the coumadin ridge. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thicknesses are
normal. The left ventricular cavity is moderately dilated.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is mildly depressed (LVEF=45-50%).
[Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.] The
right ventricular cavity is dilated with mild global free wall
hypokinesis. The ascending, transverse and descending thoracic
aorta are normal in diameter and free of atherosclerotic plaque.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. There is a moderate-sized vegetation on
the aortic valve. No aortic valve abscess is seen. Severe (4+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is partial anterior mitral leaflet
flail. There is a moderate-sized vegetation on the mitral valve.
Severe (4+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is a small pericardial
effusion.

Post bypass
Patient is in sinus rhythm and receiving an infusion of
Norepinephrine, Vasopressin and Milrinone. LVEF= 40%. Mechanical
valve seen in the aortic position. It appears well seated and
the lealfets move well. Peak gradient across the aortic valve is
26 mm Hg and the mean gradient is 13 mm Hg. Washing jets typical
for this type of valve are seen. Mechanical valve seen in the
mitral posiiton. It appears well seated and the leaflets move
well. The mean gradient across the mitral valve is 3 mm Hg and
the peak gradient is 5 mm Hg. Washing jets typical for this type
of valve are also seen. Trivial tricuspid regurgitation seen.
Aorta is intact post decannulation.




Brief Hospital Course:
MEDICINE COURSE:
28 yo M with hemodynamically significant strep endocarditis in
setting of likely [**Hospital 15254**] transferred to CCU after decompensation
with worsening heart failure, hypoxia, chest pain with EKG
changes and troponin leak concerning for coronary emboli now s/p
temporary pacer placement with plan for surgical intervention on
[**7-2**]
.
# Bradycardia:  On [**6-30**] patient with episodes of intermittent
symptomatic bradycardia to high 30 to low 40's. At that time
tele with wide complex rhythm, poor baseline thus difficult to
assess for p waves though appears to have some p waves on strip,
appear to be non-conducting at an atrial rate of ~60 and a
ventricular rate of ~40 consistent with intermittent heart block
in setting of endocarditis/aortic wall abscess.  Patient was
subsequently hemodynamically stable with temporary pacer in
place. Transfered to OR for surgical treatment of his
endocarditis
.
# Hypoxia:  Likely decompensation in setting of wide open MV and
AV as result of infective endocarditis.  Clinically volume up.

# Streptococcus Infective Endocarditis:  Has vegetations on MV,
AV and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]. High concern for emboli given increase in trop,
change in mental status though CT was negative.  Clinically has
decompensated in spite of maximum medical therapy with
appropriate antibiotics, treatment for heart failure.  After
extensive discussion plan to forge head with surgical
intervention.

# Chest Pain:  Occurs with his heart block likely precipitating
cardiac ischemia. EKG with worsening TWI initially in precordial
leads and now in inferior leads as well.  Trop bump peak at
0.37, down to 0.32.  Per literature review, 40% of patients with
IE have troponin leak.  Also concern for coronary emboli though
ischemic from CHB most likely.  No role for systemic
anticoagulation or cath in this setting. - temporary pacer in
place.

#  Acute Renal Failure:  New in last 24 hours, likely in setting
of worsening heart failure and poor forward flow. In setting of
aggressive diuresis creatinine stable but elevated at 1.7 with
adequate UOP.
# elevated lactate: likely [**3-8**] to poor forward flow and likely
peripheral ischemia
.
# Drug Dependance and Abuse:  Cocaine positive at OSH though
patient denied.

POST-OP COURSE:
The patient was brought to the Operating Room on [**2124-7-2**] where
the patient underwent AVR (23mm St. [**Male First Name (un) 923**] mechanical), MVR (31mm
St. [**Male First Name (un) 923**] mechanical) with Dr. [**First Name (STitle) **].   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, weaned from inotropic and
vasopressor support by POD 2.  Beta blocker was initiated and
the patient was gently diuresed toward the preoperative weight.
Coumadin was initiated for mechanical valves, with a heparin
bridge. Initial gram stain from OR tissue grew gram negative
rods.  ID continued to follow for antibiotic management.
 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 #7 he was ambulating freely, the
wound was healing and pain was controlled with oral analgesics.
The patient was discharged to [**Hospital **] rehab in good condition
with appropriate follow up instructions.

Medications on Admission:

Buprenorphine-nalaxone 8 mg-2mg sublingually [**Hospital1 **]
Klonoprin 0.25 mg Daily
Furosemide 80 mg daily
Lisinopril 10 mg daily
Potassium 20 mEq daily


Discharge Medications:
1. metoprolol tartrate 25 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO BID
(2 times a day).
2. potassium chloride 10 mEq [**Hospital1 8426**] Extended Release Sig: Two
(2) [**Hospital1 8426**] Extended Release PO Q12H (every 12 hours).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. ranitidine HCl 150 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO BID (2
times a day).
5. aspirin 81 mg [**Hospital1 8426**], Delayed Release (E.C.) Sig: One (1)
[**Hospital1 8426**], Delayed Release (E.C.) PO DAILY (Daily).
6. warfarin 1 mg [**Hospital1 8426**] Sig: [**Name8 (MD) **] MD [**First Name (Titles) 8426**] [**Last Name (Titles) **] DAILY (Daily): INR
goal=2.5-3.5 for  mechanical AVR/MVR .
7. acetaminophen 325 mg [**Last Name (Titles) 8426**] Sig: Two (2) [**Last Name (Titles) 8426**] PO Q4H (every
4 hours) as needed for pain/fever.
8. oxycodone-acetaminophen 5-325 mg [**Last Name (Titles) 8426**] Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
9. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
10. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
11. benzocaine 20 % Paste Sig: One (1) Appl Mucous membrane QID
(4 times a day) as needed for oral sores.
12. ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback Sig:
One (1)  Intravenous Q24H (every 24 hours): Start date: [**2124-7-2**]
Stop date: [**2124-7-29**] (4 weeks as of surgery)

.
13. gentamicin 40 mg/mL Solution Sig: 4.5  Injection Q24H (every
24 hours): Start date: [**2124-7-2**]
Stop date: [**2124-7-15**] (2 weeks as of surgery)

.
14. sodium chloride 0.9 % 0.9 % Syringe Sig: Ten (10) ML
Injection once a day as needed for line flush: & PRN.
15. warfarin 2 mg [**Month/Day/Year 8426**] Sig: One (1) [**Month/Day/Year 8426**] PO once for 1
doses: administer at 4PM .
16. furosemide 10 mg/mL Solution Sig: Four (4)  Injection [**Hospital1 **] (2
times a day).


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 **]-[**Hospital1 8**]

Discharge Diagnosis:
Aortic and mitral valve endocarditis s/p Aortic and Mitral valve
replacement

Past medical history:
Viridin streptococcal endocarditis
PICC line infection - Stenotrophomonas/Enterobacter cloacae
Anxiety
Depression
Asthma
surgery for pilonidal cyst
s/p Hernia repair


Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Edema- 2+

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**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**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) **] [**Telephone/Fax (1) 170**] Date/Time:[**2124-7-31**] 1:45
Cardiologist: Dr. [**Last Name (STitle) 23097**] [**8-8**] at 2:35pm
[**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2124-7-24**] 10:30

Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 67391**] in [**5-9**] weeks [**Telephone/Fax (1) 87956**]

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

Labs: PT/INR for Coumadin ?????? indication: Mechanical Aortic and
Mitral Valves
Goal INR 2.5-3.5
First draw [**2124-7-10**]
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by MD

*****ANTIBIOTIC REGIMEN AND PROJECTED DURATION:
[**Doctor Last Name **] and DOSE:
Ceftriaxone 2gmQ24h
Start date: [**2124-7-2**]
Stop date: [**2124-7-29**] (4 weeks as of surgery)

Gentamicin 180mg IV Q24
Start date: [**2124-7-2**]
Stop date: [**2124-7-15**] (2 weeks as of surgery)

REQUIRED LABORATORY MONITORING:
LAB TESTS: CBCdiff, BUN, CREA, LFTs, Vanco trough, Gent trough,
ESR, CRP
FREQUENCY: Qweekly

All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 1353**]

FOLLOW UP APPOINTMENTS SCHEDULED:
[**2124-7-24**]  10:30a   ID,[**Doctor Last Name **],[**Doctor First Name **]
  LM [**Hospital Unit Name **], BASEMENT
  ID WEST (SB)

All questions regarding outpatient antibiotics should be
directed
to the infectious disease R.Ns. at ([**Telephone/Fax (1) 1354**]


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

Completed by:[**2124-7-9**]
{'Acute and subacute bacterial endocarditis,Acute systolic heart failure,Acute kidney failure, unspecified,Atrioventricular block, complete,Other and unspecified infection due to central venous catheter,Other chronic pulmonary heart diseases,Hyposmolality and/or hyponatremia,Bacteremia,Streptococcus infection in conditions classified elsewhere and of unspecified site, other streptococcus,Aortic valve disorders,Cocaine dependence, unspecified,Dysthymic disorder,Anemia of other chronic disease,Pilonidal cyst without mention of abscess,Asthma, unspecified type, unspecified,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus,Family history of malignant neoplasm of gastrointestinal tract,Other postprocedural status'}


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: Intermittent bradycardia, hypoxia, chest pain with TWI and trop
leak in setting of infective endocarditis

PRESENT ILLNESS: 28 yo M with PMH of IVDU, and aortic valve infective
endocarditis admitted with infective endocarditis.  He is
transferred to the CCU for more monitoring in setting of
worsened hypoxia, altered mental status and intermittent
hypotension/bradycardia thought to be vagal in nature.
.
He was admitted here on [**6-26**] after a 3 day stay at an OSH.  The
day prior to that he presented to his PCP and found to have a 7
point hct drop 31--->24 and was referred to an OSH ED. There, he
has no elevation if WBC but had a 7% bandemia and blood cultures
grew out strep.  He was positive for cocain as well. After his
blood cultures turned positive, he was transferred here for
further care as there had been plan for valve replacement with
Dr. [**Last Name (STitle) 65483**].
.
Of note, his last episode of infective endocarditis was in the
fall of [**2123**] and was treated with 3 months of iv antibiotics
(unknown type). He had previously been on IV abx (unclear which
kind for 3 months
.
Since admission here, he has been doing well and had been
treated with ceftriaxone and gentamycin.  ID has been following.
 Blood cultures here have been negative.
.
He has been continued on his cardiac medications and received
diuresis for fluid overload with lasix thought to be from his
severe MR.  Repeat echo here showed 4+ MR, 4+ AI, EF 65% with
1cm vegetations on both the aoritic and mitral valves.  There
was also a likely vegetation attached to the left atrial wall in
the region of the warfarin ridge.  Finally, the aortic root
appeared thickened concerning for an abscess/phlegmon.
.
CT surgery was consulted given wide open MV and AV on echo.
Though there is CT surgery note from this admission, per intern
notes, recommendation was antibiotics, out pt drug rehab and
goal of being drug free for 6 months prior to consideration for
valve replacement.
.
He had been doing well since admission until last night at 10pm
when he became anxious, reported chest pain. Also had 2 episodes
of bradycardia to high 30's which resolved without intervention
and tele showed ? junctional rhythm. EKG showed TWI in the
precordial leads.  The overnight team spoke with the cardiology
fellow who felt that this was unlikely to be heart block as it
resolved with no intervention.  Felt to be vagal and likely
related to anxiety and he received ativan 1mg iv and he felt
better. Cardiac enzymes were sent and trop was 0.37 and CK/MB
were normal.  Felt to likely be a coronary septic emboli and
systemic anticoagulation is not favored given high risk of CNS
emboli and converstion to hemorrhage.  CT head was negative
though MRI was recommended for complete rule out of emboli.
.
At 6am this morning, he triggered for tachypnia, hypoxia to mid
80's on room air.  He noted to be diaphoretic and with chest
pain.  See trigger note for full details.  He was again
bradycardic, with BP's in the 100's, hypoxia to mid 80's on room
air which reoslved to 2L nc.  EKG showed deeper TWI in
precordial leads and TWI in inferior leads. Repeat trop down
trended to 0.32 and CK/MB normal.  Cr increased to 1.6 and Na
down to 130.  Lactate was 3. There was concern that he had
friends visiting the evening before and that he could have used
an illicit drug.  A room search was done and suboxone/naloxone
combo pills were found.  Pill count showed an appropriate number
of pills.  Urine and serum tox were negative.

MEDICAL HISTORY: Aortic and mitral valve endocarditis s/p Aortic and Mitral valve
replacement

MEDICATION ON ADMISSION: Buprenorphine-nalaxone 8 mg-2mg sublingually [**Hospital1 **]
Klonoprin 0.25 mg Daily
Furosemide 80 mg daily
Lisinopril 10 mg daily
Potassium 20 mEq daily

ALLERGIES: Advil / Aspirin

PHYSICAL EXAM: VS: Tc 99.2 BP 96/53 HR 65 RR 18 100% RA
GENERAL: diaphoretic male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: Eyebrown ring above left eyebrow. No evidence of focal
hemmorage. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink

FAMILY HISTORY: Father died at age 57 of an abdominal aortic aneurysm (heavy
smoker). Mother had [**Name2 (NI) 499**] cancer with a colectomy, GF died of
asbestos

SOCIAL HISTORY: -Tobacco: 1 ppd
-ETOH:  Denies
-Illicit drugs:  Denies, but cocaine postive at OSH 

### Response:
{'Acute and subacute bacterial endocarditis,Acute systolic heart failure,Acute kidney failure, unspecified,Atrioventricular block, complete,Other and unspecified infection due to central venous catheter,Other chronic pulmonary heart diseases,Hyposmolality and/or hyponatremia,Bacteremia,Streptococcus infection in conditions classified elsewhere and of unspecified site, other streptococcus,Aortic valve disorders,Cocaine dependence, unspecified,Dysthymic disorder,Anemia of other chronic disease,Pilonidal cyst without mention of abscess,Asthma, unspecified type, unspecified,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus,Family history of malignant neoplasm of gastrointestinal tract,Other postprocedural status'}
