Datasets:

ashishkgpian

/

symptoms2diseases

like 1

CHIEF COMPLAINT: Back and leg pain PRESENT ILLNESS: Ms. [**Name14 (STitle) 8661**] has a long history of back and leg pain. She has attempted conservative therapy including physical therapy and has failed. She now presents for surgical intervention. MEDICAL HISTORY: L leg lymphedema h/o DVTs x 3 HTN Ho chol Depression MEDICATION ON ADMISSION: Dyazide 37.5/25mg', Lipitor 10mg', ASA 81mg', Citracal 630mg', Celexa 10mg', Fosamax 35mg Qwk (last on [**3-9**]), Vicodin 5/500mg prn, Relafen 750mg prn, Motrin/Aleve prn ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: NAD RRR CTA B Abd soft NT/ND BUE- good strength at biceps, triceps, wrist extension and flexion, finger extension and flexion and intrinsics; sensation intact in all dermatomes; reflexes intact at biceps, triceps and brachioradialis BLE- good strength at hip flexion and extension/abduction/adduction, knee flexion and extension, ankle dorsiflexion and plantar flexion, [**Last Name (un) 938**]/FHL; sensation intact distally; reflexes deminished at quads and Achilles FAMILY HISTORY: N/C SOCIAL HISTORY: Denies

Lumbosacral spondylosis without myelopathy,Acute posthemorrhagic anemia

Lumbosacral spondylosis,Ac posthemorrhag anemia

Admission Date: [**2188-3-17**] Discharge Date: [**2188-3-24**] Date of Birth: [**2124-7-29**] Sex: F Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3190**] Chief Complaint: Back and leg pain Major Surgical or Invasive Procedure: Anterior and posterior lumbar decompression and fusion L2-S1. History of Present Illness: Ms. [**Name14 (STitle) 8661**] has a long history of back and leg pain. She has attempted conservative therapy including physical therapy and has failed. She now presents for surgical intervention. Past Medical History: L leg lymphedema h/o DVTs x 3 HTN Ho chol Depression Social History: Denies Family History: N/C Physical Exam: NAD RRR CTA B Abd soft NT/ND BUE- good strength at biceps, triceps, wrist extension and flexion, finger extension and flexion and intrinsics; sensation intact in all dermatomes; reflexes intact at biceps, triceps and brachioradialis BLE- good strength at hip flexion and extension/abduction/adduction, knee flexion and extension, ankle dorsiflexion and plantar flexion, [**Last Name (un) 938**]/FHL; sensation intact distally; reflexes deminished at quads and Achilles Pertinent Results: [**2188-3-23**] 05:10AM BLOOD WBC-7.2 RBC-3.77* Hgb-11.4* Hct-32.9* MCV-87 MCH-30.3 MCHC-34.7 RDW-14.6 Plt Ct-241# [**2188-3-20**] 05:15AM BLOOD WBC-8.5 RBC-3.86* Hgb-11.5* Hct-33.5* MCV-87 MCH-29.8 MCHC-34.2 RDW-16.0* Plt Ct-135* [**2188-3-19**] 03:08AM BLOOD WBC-8.7 RBC-3.79* Hgb-11.3* Hct-32.6* MCV-86 MCH-29.7 MCHC-34.5 RDW-16.3* Plt Ct-111* [**2188-3-20**] 05:15AM BLOOD Glucose-88 UreaN-6 Creat-0.4 Na-141 K-3.5 Cl-104 HCO3-31 AnGap-10 [**2188-3-19**] 03:08AM BLOOD Glucose-161* UreaN-6 Creat-0.4 Na-140 K-3.7 Cl-107 HCO3-27 AnGap-10 Brief Hospital Course: Ms. [**Known lastname 23**] was admitted to the service of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**] for a lumbar fusion L2-S1. She was informed and consented for the procedure and elected to proceed. Please see Operative Note for procedure in detail. Post-operativley she was transfered to the T/SICU due to blood loss anemia. She was transfused to a stable hematocrit and she remained hemodynamically stable. She was administered antibiotics and pain medication. Her catheter and drain were removed POD 2 and she was able to take PO's. Her pain was well controlled and she was able to work with physical therapy. She will return to clinic in ten days. She was discharged in good condition. Medications on Admission: Dyazide 37.5/25mg', Lipitor 10mg', ASA 81mg', Citracal 630mg', Celexa 10mg', Fosamax 35mg Qwk (last on [**3-9**]), Vicodin 5/500mg prn, Relafen 750mg prn, Motrin/Aleve prn Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. Nabumetone 750 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Phenol-Phenolate Sodium Mouthwash Sig: One (1) Spray Mucous membrane Q4H (every 4 hours) as needed. 8. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed. 12. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 13. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q8H (every 8 hours). Disp:*90 Tablet Sustained Release 12 hr(s)* Refills:*0* 14. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. Disp:*100 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Lumbar spondylosis L2-S1 Discharge Condition: Good Discharge Instructions: Keep the incisions dry. You may shower as long as you cover the incisions with Band-aids. Do not take a bath or submerge the incisions under water. You need to wear the brace whenever you are out of bed. You do not need the brace when you are in bed. Do not lift anything heavier than a gallon of milk. do not bend or twist from the lower back. Do not smoke. call the office if you have a fever over 101F or if you have an increase in pain or discharge from the incisions. Physical Therapy: No lifting heavier than 10 lb, no bending or twisting from the lower back. Lumbar corset brace while ambulating, not needed when in bed or chair Treatments Frequency: Dry dressing to posterior incision daily to protect incision Followup Instructions: Dr. [**Last Name (STitle) 363**] at previously scheduled appointment. Please call [**Telephone/Fax (1) 18552**] for an appointment. Completed by:[**2188-3-31**]

721,285

{'Lumbosacral spondylosis without myelopathy,Acute posthemorrhagic anemia'}

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: Back and leg pain PRESENT ILLNESS: Ms. [**Name14 (STitle) 8661**] has a long history of back and leg pain. She has attempted conservative therapy including physical therapy and has failed. She now presents for surgical intervention. MEDICAL HISTORY: L leg lymphedema h/o DVTs x 3 HTN Ho chol Depression MEDICATION ON ADMISSION: Dyazide 37.5/25mg', Lipitor 10mg', ASA 81mg', Citracal 630mg', Celexa 10mg', Fosamax 35mg Qwk (last on [**3-9**]), Vicodin 5/500mg prn, Relafen 750mg prn, Motrin/Aleve prn ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: NAD RRR CTA B Abd soft NT/ND BUE- good strength at biceps, triceps, wrist extension and flexion, finger extension and flexion and intrinsics; sensation intact in all dermatomes; reflexes intact at biceps, triceps and brachioradialis BLE- good strength at hip flexion and extension/abduction/adduction, knee flexion and extension, ankle dorsiflexion and plantar flexion, [**Last Name (un) 938**]/FHL; sensation intact distally; reflexes deminished at quads and Achilles FAMILY HISTORY: N/C SOCIAL HISTORY: Denies ### Response: {'Lumbosacral spondylosis without myelopathy,Acute posthemorrhagic anemia'}

CHIEF COMPLAINT: Hypotension, fever PRESENT ILLNESS: Mr. [**Known firstname 2398**] [**Known lastname **] is a 70M with HIV (CD4 350 in [**5-8**]), SCC s/p RLL lobectomy [**8-7**] complicated by bronchopleural fistula treated with [**Last Name (un) 72968**] window, as well as empyema and invasive aspergillosis treated with voriconazole referred from [**Hospital1 **] [**Hospital1 8**] for hypotension and fever to 101.8. He was recently admitted from [**2147-8-7**] to [**2147-8-31**] with aspiration PNA, PCP pneumonia and septic shock. His antibiotic course of vanco/cefepime/cipro was completed on [**2147-9-2**]. He subsequently developed hypotension to 70/40, refractory to 5L IVF, on [**9-2**] the day prior to admission. This morning he was given doses of vanco/[**Last Name (un) 2830**]/cipro. MEDICAL HISTORY: -- trach and PEG placed last admission -History of multivessel CAD s/p PCI of the proximal left circumflex with a bare metal stent [**2143**] w/ Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Hospital 12017**] [**Hospital 12018**] Hospital) -HIV-infection, diagnosed in [**2137**], well-controlled. Currently on Truvada and Raltegravir. Last reported CD4 count 354 ([**2147-5-1**]), viral load <48 copies. Pt states that his VL has always been undetectable -Chronic LV dysfunction last EF 55% -Severe migratory polyarthritis, on prolonged high-dose steroid use for presumed "adrenal insufficiency" -moderate MR [**Name13 (STitle) 19667**] -herpes labialis -TMJ -B/L inguinal hernia repair -SCC s/p RLL lobectomy [**8-7**] complicated by bronchopleural fistula treated with [**Last Name (un) 72968**] window, as well as empyema and invasive aspergillosis MEDICATION ON ADMISSION: Vancomycin, Meropenem, Ciprofloxacin --> restarted Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for yeast. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) inj Subcutaneous DAILY (Daily). Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for sob/wheeze. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for sob/wheeze. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Prednisone 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Sulfasalazine 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid Sig: Five (5) mL PO DAILY (Daily). Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). Escitalopram 10 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). Ranitidine HCl 15 mg/mL Syrup Sig: Ten (10) mL PO DAILY (Daily). Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Emtricitabine 200 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). Raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Acetaminophen 650 mg/20.3 mL Solution Sig: 1-2 doses PO Q6H (every 6 hours) as needed for fever. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 2-4 Puffs Inhalation Q6H (every 6 hours) as needed for SOB/Wheeze. Neutra-Phos 2 PKT PO/NG [**Hospital1 **] Sliding scale humalog insulin at meals and bedtime ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Vitals on arrival to the MICU: T 99.2, 113, 116/73, 100% on PS [**5-3**] and FO2 General: sitting with eyes closed, trached on vent HEENT: Sclera anicteric, dry MM, poor dentition, left slightly greater tha right, both pupils reactive to light, arcus sensilus pupil (stable) Neck: hard to assess JVD, trached, connected to vent Lungs: rhonchorus, coarse rales; R-sided chest dressing c/d/i CV: regular fast rate, no murmurs appreciated Abdomen: + BS, soft, NTND, diffuse ecchymoses c/w lovenox shots; old sutures retained in LLQ (CDI); PEG site with minimal erythema and no discharge Skin: scattered, diffuse telangiectasias (not spiders) scatter on face/chest/limbs; friable skin with some areas of eschar on chest, do not appear superinfected Ext: warm, dry +PP no edema Neuro: sleepy, arouses when spoken to [**Last Name (un) **]; hard to understand paie witht PMV but he attept to answer questions FAMILY HISTORY: His mother had CVA/stroke. SOCIAL HISTORY: Currently residing in [**Hospital **] [**Hospital 8**] Rehabilitation. The patient is not married and lives alone. He has a history of 150 pack-year, stopped smoking in [**2143**]. He does not drink alcohol. HIV sexually transmitted.

Unspecified septicemia,Septic shock,Human immunodeficiency virus [HIV] disease,Pneumonitis due to inhalation of food or vomitus,Acute and chronic respiratory failure,Empyema with fistula,Aspergillosis,Chronic diastolic heart failure,Glucocorticoid deficiency,Severe sepsis,Hypovolemia,Anemia, unspecified,Percutaneous transluminal coronary angioplasty status,Coronary atherosclerosis of native coronary artery,Tracheostomy status,Personal history of malignant neoplasm of bronchus and lung,Attention to other artificial opening of digestive tract

Septicemia NOS,Septic shock,Human immuno virus dis,Food/vomit pneumonitis,Acute & chronc resp fail,Empyema with fistula,Aspergillosis,Chr diastolic hrt fail,Glucocorticoid deficient,Severe sepsis,Hypovolemia,Anemia NOS,Status-post ptca,Crnry athrscl natve vssl,Tracheostomy status,Hx-bronchogenic malignan,Atten to enterostomy NEC

Admission Date: [**2147-9-3**] Discharge Date: [**2147-9-14**] Date of Birth: [**2077-7-9**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 398**] Chief Complaint: Hypotension, fever Major Surgical or Invasive Procedure: Left Radial Arterial Line PICC removal PICC placement Bronchoscopy Post-pyloric PEG advancement [**2147-9-13**]; revision on [**2147-9-14**] History of Present Illness: Mr. [**Known firstname 2398**] [**Known lastname **] is a 70M with HIV (CD4 350 in [**5-8**]), SCC s/p RLL lobectomy [**8-7**] complicated by bronchopleural fistula treated with [**Last Name (un) 72968**] window, as well as empyema and invasive aspergillosis treated with voriconazole referred from [**Hospital1 **] [**Hospital1 8**] for hypotension and fever to 101.8. He was recently admitted from [**2147-8-7**] to [**2147-8-31**] with aspiration PNA, PCP pneumonia and septic shock. His antibiotic course of vanco/cefepime/cipro was completed on [**2147-9-2**]. He subsequently developed hypotension to 70/40, refractory to 5L IVF, on [**9-2**] the day prior to admission. This morning he was given doses of vanco/[**Last Name (un) 2830**]/cipro. En route from [**Hospital3 **], he was hypotensive, so the ambulance stopped at [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8**] ER. Supposedly, no major interventions were done (paperwork is now lost). In the ED here at [**Hospital1 18**], VS were HR 110's, SBP 110-120's. He received hydrocortisone 100 mg IV. Cannot review ROS with patient on arrival due to being on the vent. Past Medical History: -- trach and PEG placed last admission -History of multivessel CAD s/p PCI of the proximal left circumflex with a bare metal stent [**2143**] w/ Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Hospital 12017**] [**Hospital 12018**] Hospital) -HIV-infection, diagnosed in [**2137**], well-controlled. Currently on Truvada and Raltegravir. Last reported CD4 count 354 ([**2147-5-1**]), viral load <48 copies. Pt states that his VL has always been undetectable -Chronic LV dysfunction last EF 55% -Severe migratory polyarthritis, on prolonged high-dose steroid use for presumed "adrenal insufficiency" -moderate MR [**Name13 (STitle) 19667**] -herpes labialis -TMJ -B/L inguinal hernia repair -SCC s/p RLL lobectomy [**8-7**] complicated by bronchopleural fistula treated with [**Last Name (un) 72968**] window, as well as empyema and invasive aspergillosis Social History: Currently residing in [**Hospital **] [**Hospital 8**] Rehabilitation. The patient is not married and lives alone. He has a history of 150 pack-year, stopped smoking in [**2143**]. He does not drink alcohol. HIV sexually transmitted. Family History: His mother had CVA/stroke. Physical Exam: Vitals on arrival to the MICU: T 99.2, 113, 116/73, 100% on PS [**5-3**] and FO2 General: sitting with eyes closed, trached on vent HEENT: Sclera anicteric, dry MM, poor dentition, left slightly greater tha right, both pupils reactive to light, arcus sensilus pupil (stable) Neck: hard to assess JVD, trached, connected to vent Lungs: rhonchorus, coarse rales; R-sided chest dressing c/d/i CV: regular fast rate, no murmurs appreciated Abdomen: + BS, soft, NTND, diffuse ecchymoses c/w lovenox shots; old sutures retained in LLQ (CDI); PEG site with minimal erythema and no discharge Skin: scattered, diffuse telangiectasias (not spiders) scatter on face/chest/limbs; friable skin with some areas of eschar on chest, do not appear superinfected Ext: warm, dry +PP no edema Neuro: sleepy, arouses when spoken to [**Last Name (un) **]; hard to understand paie witht PMV but he attept to answer questions Pertinent Results: ADMISSION LABS: Notable for lipase 215, BUN10, Cr 0.3, WBC 15.7 with 4% bands, Hct 25.4, plt 637 Lactate 1.0 AST: 97 ALT: 76 AP: 170 Tbili: 0.2 UA negative IMAGING: [**2147-9-3**] CT TORSO with contrast: 1. Small volume of pneumoperitoneum in the setting of interval recnetly placed percutaneous gastrostomy tube. Would correlate to the timing of the tube placement as this is a likely etiology if very recently placed. 2. Widespread reticular and ground-glass opacities as well as more dense consolidation in the left lung, progressed from the recent comparison study, concerning for infectious process. 3. Increased size and prevalence of multiple mediastinal lymph nodes, possibly reactive given the findings in the lungs. Followup upon resolution of symptoms is recommended. 4. Endobronchial material partially occluding the right mainstem bronchus, slightly increased since the previous study. 5. Trace pelvic free fluid. 6. Numerous spinal compression deformities, similar to the recent comparison. [**2147-9-4**] BRONCHIAL WASHING: -- negative for malignant cells [**2147-9-7**] BARIUM STUDY via PEG to evaluate for reflux/aspiration: No evidence of gastroesophageal reflux after injection barium through the patient's PEG tube. However, patient cooperation is required for complete evaluation for reflux and due to the patient's waxing and [**Doctor Last Name 688**] alertness, the study was limited. [**2147-9-8**]: BILATERAL LENI's No evidence of DVT in right or left lower extremity. [**2147-9-12**] CXR: Multifocal consolidation of left lung is stable since [**2147-9-8**]. MICROBIOLOGY: [**2147-9-3**] BLOOD CULTURES x 2: negative [**2147-9-4**] MYCOTIC BLOOD CULTURES: negative [**2147-9-7**] BLOOD CULTURE: negative [**2147-9-13**] BLOOD CULTURE: pending, NGTD [**2147-9-4**] URINE CULTURE: negative [**2147-9-4**] URINE LEGIONELLA: negative [**2147-9-4**] BRONCHIOALVEOLAR LAVAGE: RESPIRATORY CULTURE (Final [**2147-9-6**]): YEAST. 10,000-100,000 ORGANISMS/ML.. LEGIONELLA CULTURE (Final [**2147-9-11**]): NO LEGIONELLA ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [**2147-9-5**]): NO FUNGAL ELEMENTS SEEN. Immunoflourescent test for Pneumocystis jirovecii (carinii): NEGATIVE FUNGAL CULTURE (Preliminary): YEAST. OF TWO COLONIAL MORPHOLOGIES. NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED. VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary): No Virus isolated so far. ACID FAST SMEAR (Final [**2147-9-5**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. [**2147-9-4**] Beta-glucan: >500 pg/mL [**2147-9-8**] Beta-glucan: >500 pg/mL * Titers requested on [**2147-9-14**] on both of these above. Levels were pending on discharge. [**2147-9-4**] ASPERGILLUS GALACTOMANNAN ANTIGEN: 0.1 (negative) [**2147-9-8**] ASPERGILLUS GALACTOMANNAN ANTIGEN: 0.1 (negative) [**2147-9-14**] Voriconazole level: added on to am labs from [**9-14**]. Level penidng at discharge; it is a send out lab. Brief Hospital Course: Mr. [**Known lastname **] is a 70 yo M h/o HIV, (CD4 350 in [**5-8**] and VL undetect), SCC s/p RLL lobectomy [**8-7**] complicated by bronchopleural fistula involving aspergillosis treated with [**Last Name (un) 72968**] window- open to air, as well as empyema and invasive aspergillosis treated with voriconazole referred from [**Hospital1 **] [**Hospital1 8**] for hypotension and fever secondary to a recurrent pneumonia. # Hypotension/Pneumonia: He completed a 10 day course of vancomycin, ciprofloxacin and cefepime at rehab for HAP. Upon admission, he was started empirically on vancomycin, meropenem and ciprofloxacin, as well as voriconazole given his history of aspergillus infection. He completed an eight day course of vancomycin and meropenem. CT chest showed widespread reticular and ground-glass opacities as well as more dense consolidation in the left lung. A bronchoscopy was performed on [**2147-9-4**] that showed no evidence of malignancy or fungus. Bacterial cultures were negative, however several bacterial and fungal cultures were preliminary reports. Beta glucan test was >500 and Galactomanan was negative on two separate measures. Given these findings and the patient's history of aspergillus infection, the Infectious Disease doctors [**Name5 (PTitle) 2985**] the [**Name5 (PTitle) **] should remain on life long voriconazole. There is a voriconazole level and B glucan titer pending at time of discharge that will be followed by his ID physicians at [**Hospital1 18**]. Pt scheduled to f/u with Drs. [**First Name (STitle) **] and [**Name5 (PTitle) 9461**] in 2 weeks and 6 weeks. . # ASPIRATION: Barium study on [**2147-9-7**] showed no reflux, though it was a poor study because of inability to cooperate with valsalva manuver. Suspicion for recurrent aspiration remained high, especially because nursing staff noted bilious secretions. [**9-13**] an IR guided advancement of his gastric tube to post-pyloric positioning was performed without difficulty. Unfortunately, this tube broke and had to be replaced by IR on [**2147-9-14**]. It is recommended that patient remain on continuous tube feeding through the jejunal tube. . # ORAL SECRETIONS: Pt started on scopolamine patch to assist management of oral secretions. Would suggest continuing this medication. . # Anemia: patient's hematocrit remained in the low to mid-20s. He required one blood cell transfusion for a Hematocrit of 20.1. This was not felt to be active bleeding. He was started on iron supplements. His hematocrit should be trended in the rehab facility. Hct at discharge was 23.2. # HIV: continued on home HAART medications.Recommend continuing home HAART regimen and following up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 85243**]) after discharge from rehab. # CAD: Patient with known history of CAD s/p PCI. During admission he was continued on aspirin and statin. His metoprolol was restarted at a lower dose of 12.5 q 8 hours as his blood pressure could not tolerate higher doses. # BP fistula/[**Last Name (un) 72968**] Window: No evidence of infection during hospitalization. Dressing changes daily during hospitalization. Patient has a follow up scheduled with is thoracic surgeon. He will continue to require daily dressing changes. . # Nutrition: Nutren Pulmonary Full strength; Additives: Banana flakes, 3 packets per day; Starting rate: 20 ml/hr; Advance rate by 10 ml q4h Goal rate: 50 ml/hr Residual Check: q4h Hold feeding for residual >= : 150 ml Flush w/ 50 ml water q6h . # Respiratory Status: Would continue to wean off vent support as tolerated. Pt reports continued fatigue with prolonged periods of trach collar which likely represents muscle fatigue. . # Glycemic Control: FSBS QID with sliding scale insulin . # Lines: PICC on admission removed and new PICC placed [**2147-9-6**]. Tip grew coag negative staph considered a contaminant. . # Prophylaxis: - Continue lovenox 40 mg sc daily for DVT prophylaxis. - Continue ranitidine 150 mg daily for stress ulcer prophylaxis while on ventilator. - Continue VAP prophylaxis with mouth care [**Hospital1 **] while using ventilator # Contact: Sister [**Name (NI) 55745**] # [**Name2 (NI) 7092**] status: DNR (confirmed with sister [**Name (NI) 55745**] his HCP) PENDING ISSUES FOR FOLLOW-UP: 1. Voriconazole level from [**2147-9-14**] was pending at time of discharge. Voriconazole dosing should be tailored appropriately. 2. Beta-glucan titers from [**9-4**] and [**9-8**] were pending at time of discharge. These were ordered at the suggestion of the ID service consulting on him. They recommended voriconazole 300 mg [**Hospital1 **] for lifelong therapy (see above), though this may need to be adjusted pending results of the titers. Medications on Admission: Vancomycin, Meropenem, Ciprofloxacin --> restarted Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for yeast. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) inj Subcutaneous DAILY (Daily). Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for sob/wheeze. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for sob/wheeze. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Prednisone 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Sulfasalazine 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid Sig: Five (5) mL PO DAILY (Daily). Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). Escitalopram 10 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). Ranitidine HCl 15 mg/mL Syrup Sig: Ten (10) mL PO DAILY (Daily). Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Emtricitabine 200 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). Raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Acetaminophen 650 mg/20.3 mL Solution Sig: 1-2 doses PO Q6H (every 6 hours) as needed for fever. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 2-4 Puffs Inhalation Q6H (every 6 hours) as needed for SOB/Wheeze. Neutra-Phos 2 PKT PO/NG [**Hospital1 **] Sliding scale humalog insulin at meals and bedtime Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 3. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous DAILY (Daily). 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). 6. Sulfasalazine 500 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 8. Escitalopram 20 mg Tablet Sig: Two (2) Tablet PO once a day. 9. Ranitidine HCl 15 mg/mL Syrup Sig: One [**Age over 90 1230**]y (150) mg PO DAILY (Daily). 10. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1) Tablet PO at bedtime. 11. Emtricitabine 200 mg Capsule Sig: One (1) Capsule PO at bedtime. 12. Raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Prednisone 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 15. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for sob, wheezing. 16. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for sob, wheezing. 17. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72HR () as needed for secretions. 18. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8 hours) as needed for pain, headache. 19. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for sleep. 20. Voriconazole 200 mg Tablet Sig: 1.5 Tablets PO Q12H (every 12 hours). 21. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 22. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 23. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO Q 8H (Every 8 Hours). 24. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane [**Hospital1 **] (2 times a day) as needed for cleaning. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Primary: Aspiration Pneumonia Secondary: Respiratory Failure HIV H/o aspergillus infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Trached on vent Discharge Instructions: You were admitted for low blood pressure and a fever. You were found to have an aspiration pneumonia. We treated you with antibiotics. We also advance your gastric tube to help prevent aspiration. You tolerated this procedure well. The infectious disease doctors [**Name5 (PTitle) 2985**] [**Name5 (PTitle) **] should continue your anti-aspergillus antibiotic, voriconazole for life. Your medication changes include: START: 1. Voriconazole 300 mg twice per day 2. Scopolamine patch every 72 hours as needed for excess secretions 3. Trazadone 25 mg every evening as needed for insomnia 4. Ferrous Sulfate 300 mg daily DECREASE: 1. Metoprolol to 12.5 mg every eight hours Followup Instructions: Provider: [**Name10 (NameIs) 1532**] [**Last Name (NamePattern4) 8786**], MD Phone:[**Telephone/Fax (1) 3020**] Date/Time:[**2147-10-3**] 11:00 Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (Infectious Disease) Date/Time: [**2147-9-27**] at 10am Phone: [**Last Name (NamePattern1) 85244**], [**Hospital **] Medical Office Bldg . Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9461**] (Infectious Disease) Date/Time: [**2147-10-24**] at 11am Phone: [**Last Name (NamePattern1) 85244**], [**Hospital **] Medical Office Bldg Completed by:[**2147-9-14**]

038,785,042,507,518,510,117,428,255,995,276,285,V458,414,V440,V101,V554

{'Unspecified septicemia,Septic shock,Human immunodeficiency virus [HIV] disease,Pneumonitis due to inhalation of food or vomitus,Acute and chronic respiratory failure,Empyema with fistula,Aspergillosis,Chronic diastolic heart failure,Glucocorticoid deficiency,Severe sepsis,Hypovolemia,Anemia, unspecified,Percutaneous transluminal coronary angioplasty status,Coronary atherosclerosis of native coronary artery,Tracheostomy status,Personal history of malignant neoplasm of bronchus and lung,Attention to other artificial opening of digestive tract'}

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: Hypotension, fever PRESENT ILLNESS: Mr. [**Known firstname 2398**] [**Known lastname **] is a 70M with HIV (CD4 350 in [**5-8**]), SCC s/p RLL lobectomy [**8-7**] complicated by bronchopleural fistula treated with [**Last Name (un) 72968**] window, as well as empyema and invasive aspergillosis treated with voriconazole referred from [**Hospital1 **] [**Hospital1 8**] for hypotension and fever to 101.8. He was recently admitted from [**2147-8-7**] to [**2147-8-31**] with aspiration PNA, PCP pneumonia and septic shock. His antibiotic course of vanco/cefepime/cipro was completed on [**2147-9-2**]. He subsequently developed hypotension to 70/40, refractory to 5L IVF, on [**9-2**] the day prior to admission. This morning he was given doses of vanco/[**Last Name (un) 2830**]/cipro. MEDICAL HISTORY: -- trach and PEG placed last admission -History of multivessel CAD s/p PCI of the proximal left circumflex with a bare metal stent [**2143**] w/ Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Hospital 12017**] [**Hospital 12018**] Hospital) -HIV-infection, diagnosed in [**2137**], well-controlled. Currently on Truvada and Raltegravir. Last reported CD4 count 354 ([**2147-5-1**]), viral load <48 copies. Pt states that his VL has always been undetectable -Chronic LV dysfunction last EF 55% -Severe migratory polyarthritis, on prolonged high-dose steroid use for presumed "adrenal insufficiency" -moderate MR [**Name13 (STitle) 19667**] -herpes labialis -TMJ -B/L inguinal hernia repair -SCC s/p RLL lobectomy [**8-7**] complicated by bronchopleural fistula treated with [**Last Name (un) 72968**] window, as well as empyema and invasive aspergillosis MEDICATION ON ADMISSION: Vancomycin, Meropenem, Ciprofloxacin --> restarted Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for yeast. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) inj Subcutaneous DAILY (Daily). Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for sob/wheeze. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for sob/wheeze. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Prednisone 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Sulfasalazine 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid Sig: Five (5) mL PO DAILY (Daily). Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). Escitalopram 10 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). Ranitidine HCl 15 mg/mL Syrup Sig: Ten (10) mL PO DAILY (Daily). Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Emtricitabine 200 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). Raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Acetaminophen 650 mg/20.3 mL Solution Sig: 1-2 doses PO Q6H (every 6 hours) as needed for fever. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 2-4 Puffs Inhalation Q6H (every 6 hours) as needed for SOB/Wheeze. Neutra-Phos 2 PKT PO/NG [**Hospital1 **] Sliding scale humalog insulin at meals and bedtime ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Vitals on arrival to the MICU: T 99.2, 113, 116/73, 100% on PS [**5-3**] and FO2 General: sitting with eyes closed, trached on vent HEENT: Sclera anicteric, dry MM, poor dentition, left slightly greater tha right, both pupils reactive to light, arcus sensilus pupil (stable) Neck: hard to assess JVD, trached, connected to vent Lungs: rhonchorus, coarse rales; R-sided chest dressing c/d/i CV: regular fast rate, no murmurs appreciated Abdomen: + BS, soft, NTND, diffuse ecchymoses c/w lovenox shots; old sutures retained in LLQ (CDI); PEG site with minimal erythema and no discharge Skin: scattered, diffuse telangiectasias (not spiders) scatter on face/chest/limbs; friable skin with some areas of eschar on chest, do not appear superinfected Ext: warm, dry +PP no edema Neuro: sleepy, arouses when spoken to [**Last Name (un) **]; hard to understand paie witht PMV but he attept to answer questions FAMILY HISTORY: His mother had CVA/stroke. SOCIAL HISTORY: Currently residing in [**Hospital **] [**Hospital 8**] Rehabilitation. The patient is not married and lives alone. He has a history of 150 pack-year, stopped smoking in [**2143**]. He does not drink alcohol. HIV sexually transmitted. ### Response: {'Unspecified septicemia,Septic shock,Human immunodeficiency virus [HIV] disease,Pneumonitis due to inhalation of food or vomitus,Acute and chronic respiratory failure,Empyema with fistula,Aspergillosis,Chronic diastolic heart failure,Glucocorticoid deficiency,Severe sepsis,Hypovolemia,Anemia, unspecified,Percutaneous transluminal coronary angioplasty status,Coronary atherosclerosis of native coronary artery,Tracheostomy status,Personal history of malignant neoplasm of bronchus and lung,Attention to other artificial opening of digestive tract'}

CHIEF COMPLAINT: Choledocholithiasis. PRESENT ILLNESS: The patient is an 89-year-old female who was transferred from [**Hospital 5871**] [**Hospital 12018**] Medical Center in [**Location (un) 5871**], Mass. The patient was admitted there on [**2106-3-30**] with concerns of biliary colic. Her initial abdominal/pelvic CT noted cholelithiasis. Pain was relieved with multiple doses of narcotics and bowel rest. She had an elevated white blood cell count and low grade fever and was started empirically on IV Levaquin and Flagyl for possible early cholangitis. She underwent a MRCP which revealed marked common bile duct dilatation with large stones in both the cystic duct and the common bile duct. Dr. [**Last Name (STitle) **] at [**Hospital1 18**] was consulted with and accepted the patient in transfer to [**Hospital1 **] for high risk ERCP. On ERCP, there was a large esophageal diverticulum at 33 cm. There was also a large paraesophageal hernia at the distal esophagus and a large periampullary diverticulum with mildly dilated proximal PD. She had a common bile duct grossly dilated, suggestive of choledochal cyst. A large 5 cm stone within the common bile duct. The intra-hepatic ducts were not significantly dilated. Sphincterotomy was not performed at that time due to the patient being on Lovenox for new bundle branch block. She was referred to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and it was noted that LFTs trended down after her ERCP. MEDICAL HISTORY: Significant for hypertension and hyperthyroidism. MEDICATION ON ADMISSION: ALLERGIES: The patient is allergic to penicillin and shellfish. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: The patient lives alone. She has 5 children. She is Catholic, nonsmoker and no recreational drug use. Drinks two to three drinks per week.

Calculus of gallbladder and bile duct with other cholecystitis, with obstruction,Pulmonary collapse,Atrial fibrillation,Thyrotoxicosis without mention of goiter or other cause, and without mention of thyrotoxic crisis or storm,Unspecified essential hypertension

Gall&bil cal w/oth w obs,Pulmonary collapse,Atrial fibrillation,Thyrotox NOS no crisis,Hypertension NOS

Admission Date: [**2106-5-19**] Discharge Date: [**2106-5-24**] Service: [**Last Name (un) **] CHIEF COMPLAINT: Choledocholithiasis. HISTORY OF PRESENT ILLNESS: The patient is an 89-year-old female who was transferred from [**Hospital 5871**] [**Hospital 12018**] Medical Center in [**Location (un) 5871**], Mass. The patient was admitted there on [**2106-3-30**] with concerns of biliary colic. Her initial abdominal/pelvic CT noted cholelithiasis. Pain was relieved with multiple doses of narcotics and bowel rest. She had an elevated white blood cell count and low grade fever and was started empirically on IV Levaquin and Flagyl for possible early cholangitis. She underwent a MRCP which revealed marked common bile duct dilatation with large stones in both the cystic duct and the common bile duct. Dr. [**Last Name (STitle) **] at [**Hospital1 18**] was consulted with and accepted the patient in transfer to [**Hospital1 **] for high risk ERCP. On ERCP, there was a large esophageal diverticulum at 33 cm. There was also a large paraesophageal hernia at the distal esophagus and a large periampullary diverticulum with mildly dilated proximal PD. She had a common bile duct grossly dilated, suggestive of choledochal cyst. A large 5 cm stone within the common bile duct. The intra-hepatic ducts were not significantly dilated. Sphincterotomy was not performed at that time due to the patient being on Lovenox for new bundle branch block. She was referred to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and it was noted that LFTs trended down after her ERCP. PAST MEDICAL HISTORY: Significant for hypertension and hyperthyroidism. MEDICATIONS AT HOME: Atenolol 25 mg daily; triamterene/hydrochlorothiazide 37.5/25 mg p.o. daily; Ursodiol 300 mg p.o. b.i.d., aspirin 81 mg once a day, calcium, vitamin D and multivitamin once a day. ALLERGIES: The patient is allergic to penicillin and shellfish. There is a past medical history of vaginal hysterectomy in [**2079**]. Osteoporosis; hiatal hernia with reflux. SOCIAL HISTORY: The patient lives alone. She has 5 children. She is Catholic, nonsmoker and no recreational drug use. Drinks two to three drinks per week. HOSPITAL COURSE: She was taken to the OR on [**2106-5-19**] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and underwent Roux-en-Y choledochojejunostomy, common bile duct exploration. Attending was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] under general anesthesia. Please see operative report for further details. Postoperatively she did well. Her pain was controlled with PCA, Dilaudid and one dose of Toradol. Her vital signs were stable. She was initially n.p.o. She remained on IV Flagyl and Levaquin. Her urine output was a little on the low side postoperatively. She also had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 406**] drain draining serosanguineous fluid. Her [**Doctor First Name **] was calculated; it was less than 1. Urine output averaged between 15-35 cc an hour. On postop day 2, she spiked a temperature to 101. Blood cultures and urine cultures were drawn. Blood cultures were negative to date as well as a urine culture which was negative. Her urinalysis was negative. A chest x-ray at that time showed postoperative appearance with low lung volumes and bibasilar atelectasis but no definite focal consolidation. She was given incentive spirometer with encouragement to use this. She was also assisted out of bed and she ambulated. Her LFTs trended down. Her diet was advanced. On postop day #3, she had an episode of AFib overnight which converted to sinus rhythm. She continued on atenolol 25 mg once a day for this for rate control. Her incision appeared well approximated and was clean and dry. Her abdomen appeared soft with positive bowel sounds. On postop day #6 vital signs were stable. She was ambulatory with assistance. Abdomen was soft. JP drain was removed. She had a bowel movement and she was tolerating her diet fair. Appetite was poor. She was given supplements which she was drinking. Plan is for her to home with VNA for home safety check and assessment for home health aide. Follow-up appointment was scheduled with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in the outpatient clinic for [**5-29**] at 2:30. DISCHARGE MEDICATIONS: 1. Ursodiol 300 mg 1 capsule p.o. b.i.d. 2. Triamterene hydrochlorothiazide 37.5/25 mg p.o. daily. 3. Atenolol 25 mg one daily. 4. Ibuprofen 400 mg 1 tablet p.o. q.8h. 5. Hydromorphone 2 mg tabs [**1-26**] tablet p.o. p.r.n. q. [**3-28**] hours as needed for pain. 6. Aspirin 81 mg once a day. 7. Colace 100 mg p.o. b.i.d. while taking pain medication. DISCHARGE DIAGNOSES: Cholelithiasis with multiple intra- hepatic stones. CONDITION ON DISCHARGE: Stable. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**] Dictated By:[**Name8 (MD) 4664**] MEDQUIST36 D: [**2106-5-24**] 15:22:40 T: [**2106-5-25**] 05:24:16 Job#: [**Job Number 72068**]

574,518,427,242,401

{'Calculus of gallbladder and bile duct with other cholecystitis, with obstruction,Pulmonary collapse,Atrial fibrillation,Thyrotoxicosis without mention of goiter or other cause, and without mention of thyrotoxic crisis or storm,Unspecified essential hypertension'}

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: Choledocholithiasis. PRESENT ILLNESS: The patient is an 89-year-old female who was transferred from [**Hospital 5871**] [**Hospital 12018**] Medical Center in [**Location (un) 5871**], Mass. The patient was admitted there on [**2106-3-30**] with concerns of biliary colic. Her initial abdominal/pelvic CT noted cholelithiasis. Pain was relieved with multiple doses of narcotics and bowel rest. She had an elevated white blood cell count and low grade fever and was started empirically on IV Levaquin and Flagyl for possible early cholangitis. She underwent a MRCP which revealed marked common bile duct dilatation with large stones in both the cystic duct and the common bile duct. Dr. [**Last Name (STitle) **] at [**Hospital1 18**] was consulted with and accepted the patient in transfer to [**Hospital1 **] for high risk ERCP. On ERCP, there was a large esophageal diverticulum at 33 cm. There was also a large paraesophageal hernia at the distal esophagus and a large periampullary diverticulum with mildly dilated proximal PD. She had a common bile duct grossly dilated, suggestive of choledochal cyst. A large 5 cm stone within the common bile duct. The intra-hepatic ducts were not significantly dilated. Sphincterotomy was not performed at that time due to the patient being on Lovenox for new bundle branch block. She was referred to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and it was noted that LFTs trended down after her ERCP. MEDICAL HISTORY: Significant for hypertension and hyperthyroidism. MEDICATION ON ADMISSION: ALLERGIES: The patient is allergic to penicillin and shellfish. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: The patient lives alone. She has 5 children. She is Catholic, nonsmoker and no recreational drug use. Drinks two to three drinks per week. ### Response: {'Calculus of gallbladder and bile duct with other cholecystitis, with obstruction,Pulmonary collapse,Atrial fibrillation,Thyrotoxicosis without mention of goiter or other cause, and without mention of thyrotoxic crisis or storm,Unspecified essential hypertension'}

CHIEF COMPLAINT: The patient was transferred for further management of ventilatory failure and persistent right pneumothorax. The patient was transferred from [**Hospital3 15402**] Medical Center. PRESENT ILLNESS: This is a 36 year old female with recently diagnosed AIDS admitted on [**2174-1-12**], to [**Hospital6 16522**] with diffuse interstitial infiltrates. The patient had respiratory failure and was intubated on [**2174-1-13**]. She was diagnosed with PCP [**Last Name (NamePattern4) **] [**2174-1-14**], by bronchoscopy. The patient was initially started on Bactrim and steroids, but had a rise in her liver function tests and was changed subsequently to Clindamycin and *************** and then subsequently to Pentamidine due to lack of clinical improvement. The patient's hospitalization at [**Hospital3 15402**] was complicated by a left sided pneumothorax about 10 to 15% secondary to subclavian catheter placement on [**2174-2-13**], with two chest tubes placed at the time. The patient then suffered a right sided pneumothorax on [**2174-2-3**], and subsequently had three chest tubes placed with residual 50% pneumothorax. The patient's hospitalization at [**Hospital3 15402**] was also complicated by ventilatory failure. They had difficulty with ventilation. The patient's clinical status continued to deteriorate. They had attempted to reverse the patient's I:E ratio and had to use increased amounts of PEEP. The patient underwent tracheostomy on [**2174-2-1**]. The patient initially improved slightly, was off paralytics but was extremely weak. Subsequently, the patient was stable on assist control, tidal volumes of 300, PEEP 7.5, FIO2 70%. Subsequently, the patient suffered the pneumothorax on the right on [**2174-2-3**], and subsequently had to go back to pressure enteral ventilation. The patient also had line sepsis at the outside hospital with Enterobacter cloacae. The patient was treated with Vancomycin and Imipenem for this. The patient was also febrile to 101 on the day prior to transfer from [**Hospital6 41391**]. The patient also had an episode of asystolic arrest on [**2174-1-27**], due to mucous plugging in early [**Month (only) 956**] which resolved with aggressive suctioning. The patient had a history of transaminitis as well which was attributed to Bactrim at the outside hospital. The patient was newly diagnosed with AIDS on Bactrim and Azithromycin for prophylaxis as well as HAART. The patient was also on a prolonged course of steroids initially due to PCP [**Name Initial (PRE) 2**]. The patient was transferred for further management of the right sided pneumothorax and difficulty with ventilation. MEDICAL HISTORY: 1. HIV/AIDS acquired from intravenous drug abuse diagnosed in [**10-30**], with CD4 of 10, viral load of 6631. 2. History of intravenous drug use. 3. Hepatitis C. 4. Asthma. 5. History of supraventricular tachycardia. MEDICATION ON ADMISSION: ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: The patient has a history of former intravenous drug abuse who has a history of confirmed "Do Not Resuscitate" as her code status.

Iatrogenic pneumothorax,Human immunodeficiency virus [HIV] disease,Pneumocystosis,Empyema with fistula,Infection and inflammatory reaction due to other vascular device, implant, and graft,Unspecified septicemia

Iatrogenic pneumothorax,Human immuno virus dis,Pneumocystosis,Empyema with fistula,React-oth vasc dev/graft,Septicemia NOS

Admission Date: [**2174-2-27**] Discharge Date: [**2174-3-5**] Date of Birth: [**2137-5-13**] Sex: F Service: FENNARD-ICU CHIEF COMPLAINT: The patient was transferred for further management of ventilatory failure and persistent right pneumothorax. The patient was transferred from [**Hospital3 15402**] Medical Center. HISTORY OF PRESENT ILLNESS: This is a 36 year old female with recently diagnosed AIDS admitted on [**2174-1-12**], to [**Hospital6 16522**] with diffuse interstitial infiltrates. The patient had respiratory failure and was intubated on [**2174-1-13**]. She was diagnosed with PCP [**Last Name (NamePattern4) **] [**2174-1-14**], by bronchoscopy. The patient was initially started on Bactrim and steroids, but had a rise in her liver function tests and was changed subsequently to Clindamycin and *************** and then subsequently to Pentamidine due to lack of clinical improvement. The patient's hospitalization at [**Hospital3 15402**] was complicated by a left sided pneumothorax about 10 to 15% secondary to subclavian catheter placement on [**2174-2-13**], with two chest tubes placed at the time. The patient then suffered a right sided pneumothorax on [**2174-2-3**], and subsequently had three chest tubes placed with residual 50% pneumothorax. The patient's hospitalization at [**Hospital3 15402**] was also complicated by ventilatory failure. They had difficulty with ventilation. The patient's clinical status continued to deteriorate. They had attempted to reverse the patient's I:E ratio and had to use increased amounts of PEEP. The patient underwent tracheostomy on [**2174-2-1**]. The patient initially improved slightly, was off paralytics but was extremely weak. Subsequently, the patient was stable on assist control, tidal volumes of 300, PEEP 7.5, FIO2 70%. Subsequently, the patient suffered the pneumothorax on the right on [**2174-2-3**], and subsequently had to go back to pressure enteral ventilation. The patient also had line sepsis at the outside hospital with Enterobacter cloacae. The patient was treated with Vancomycin and Imipenem for this. The patient was also febrile to 101 on the day prior to transfer from [**Hospital6 41391**]. The patient also had an episode of asystolic arrest on [**2174-1-27**], due to mucous plugging in early [**Month (only) 956**] which resolved with aggressive suctioning. The patient had a history of transaminitis as well which was attributed to Bactrim at the outside hospital. The patient was newly diagnosed with AIDS on Bactrim and Azithromycin for prophylaxis as well as HAART. The patient was also on a prolonged course of steroids initially due to PCP [**Name Initial (PRE) 2**]. The patient was transferred for further management of the right sided pneumothorax and difficulty with ventilation. PAST MEDICAL HISTORY: 1. HIV/AIDS acquired from intravenous drug abuse diagnosed in [**10-30**], with CD4 of 10, viral load of 6631. 2. History of intravenous drug use. 3. Hepatitis C. 4. Asthma. 5. History of supraventricular tachycardia. MEDICATIONS ON TRANSFER FROM OUTSIDE HOSPITAL: 1. Heparin subcutaneous 5,000 units twice a day. 2. Multivitamin. 3. Aqua Tears four times a day. 4. Prilosec 20 mg twice a day. 5. Free water boluses, 250 cc three times a day. 6. Diflucan 100 mg p.o. once daily. 7. Zerit 30 mg p.o. twice a day. 8. Lopressor 25 mg p.o. twice a day. 9. Imipenem 500 mg intravenous q6hours. 10. Sliding scale insulin. 11. Zithromax 1200 mg p.o. q.week. 12. Nevirapine 200 mg p.o. twice a day. 13. Solu-Medrol 40 mg intravenously once daily. 14. Vancomycin one gram intravenous q12hours. 15. Morphine Sulfate drip at 4 mcg/hour. 16. Ativan 3 mg per hour. 17. Limbics gtts 20 mcg/kg/hour. 18. Bactrim single strength one tablet p.o. once daily. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient has a history of former intravenous drug abuse who has a history of confirmed "Do Not Resuscitate" as her code status. PHYSICAL EXAMINATION: In general, vital signs revealed temperature 101.4, pulse 123, respiratory rate 30, blood pressure 118/74, pressure control ventilation with PEEP of 5, FIO2 70%, 300 tidal volume. I:E ratio set at 1.0 to 1.5, oxygen saturation 96%. Head, eyes, ears, nose and throat examination - The mucous membranes were dry. The patient was intubated and sedated. Neck - The patient had a tracheostomy collar in place. Right IJ in place. Pulmonary - There were decreased breath sounds in the right apex. The patient had three chest tubes placed at the outside hospital. Cardiovascular - The patient was tachycardia, no rubs or gallops were appreciated. The abdomen was soft, slightly distended, hypoactive bowel sounds. Extremities were without edema. Neurologically, the patient was paralyzed. LABORATORY DATA: On admission, white blood cell count 2.0, hematocrit 30, platelets 279,000. Sodium 134, potassium 4.4, chloride 90, bicarbonate 38, blood urea nitrogen 11, creatinine 0.1, blood glucose 143. Calcium 9.0, magnesium 1.6, phosphorus 1.7. Arterial blood gases revealed pH 7.49, pCO2 49, pO2 76. Electrocardiogram on [**2174-2-27**], showed sinus tachycardia at a rate of 130, tall P waves in the precordium, T wave inversions in lead I and aVL. Chest x-ray at the outside hospital on [**2174-2-27**], showed diffuse dense bilateral interstitial infiltrates without significant pleural effusions. HOSPITAL COURSE: The patient was admitted from [**Hospital6 41391**] to Fennard Intensive Care Unit in ventilatory failure. The patient was attempted high frequency oscillatory ventilation for several days to manage her bronchofistula as well as her difficulty in ventilation. It was felt this was most likely due to pneumothorax, the chest tubes and the PCP all contributing. The patient had a chest CT done which showed one of the chest tubes not within the thorax, the others abutting the mediastinum and appropriate positions. There were extensive destructive bullous changes within both lungs, most severe on the right. There was complete consolidation with ground glass opacities within both lungs. The differential diagnosis includes adult respiratory distress syndrome and infection. There was left adrenal nodularity which was felt to be likely normal variant. There was subsequent air in the anterior chest. There was a large right pneumothorax on the chest CT. Chest x-ray showed tracheostomy, IJ and gastrostomy tube in appropriate position, large pneumothorax with three chest tubes on the right, extensive bilateral diffuse opacities in both lungs. High frequency oscillation was attempted for several days with minimal improvement of the patient's pulmonary status. The patient continued to have increased oxygen requirements and had worsening hypercapnia. In accordance with the family's wishes, the patient was given a trial of high frequency oscillatory ventilation for a total of five days. Subsequently, the family decided to withdraw ventilatory support on [**2174-3-5**], and the patient was subsequently pronounced at 8:20 p.m. after ventilatory support was discontinued. Infectious disease - For the patient's PCP the patient was continued on Bactrim and Azithromycin as well as HAART discontinued as per the infectious disease team recommendations. The patient was continued on Imipenem. The patient was initially treated with Flagyl for questionable history of C. difficile. C. difficile toxins were negative. The patient remained febrile without any further clear sources. The patient was covered on broad spectrum antibiotics. Gastrointestinal - The patient has a history of transaminitis felt most likely to be related to Bactrim versus the patient's history of hepatitis C. No further workup was done. The patient did not have any gastrointestinal bleed or any disturbance in her hepatic function. Cardiovascular - The patient remained tachycardic throughout the hospital stay. This was felt likely to be due to the patient's concurrent infection and the patient's history of supraventricular tachycardia. No beta blockers were given. It was felt that this patient was in sinus tachycardia. The patient had ventilatory support discontinued on [**2174-3-5**], as noted above and the patient was pronounced on [**2174-3-5**], at 8:20 p.m. The family was present at the time ventilatory support was discontinued. The family declined postmortem examination. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3851**] Dictated By:[**Name8 (MD) 9784**] MEDQUIST36 D: [**2174-8-24**] 18:55 T: [**2174-8-24**] 19:16 JOB#: [**Job Number **]

512,042,136,510,996,038

{'Iatrogenic pneumothorax,Human immunodeficiency virus [HIV] disease,Pneumocystosis,Empyema with fistula,Infection and inflammatory reaction due to other vascular device, implant, and graft,Unspecified septicemia'}

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: The patient was transferred for further management of ventilatory failure and persistent right pneumothorax. The patient was transferred from [**Hospital3 15402**] Medical Center. PRESENT ILLNESS: This is a 36 year old female with recently diagnosed AIDS admitted on [**2174-1-12**], to [**Hospital6 16522**] with diffuse interstitial infiltrates. The patient had respiratory failure and was intubated on [**2174-1-13**]. She was diagnosed with PCP [**Last Name (NamePattern4) **] [**2174-1-14**], by bronchoscopy. The patient was initially started on Bactrim and steroids, but had a rise in her liver function tests and was changed subsequently to Clindamycin and *************** and then subsequently to Pentamidine due to lack of clinical improvement. The patient's hospitalization at [**Hospital3 15402**] was complicated by a left sided pneumothorax about 10 to 15% secondary to subclavian catheter placement on [**2174-2-13**], with two chest tubes placed at the time. The patient then suffered a right sided pneumothorax on [**2174-2-3**], and subsequently had three chest tubes placed with residual 50% pneumothorax. The patient's hospitalization at [**Hospital3 15402**] was also complicated by ventilatory failure. They had difficulty with ventilation. The patient's clinical status continued to deteriorate. They had attempted to reverse the patient's I:E ratio and had to use increased amounts of PEEP. The patient underwent tracheostomy on [**2174-2-1**]. The patient initially improved slightly, was off paralytics but was extremely weak. Subsequently, the patient was stable on assist control, tidal volumes of 300, PEEP 7.5, FIO2 70%. Subsequently, the patient suffered the pneumothorax on the right on [**2174-2-3**], and subsequently had to go back to pressure enteral ventilation. The patient also had line sepsis at the outside hospital with Enterobacter cloacae. The patient was treated with Vancomycin and Imipenem for this. The patient was also febrile to 101 on the day prior to transfer from [**Hospital6 41391**]. The patient also had an episode of asystolic arrest on [**2174-1-27**], due to mucous plugging in early [**Month (only) 956**] which resolved with aggressive suctioning. The patient had a history of transaminitis as well which was attributed to Bactrim at the outside hospital. The patient was newly diagnosed with AIDS on Bactrim and Azithromycin for prophylaxis as well as HAART. The patient was also on a prolonged course of steroids initially due to PCP [**Name Initial (PRE) 2**]. The patient was transferred for further management of the right sided pneumothorax and difficulty with ventilation. MEDICAL HISTORY: 1. HIV/AIDS acquired from intravenous drug abuse diagnosed in [**10-30**], with CD4 of 10, viral load of 6631. 2. History of intravenous drug use. 3. Hepatitis C. 4. Asthma. 5. History of supraventricular tachycardia. MEDICATION ON ADMISSION: ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: The patient has a history of former intravenous drug abuse who has a history of confirmed "Do Not Resuscitate" as her code status. ### Response: {'Iatrogenic pneumothorax,Human immunodeficiency virus [HIV] disease,Pneumocystosis,Empyema with fistula,Infection and inflammatory reaction due to other vascular device, implant, and graft,Unspecified septicemia'}

CHIEF COMPLAINT: EKG changes PRESENT ILLNESS: 86 yo female with COPD, pulm HTN, TR who presented to OSH after a stranger knocked into her at her [**Hospital3 **] facility causing her to fall and fracture her left hip. She did not have any LOC. In addition, she sustained a laceration to her right lower leg and received 6 stiches at OSH. At OSH, pt had CT scan of Left hip which showed a cervical neck fracture of the left proximal femur. She had a routine pre-op evaluation; however her pre-op EKG showed ST elevations in V2-V4. The patient was completely asymptomatic. She denied chest pain or pressure. Her SOB was at baseline. She did have some nausea, vomiting and diaphoresis at the OSH. She was transferred to [**Hospital1 18**] for cardiac cath. Her cardiac cath earlier today showed clean coronaries. The patient tolerated the procedure without complication. The orthopedic team was consulted for management of her hip fracture. . The patient denies any chest pain or pressure currently. She reports that she does not want to undergo hip repair despite being informed of the risks. She refuses to go to get x-rays for further evaluation. . ROS: She denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, or hemoptysis. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. Has occasional abdominal pain, alternating diarrhea and constipation but has not had a colonoscopy, occasional blood in stool with straining. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. MEDICAL HISTORY: Pulmonary HTN Tricuspid regurgitation CPD Osteoporosis c/b thoracic spine fracture resulting in chronic mid back pain Hypertension h/o pyelonephritis h/o left hydronephrosis of uncertain eitology h/o pneumonia - required stay in rehab prior to transfer to [**Hospital3 **] s/p appendectomy s/p oophrectomy MEDICATION ON ADMISSION: Celexa 10mg PO daily Omeprazole 20mg PO daily Senna 2 tabs daily at 4pm Lisinopril 5 mg PO daily Lidoderm 5% patch, one patch to lower back 12 hrs each day Calcium with Vit D 600mg PO BID Tylenol 650mg Q4hrs PRN for pain Compazine 10mg PO BID PRN nausea/vomiting Ibuprofen prn ALLERGIES: No Drug Allergy Information on File PHYSICAL EXAM: ADMISSION PHYSICAL EXAM VS: T=98.1 BP=102/49 HR=63 RR=15 O2 sat=96% 4L GENERAL: thin elderly female in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. FAMILY HISTORY: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. SOCIAL HISTORY: She lives in an [**Hospital3 **] facility at [**Location (un) 582**]. Had been living independently until 3 months ago when she had a pneumonia and required inpatient rehab prior to her transfer to [**Hospital 4382**]. Son is an administrator and internist at [**Hospital1 3325**]. Has 2 daughters who live locally. -Tobacco history: She started smoking as a teenager and quit smoking 3 months ago. -ETOH: denies -Illicit drugs: denies

Nonspecific abnormal electrocardiogram [ECG] [EKG],Other pulmonary embolism and infarction,Unspecified pleural effusion,Closed fracture of unspecified part of neck of femur,Other chronic pulmonary heart diseases,Diseases of tricuspid valve,Fall resulting in striking against other object,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other emphysema,Unspecified essential hypertension,Osteoporosis, unspecified,Esophageal reflux,Hyperpotassemia

Abnorm electrocardiogram,Pulm embol/infarct NEC,Pleural effusion NOS,Fx neck of femur NOS-cl,Chr pulmon heart dis NEC,Tricuspid valve disease,Fall striking object NEC,DMII wo cmp nt st uncntr,Emphysema NEC,Hypertension NOS,Osteoporosis NOS,Esophageal reflux,Hyperpotassemia

Admission Date: [**2126-4-12**] Discharge Date: [**2126-4-14**] Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 1515**] Chief Complaint: EKG changes Major Surgical or Invasive Procedure: Cardiac catheterization [**2126-4-12**] History of Present Illness: 86 yo female with COPD, pulm HTN, TR who presented to OSH after a stranger knocked into her at her [**Hospital3 **] facility causing her to fall and fracture her left hip. She did not have any LOC. In addition, she sustained a laceration to her right lower leg and received 6 stiches at OSH. At OSH, pt had CT scan of Left hip which showed a cervical neck fracture of the left proximal femur. She had a routine pre-op evaluation; however her pre-op EKG showed ST elevations in V2-V4. The patient was completely asymptomatic. She denied chest pain or pressure. Her SOB was at baseline. She did have some nausea, vomiting and diaphoresis at the OSH. She was transferred to [**Hospital1 18**] for cardiac cath. Her cardiac cath earlier today showed clean coronaries. The patient tolerated the procedure without complication. The orthopedic team was consulted for management of her hip fracture. . The patient denies any chest pain or pressure currently. She reports that she does not want to undergo hip repair despite being informed of the risks. She refuses to go to get x-rays for further evaluation. . ROS: She denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, or hemoptysis. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. Has occasional abdominal pain, alternating diarrhea and constipation but has not had a colonoscopy, occasional blood in stool with straining. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: Pulmonary HTN Tricuspid regurgitation CPD Osteoporosis c/b thoracic spine fracture resulting in chronic mid back pain Hypertension h/o pyelonephritis h/o left hydronephrosis of uncertain eitology h/o pneumonia - required stay in rehab prior to transfer to [**Hospital3 **] s/p appendectomy s/p oophrectomy Social History: She lives in an [**Hospital3 **] facility at [**Location (un) 582**]. Had been living independently until 3 months ago when she had a pneumonia and required inpatient rehab prior to her transfer to [**Hospital 4382**]. Son is an administrator and internist at [**Hospital1 3325**]. Has 2 daughters who live locally. -Tobacco history: She started smoking as a teenager and quit smoking 3 months ago. -ETOH: denies -Illicit drugs: denies Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION PHYSICAL EXAM VS: T=98.1 BP=102/49 HR=63 RR=15 O2 sat=96% 4L GENERAL: thin elderly female in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with no JVD. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: LLE shortened and externally rotated. No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: [**2126-4-12**] 09:28PM BLOOD WBC-10.4 RBC-3.87* Hgb-12.0 Hct-36.9 MCV-95 MCH-31.0 MCHC-32.5 RDW-13.5 Plt Ct-259 [**2126-4-13**] 03:58AM BLOOD WBC-10.5 RBC-3.75* Hgb-11.7* Hct-35.4* MCV-94 MCH-31.2 MCHC-33.1 RDW-13.4 Plt Ct-235 [**2126-4-12**] 09:28PM BLOOD Glucose-123* UreaN-27* Creat-1.2* Na-132* K-5.5* Cl-101 HCO3-26 AnGap-11 [**2126-4-13**] 03:58AM BLOOD Glucose-105 UreaN-28* Creat-1.2* Na-133 K-5.5* Cl-101 HCO3-28 AnGap-10 [**2126-4-13**] 01:24PM BLOOD Glucose-158* UreaN-27* Creat-1.1 Na-135 K-4.2 Cl-103 HCO3-25 AnGap-11 [**2126-4-12**] 09:28PM BLOOD CK(CPK)-52 [**2126-4-13**] 03:58AM BLOOD CK(CPK)-41 [**2126-4-13**] 01:24PM BLOOD proBNP-[**Numeric Identifier 82170**]* [**2126-4-12**] 09:28PM BLOOD Mg-1.9 [**2126-4-13**] 03:58AM BLOOD Calcium-9.0 Phos-3.7 Mg-2.0 [**2126-4-13**] 01:24PM BLOOD Mg-1.8 [**2126-4-12**] 02:26PM BLOOD Type-ART O2 Flow-100 pO2-319* pCO2-58* pH-7.26* calTCO2-27 Base XS--1 [**2126-4-12**] 02:46PM BLOOD Type-ART pO2-74* pCO2-54* pH-7.27* calTCO2-26 Base XS--2 Intubat-NOT INTUBA . Cardiac Catheterization [**2126-4-12**] 1. Coronary angiography in this right-dominant system revealed: --the LMCA had no angiographically apparent disease --the LAD had no angiographically apparent disease --the LCX had no angiographically apparent disease --the RCA had a calcified proximal 50% stenosis. 2. Limited resting hemodynamics revealed elevated systemic arterial systolic pressures, with SBP 156 mmHg. FINAL DIAGNOSIS: 1. No obstructive CAD 2. Moderate systemic arterial systolic hypertension. . [**2126-4-12**] TTE Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Four Chamber Length: 4.7 cm <= 5.2 cm Right Atrium - Four Chamber Length: 4.3 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 0.8 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 3.1 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 1.8 cm Left Ventricle - Fractional Shortening: 0.42 >= 0.29 Left Ventricle - Ejection Fraction: 70% >= 55% Left Ventricle - Lateral Peak E': 0.10 m/s > 0.08 m/s Left Ventricle - Septal Peak E': *0.07 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 9 < 15 Aortic Valve - Peak Velocity: 1.3 m/sec <= 2.0 m/sec Mitral Valve - E Wave: 0.8 m/sec Mitral Valve - A Wave: 1.3 m/sec Mitral Valve - E/A ratio: 0.62 Mitral Valve - E Wave deceleration time: 235 ms 140-250 ms TR Gradient (+ RA = PASP): *59 to 66 mm Hg <= 25 mm Hg Findings LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Increased IVC diameter (>2.1cm) with <35% decrease during respiration (estimated RA pressure (10-20mmHg). LEFT VENTRICLE: Normal LV wall thickness. Small LV cavity. Overall normal LVEF (>55%). No resting LVOT gradient. RIGHT VENTRICLE: RV hypertrophy. Dilated RV cavity. Borderline normal RV systolic function. Abnormal systolic septal motion/position consistent with RV pressure overload. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. AORTIC VALVE: Moderately thickened aortic valve leaflets. Minimal AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Moderate mitral annular calcification. Mild thickening of mitral valve chordae. Calcified tips of papillary muscles. No MS. LV inflow pattern c/w impaired relaxation. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Normal tricuspid valve supporting structures. No TS. Moderate to severe [3+] TR. Severe PA systolic hypertension. PERICARDIUM: No pericardial effusion. Conclusions The left atrium is normal in size. The estimated right atrial pressure is 10-20mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity is small. Overall left ventricular systolic function is normal (LVEF 70%). The right ventricular free wall is hypertrophied. The right ventricular cavity is dilated with borderline normal free wall function. There is abnormal systolic septal motion/position consistent with right ventricular pressure overload. The aortic valve leaflets are moderately thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. . [**2126-4-13**] CXR The lung volumes are near normal, the hemidiaphragms are relatively low, but not flattened. Moderate scoliosis leads to asymmetry of the rib cage. In both lungs, right more than left, a reticular pattern of opacities is seen in both perihilar regions and in the right upper region. Without comparison, the nature of these lesions is difficult to determine, they could be the result of fibrotic or a chronic inflammatory process, but could also result from chronic overhydration. Moderately enlarged cardiac silhouette, slightly enlarged right and left hilus, potentially suggesting pulmonary hypertension. No evidence of pleural effusions, no acute overhydration. Bilateral apical thickening. . [**2126-4-13**] Lower extremity doppler U/S Preliminary Report !! WET READ !! no dvt seen in either lower extremity . [**2126-4-13**] CTA CHEST Preliminary Report !! PFI !! Pulmonary embolus within the right middle lobe segmental artery. Bilateral pleural effusions. Extensive COPD, cardiomegaly, vascular calcifications. Areas of increased opacity in the right upper lobe may represent infection. Additional areas of opacity in the right middle lobe may represent infarct or atelectasis. Brief Hospital Course: 1) EKG changes - Perioperative EKG prior to transfer to [**Hospital1 18**] showed ST elevations in V3-V4 and to a lesser extent in II,III,F,V5-V6. TnI was 1.9 with normal CK. She was given aspirin, plavix, lovenox, and lopressor. A similar EKG was obtained upon transfer to [**Hospital1 18**]. Cardiac cath [**4-12**] revealed a right-dominant system with a calcified 50% proximal stenosis in the RCA but no angiographically apparent disease in the LMCA, LAD, and LCX. TTE [**2126-4-12**] revealed normal left atrial size with an estimated right atrial pressure 10-20mmHg, normal left ventricular wall thickness and a small left ventricular cavity, normal left ventricular systolic function (LVEF 70%), hypertrophied right ventricular free wall, dilated right ventricular cavity with borderline normal free wall function, abnormal systolic septal motion/position consistent with right ventricular pressure overload, moderately thickened aortic valve leaflets with a minimally increased gradient consistent with minimal aortic valve stenosis, mildly thickened mitral valve leaflets, left ventricular inflow pattern suggesting impaired relaxation, mildly thickened tricuspid valve leaflets with moderate to severe [3+] tricuspid regurgitation, and severe pulmonary artery systolic hypertension. Cardiac enzymes were trended with no elevation in her CK's threfore this was felt not to be cardiac ischemia. . 2) Pulmonary Embolus - On hospital day 2, the patient had low-grade fever, tachycardia, worsening hypoxemia with resting oxygen saturation in the mid 90's on 6 L NC, new T-wave inversions in V3 and deeper T-wave inversions in V4. CTA of the chest revealed right middle lobe segmental pulmonary emboli, right middle lobe pulmonary infarct vs. atelectasis, moderate bilateral pleural effusions, and volume overload. Heparin and lasix infusions were started. Lower extremity doppler ultrasound was negative for DVT. . 3) Left femoral neck fracture - Seen in consultation by orthopaedic surgery who recommended proceeding with ORIF. However, based on the preference of the patient and her family, she was transferred to [**Hospital3 3583**] for further management. Medications on Admission: Celexa 10mg PO daily Omeprazole 20mg PO daily Senna 2 tabs daily at 4pm Lisinopril 5 mg PO daily Lidoderm 5% patch, one patch to lower back 12 hrs each day Calcium with Vit D 600mg PO BID Tylenol 650mg Q4hrs PRN for pain Compazine 10mg PO BID PRN nausea/vomiting Ibuprofen prn Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours): do not exceed 4 grams in 24 hours. 2. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 3. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): place on between 8 AM and 8 PM then remove. 5. Heparin (Porcine) in NS 10 unit/mL Kit Sig: ASDIR units Intravenous every six (6) hours: Diagnosis: Pulmonary Embolism Patient Weight: 40.824 kg Initial Bolus: 1000 units IVP Initial Infusion Rate: 750 units/hr Target PTT: 60 - 100 seconds PTT <40: 1600 units Bolus then Increase infusion rate by 150 units/hr PTT 40 - 59: 800 units Bolus then Increase infusion rate by 100 units/hr PTT 60 - 100*: PTT 101 - 120: Reduce infusion rate by 100 units/hr PTT >120: Hold 60 mins then Reduce infusion rate by 150 units/hr. 6. Furosemide 10 mg/mL Solution Sig: 2.5 mg Injection INFUSION (continuous infusion). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 8. Calcium Carbonate 500 mg (1,250 mg) Capsule Sig: One (1) Capsule PO once a day. 9. Vitamin D 400 unit Tablet Sig: Two (2) Tablet PO once a day. Discharge Disposition: Extended Care Discharge Diagnosis: 1) Left femoral neck fracture 2) Pulmonary embolus 3) Pleural effusions 4) Pulmonary hypertension 5) Tricuspid regurgitation 6) Emphysema Discharge Condition: Transfer to [**Hospital3 3583**]. Discharge Instructions: You were admitted to the hospital following a fall and left hip fracture. You declined surgery at [**Hospital1 18**] and were transferred to [**Hospital3 3583**] at your request. You were diagnosed with blood clots in the lung, also known as pulmonary emboli, and were started on blood thinning medication. Followup Instructions: Please follow the recommendations of your medical and orthopaedic doctors [**First Name (Titles) **] [**Hospital3 3583**]. Completed by:[**2126-4-14**]

794,415,511,820,416,397,E888,250,492,401,733,530,276

{'Nonspecific abnormal electrocardiogram [ECG] [EKG],Other pulmonary embolism and infarction,Unspecified pleural effusion,Closed fracture of unspecified part of neck of femur,Other chronic pulmonary heart diseases,Diseases of tricuspid valve,Fall resulting in striking against other object,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other emphysema,Unspecified essential hypertension,Osteoporosis, unspecified,Esophageal reflux,Hyperpotassemia'}

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: EKG changes PRESENT ILLNESS: 86 yo female with COPD, pulm HTN, TR who presented to OSH after a stranger knocked into her at her [**Hospital3 **] facility causing her to fall and fracture her left hip. She did not have any LOC. In addition, she sustained a laceration to her right lower leg and received 6 stiches at OSH. At OSH, pt had CT scan of Left hip which showed a cervical neck fracture of the left proximal femur. She had a routine pre-op evaluation; however her pre-op EKG showed ST elevations in V2-V4. The patient was completely asymptomatic. She denied chest pain or pressure. Her SOB was at baseline. She did have some nausea, vomiting and diaphoresis at the OSH. She was transferred to [**Hospital1 18**] for cardiac cath. Her cardiac cath earlier today showed clean coronaries. The patient tolerated the procedure without complication. The orthopedic team was consulted for management of her hip fracture. . The patient denies any chest pain or pressure currently. She reports that she does not want to undergo hip repair despite being informed of the risks. She refuses to go to get x-rays for further evaluation. . ROS: She denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, or hemoptysis. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. Has occasional abdominal pain, alternating diarrhea and constipation but has not had a colonoscopy, occasional blood in stool with straining. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. MEDICAL HISTORY: Pulmonary HTN Tricuspid regurgitation CPD Osteoporosis c/b thoracic spine fracture resulting in chronic mid back pain Hypertension h/o pyelonephritis h/o left hydronephrosis of uncertain eitology h/o pneumonia - required stay in rehab prior to transfer to [**Hospital3 **] s/p appendectomy s/p oophrectomy MEDICATION ON ADMISSION: Celexa 10mg PO daily Omeprazole 20mg PO daily Senna 2 tabs daily at 4pm Lisinopril 5 mg PO daily Lidoderm 5% patch, one patch to lower back 12 hrs each day Calcium with Vit D 600mg PO BID Tylenol 650mg Q4hrs PRN for pain Compazine 10mg PO BID PRN nausea/vomiting Ibuprofen prn ALLERGIES: No Drug Allergy Information on File PHYSICAL EXAM: ADMISSION PHYSICAL EXAM VS: T=98.1 BP=102/49 HR=63 RR=15 O2 sat=96% 4L GENERAL: thin elderly female in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. FAMILY HISTORY: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. SOCIAL HISTORY: She lives in an [**Hospital3 **] facility at [**Location (un) 582**]. Had been living independently until 3 months ago when she had a pneumonia and required inpatient rehab prior to her transfer to [**Hospital 4382**]. Son is an administrator and internist at [**Hospital1 3325**]. Has 2 daughters who live locally. -Tobacco history: She started smoking as a teenager and quit smoking 3 months ago. -ETOH: denies -Illicit drugs: denies ### Response: {'Nonspecific abnormal electrocardiogram [ECG] [EKG],Other pulmonary embolism and infarction,Unspecified pleural effusion,Closed fracture of unspecified part of neck of femur,Other chronic pulmonary heart diseases,Diseases of tricuspid valve,Fall resulting in striking against other object,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other emphysema,Unspecified essential hypertension,Osteoporosis, unspecified,Esophageal reflux,Hyperpotassemia'}

CHIEF COMPLAINT: Motor vehicle accident. PRESENT ILLNESS: This is a 45 year old male restrained driver in a high speed motor vehicle accident, automobile versus tree, who sustained loss of consciousness and was found ambulating at the scene, alert and oriented times two. At the time, the patient was complaining of shoulder pain and a headache only. He was Med-flighted to the [**Hospital1 69**] with stable vital signs, boarded and collared. At the time, he denied any chest pain or abdominal pain. MEDICAL HISTORY: Significant for depression. MEDICATION ON ADMISSION: ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

Injury to thoracic aorta,Closed fracture of base of skull without mention of intra cranial injury, with loss of consciousness of unspecified duration,Other motor vehicle traffic accident involving collision on the highway injuring driver of motor vehicle other than motorcycle,Closed unspecified fracture of pelvis,Flail chest,Closed fracture of sacrum and coccyx without mention of spinal cord injury,Pneumonia due to escherichia coli [E. coli]

Injury thoracic aorta,Cl skul base fx-coma NOS,Mv coll w oth obj-driver,Pelvic fracture NOS-clos,Flail chest,Fx sacrum/coccyx-closed,Pneumonia e coli

Admission Date: [**2124-9-7**] Discharge Date: [**2124-10-7**] Date of Birth: [**2074-4-17**] Sex: M Service: Surgery RADIOLOGIC DATA: The patient underwent a radiological trauma series with a lateral cervical spine, demonstrating no fracture dislocation from C1 through C6. The chest x-ray showed trauma board artifact and mediastinum was widened, with displacement of the trachea to the right. There were irregular opacities present within the left lung field, concerning for contusion and there was deformity of the left upper thoracic cage, representing multiple rib fractures. No pneumothorax was demonstrated. The pelvis demonstrated disruption of the left pelvic rim. Assessment of the sacroiliac joints was limited. Given these findings, the patient was taken to the CT scanner, where CT scans of the chest and abdomen were performed. The CT scan of the chest demonstrated a descending thoracic aorta strongly suggestive of aortic transection, bilateral pleural effusions, left greater than right, multiple rib fractures, predominantly on the left side, with subcutaneous emphysema and underlying contusion in the left lung. There was also an intra-articular fracture involving the left superior pubic ramus and acetabulum, associated with hemorrhage along the left pelvic sidewall. A CT scan of the head demonstrated a left occipital condyle fracture. HOSPITAL COURSE: Cardiothoracic surgery residents were immediately contact[**Name (NI) **] and came to evaluate the patient. The [**Hospital 228**] hospital course is as follows. [**Last Name (STitle) 35700**]is patient's life threatening aortic injury, he was taken immediately to the Operating Room by Dr. [**Last Name (Prefixes) **] of cardiothoracic surgery, where a repair of a thoracic aortic transection was performed with a 20 mm woven interposition gel weave graft. This required left pulmonary vein to right common femoral artery bypass. The aorta was crossclamped immediately proximal to the left subclavian for the repair. The patient lost approximately five liters worth of blood during the procedure and received 3,000 cc of cell [**Doctor Last Name 10105**], seven liters of crystalloid, two units of fresh frozen plasma and seven units of platelets. The crossclamp time was 33 minutes. Postoperatively, the patient was transferred to the Surgical Intensive Care Unit, where he was stabilized and a neurosurgical consult was obtained for the left occipital condyle fracture that was demonstrated on the CT scan of the head. Neurosurgery performed a very limited examination secondary to the fact that the patient was sedated and intubated, but recommended continuation of the cervical collar. There was also an orthopedic consult requested for the left sided zone I sacral fracture and extra-articular anterior common fracture of the acetabulum. It was determined that it would also be managed nonoperatively. The patient subsequently had an extended Intensive Care Unit stay. He was in the Intensive Care Unit for 22 days. He was moving all four extremities postoperatively and was doing well until approximately postoperative day number five, when he developed fevers and an elevated white blood cell count. His Intensive Care Unit course was complicated by E. coli pneumonia that was diagnosed by broncho-alveolar lavage. His bronco-alveolar lavage grew out E. coli as well as Serratia, for which the infectious disease service was consulted. The patient was placed on vancomycin, ceftriaxone and gentamicin initially. The gentamicin was discontinued and the patient was placed on ciprofloxacin during his Intensive Care Unit course. His antibiotics were subsequently changed again to Zosyn, ceftriaxone and vancomycin. He completed a 14 day course of Zosyn, a 22 day course of ceftriaxone and a 12 day course of vancomycin for his hospital acquired pneumonia. The patient required a prolonged period of intubation given his pneumonia and his left flail chest that was demonstrated intraoperatively. He was not extubated until Surgical Intensive Care Unit [**Unit Number **]. During this period of intubation, he underwent multiple bronchoscopies. He required heavy sedation and would periodically by lightened for evaluation of his neurological status. He was able to move all four extremities throughout his Intensive Care Unit stay. On [**2124-9-26**], the patient was successfully extubated and, at this point, the slow process of rehabilitation was begun. He did have a postpyloric feeding tube placed and he was receiving tube feeds during his Intensive Care Unit stay. He had also been placed on Lovenox as deep vein thrombosis prophylaxis. The patient was transferred to the regular floor on [**2124-9-29**], at which point an otolaryngology consult was obtained because it was noted that, during his aortic transection repair, the left recurrent laryngeal nerve was removed. After evaluation by otolaryngology, they recommended that he undergo video stroboscopy as an outpatient. He did undergo a speech and swallow evaluation as well, which he failed. For this reason, he underwent a percutaneous endoscopic gastrostomy tube placement by interventional radiology on [**2124-10-4**]. Orthopedic surgery was following the patient throughout his course, and their final recommendations were that the patient could touch down weightbear on the left leg and that he could undergo full range of motion exercises. The patient had one to two days of nausea after percutaneous endoscopic gastrostomy tube placement, which resolved. At that point, he was tolerating his tube feeds. His mental status was much improved. He was alert and oriented, conversant, moving all four extremities. He was clear to auscultation with an irregular rhythm, tolerating his physical therapy. Given these findings, it was felt that he was stable for discharge. Summary of the patient's injuries: 1. Thoracic aortic transection, status post graft interposition repair. 2. Left occipital condyle fracture, for which patient would remain in a cervical collar. 3. Left recurrent laryngeal nerve transection, for which he would follow up with Dr. [**Last Name (STitle) **] as an outpatient; telephone number [**Telephone/Fax (1) 41**]. 4. Left pelvic fracture, requiring nonoperative treatment, for which he should follow up with orthopedic surgery in two weeks; telephone number [**Telephone/Fax (1) 2756**]. 5. Multiple left rib fractures, for which he would follow up with trauma surgery; he should call to schedule an appointment with trauma surgery. DISCHARGE MEDICATIONS: Colace 100 mg pg b.i.d. Reglan 10 mg i.v./p.o.q.6h. Lovenox 30 mg s.c.b.i.d. Nystatin swish and swallow. Paxil 20 mg pg q.d. Respalor tube feeds via PEG at 100 cc/hour. DISCHARGE INSTRUCTIONS: The patient is to remain in his cervical collar until further follow-up with trauma surgery and neurosurgery. He was instructed to follow up with neurosurgery, orthopedic surgery, otolaryngology, cardiothoracic surgery and orthopedic surgery. CONDITION AT DISCHARGE: Stable. DISCHARGE DIAGNOSES: Depression. Status post motor vehicle accident, sustaining a thoracic aortic injury, left occipital condyle fracture, left flail chest, left pelvic fracture, left recurrent laryngeal nerve transection. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Name8 (MD) 4720**] MEDQUIST36 D: [**2124-10-7**] 12:35 T: [**2124-10-7**] 12:35 JOB#: [**Job Number 35701**] Admission Date: [**2124-9-7**] Discharge Date: [**2124-10-7**] Date of Birth: [**2074-4-17**] Sex: M Service: TRAUMA SURGERY CHIEF COMPLAINT: Motor vehicle accident. HISTORY OF PRESENT ILLNESS: This is a 45 year old male restrained driver in a high speed motor vehicle accident, automobile versus tree, who sustained loss of consciousness and was found ambulating at the scene, alert and oriented times two. At the time, the patient was complaining of shoulder pain and a headache only. He was Med-flighted to the [**Hospital1 69**] with stable vital signs, boarded and collared. At the time, he denied any chest pain or abdominal pain. PAST MEDICAL HISTORY: Significant for depression. MEDICATIONS: Paxil. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: In the Emergency Department, his physical examination was as follows: Vital signs were stable with a blood pressure of 128/88, heart rate of 88, respiratory rate 22, and oxygen saturation 96%. He was boarded and collared. His GCS was 14. He was alert and oriented times three. He had a scalp laceration with arterial bleeding. His pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. His neck examination revealed trachea midline. Chest was clear to auscultation bilaterally. He did, however, have left chest tenderness. He had a regular rate and rhythm. His abdomen was soft with minimal bruising at the left waist. His pelvis was stable and extremities were warm with small abrasions in the legs. His rectal examination was normal tone, prostate was normal position, guaiac negative. He had C4 to 5 tenderness and left posterior shoulder tenderness. LABORATORY DATA: His white count on admission was 20.3 with a hematocrit of 43.5. His chemistries revealed blood urea nitrogen 20 and creatinine 0.9. He underwent a trauma series. The lateral cervical spine film was clear with no fracture dislocation to C6 but inadequate. Chest x-ray demonstrated [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**] Dictated By:[**Name8 (MD) 4720**] MEDQUIST36 D: [**2124-10-7**] 12:14 T: [**2124-10-7**] 12:32 JOB#: [**Job Number 35699**]

901,801,E815,808,807,805,482

{'Injury to thoracic aorta,Closed fracture of base of skull without mention of intra cranial injury, with loss of consciousness of unspecified duration,Other motor vehicle traffic accident involving collision on the highway injuring driver of motor vehicle other than motorcycle,Closed unspecified fracture of pelvis,Flail chest,Closed fracture of sacrum and coccyx without mention of spinal cord injury,Pneumonia due to escherichia coli [E. coli]'}

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: Motor vehicle accident. PRESENT ILLNESS: This is a 45 year old male restrained driver in a high speed motor vehicle accident, automobile versus tree, who sustained loss of consciousness and was found ambulating at the scene, alert and oriented times two. At the time, the patient was complaining of shoulder pain and a headache only. He was Med-flighted to the [**Hospital1 69**] with stable vital signs, boarded and collared. At the time, he denied any chest pain or abdominal pain. MEDICAL HISTORY: Significant for depression. MEDICATION ON ADMISSION: ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: ### Response: {'Injury to thoracic aorta,Closed fracture of base of skull without mention of intra cranial injury, with loss of consciousness of unspecified duration,Other motor vehicle traffic accident involving collision on the highway injuring driver of motor vehicle other than motorcycle,Closed unspecified fracture of pelvis,Flail chest,Closed fracture of sacrum and coccyx without mention of spinal cord injury,Pneumonia due to escherichia coli [E. coli]'}

CHIEF COMPLAINT: Nausea, vomiting, abdominal tenderness PRESENT ILLNESS: The patient rpeorts that he symtpoms began yesterday when she began to experience nausea and had several episodes of vomiting. She has also been noticing that he belly has been distended recently. She complains of on-and-off-diarrhea every five weeks or so, but has not experienced any diarrhea this week. The patient says that her abdomen hurts only when people push on it; alone and undisturbed, her abdomen is non-tender. The patient has no history of gallbladder or liver disease that she knows of. She further denies any RUQ pain. She has not experienced and hematuria or dysuria. (Per reports from [**Location (un) 620**], the patient may not have been accurate in my interview. There she was brought in with complaints of LLQ pain and jaundice.) At [**Location (un) 620**], the patient received metoprolol IV 5 mg, Zofran, and 3 liters of fluid. . In the Emergency Department, a CT scan showed "Severe intra/extrahepatic biliary dilatation; severe pancreatic duct dilatation with pancreatic atrophy; nodular enhancement at ampulla suggests possible malignancy. 2. Distended gallbladder with wall edema and perihepatic ascites, likely [**2-23**] severe biliary dilatation. 3. Stool distending the entire colon; distended small bowel likely [**2-23**] to the stool. L spigelian hernia contains a colon loop and free fluid, but no obstruction is seen at the level of the hernia, and no bowel wall thickening. 4. AVN of L femoral head again seen." The Emergency Department had discussed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] and arranged direct admit to surgical floor and possible ERCP evaluation, but then they noted that she was in AFib RVR 120's. Also has [**Apartment Address(1) **] mm in lead III, and ST depressions in V [**2-27**], worse since prior EKG. Has had a silent NSTEMI in past. Cardiology saw the patient and felt that negative stress from 8 months ago made Mi very unlikely. The patient was given metoprolol both PO and IV and a dose of Zosyn. . On the floor, the patient was tired but denied any specific abdominal pain. She denies being nauseated. She also denied feeling any palpitations. MEDICAL HISTORY: hypertension, cataracts with a recent iridectomy in [**10/2133**], hyperreflexic bladder, degenerative arthritis of her neck and back, and osteoporosis. MEDICATION ON ADMISSION: ASA 325mg daily Calcium 600 + D 1 tab daily oxybutynin 0.5 QHS Lasix 20mg QAM lisinopril 5mg daily MVI KCl SR 10mEq daily timolol 0.5% drops 1 drop to right eye [**Hospital1 **] tizanidine 4mg [**Hospital1 **] vit D 1000unit 1 tab daily Zocor 10mg QHS omeprazole 20mg daily Immodium, MoM, [**Name (NI) **] PRN ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: ADMISSION PHYSICAL EXAM: VS:T 97.9 BP 131/88 HR 103 RR 20 93% on 3L GENERAL: Frail, elderly woman in no acute distress HEENT: NC/AT, PERRL, EOMI, sclerae mildly icteric, oropharynx clear. NECK: Supple, no JVD. HEART: S1, S2, no murmurs auscultated. LUNGS: CTA bilaterally to anterior auscultation. ABDOMEN: Soft, distended, diffusely tender to palpation, no masses or HSM, no rebound/guarding. EXTREMITIES: WWP, no edema, 2+ peripheral pulses. SKIN: No rashes or lesions. LYMPH: No cervical LAD. NEURO: Awake, A&Ox3, CNs III-XII grossly intact, muscle strength [**5-26**] throughout, patellar reflexes 2+. LABS: See below. . DISCHARGE PHYSICAL EXAM: VS: 97.0 130/60 58 18 96% RA Gen: No acute distress HEENT: PERRL, EOMI, sclerae anicteric, OP clear CV: RRR, nl S1 S2, no MRG Resp: CTA bilaterally Abd: soft, mildly distended, non-tender. No rebound or guarding. No HSM. Ext: WWP, 1+ pitting edema to knee. No decrease in ROM (passive or active) in right hip. No pain on movement of any of the extremities. Psych: calm, appropriate, A&O x3 Neuro: CN II-XII grossly intact, strength 4+/5 throughout FAMILY HISTORY: Her family history is positive for a stroke in her brother. Otherwise, it is noncontributory. SOCIAL HISTORY: Lives with her daughter, ambulates at home with a cane. No smoking or alcohol.

Malignant neoplasm of other specified sites of pancreas,Obstruction of bile duct,Acute on chronic diastolic heart failure,Hematemesis,Do not resuscitate status,Other iatrogenic hypotension,Atrial fibrillation,Other ventral hernia without mention of obstruction or gangrene,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Unspecified essential hypertension,Neurogenic bladder NOS,Stress incontinence, female,Cervical spondylosis without myelopathy,Osteoporosis, unspecified,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Other alteration of consciousness,Unspecified glaucoma,Lumbago

Malig neo pancreas NEC,Obstruction of bile duct,Ac on chr diast hrt fail,Hematemesis,Do not resusctate status,Iatrogenc hypotnsion NEC,Atrial fibrillation,Ventral hernia NEC,Crnry athrscl natve vssl,Old myocardial infarct,Hypertension NOS,Neurogenic bladder NOS,Fem stress incontinence,Cervical spondylosis,Osteoporosis NOS,Elev transaminase/ldh,Other alter consciousnes,Glaucoma NOS,Lumbago

Admission Date: [**2135-9-30**] Discharge Date: [**2135-10-16**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2782**] Chief Complaint: Nausea, vomiting, abdominal tenderness Major Surgical or Invasive Procedure: ERCP ([**9-30**]) Central venous line placement ([**10-1**]) Arterial line placement ([**10-1**]); removal ([**10-2**]) ERCP for stent replacement ([**10-10**]) ERCP for stent replacement ([**10-12**]) History of Present Illness: The patient rpeorts that he symtpoms began yesterday when she began to experience nausea and had several episodes of vomiting. She has also been noticing that he belly has been distended recently. She complains of on-and-off-diarrhea every five weeks or so, but has not experienced any diarrhea this week. The patient says that her abdomen hurts only when people push on it; alone and undisturbed, her abdomen is non-tender. The patient has no history of gallbladder or liver disease that she knows of. She further denies any RUQ pain. She has not experienced and hematuria or dysuria. (Per reports from [**Location (un) 620**], the patient may not have been accurate in my interview. There she was brought in with complaints of LLQ pain and jaundice.) At [**Location (un) 620**], the patient received metoprolol IV 5 mg, Zofran, and 3 liters of fluid. . In the Emergency Department, a CT scan showed "Severe intra/extrahepatic biliary dilatation; severe pancreatic duct dilatation with pancreatic atrophy; nodular enhancement at ampulla suggests possible malignancy. 2. Distended gallbladder with wall edema and perihepatic ascites, likely [**2-23**] severe biliary dilatation. 3. Stool distending the entire colon; distended small bowel likely [**2-23**] to the stool. L spigelian hernia contains a colon loop and free fluid, but no obstruction is seen at the level of the hernia, and no bowel wall thickening. 4. AVN of L femoral head again seen." The Emergency Department had discussed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] and arranged direct admit to surgical floor and possible ERCP evaluation, but then they noted that she was in AFib RVR 120's. Also has [**Apartment Address(1) **] mm in lead III, and ST depressions in V [**2-27**], worse since prior EKG. Has had a silent NSTEMI in past. Cardiology saw the patient and felt that negative stress from 8 months ago made Mi very unlikely. The patient was given metoprolol both PO and IV and a dose of Zosyn. . On the floor, the patient was tired but denied any specific abdominal pain. She denies being nauseated. She also denied feeling any palpitations. Past Medical History: hypertension, cataracts with a recent iridectomy in [**10/2133**], hyperreflexic bladder, degenerative arthritis of her neck and back, and osteoporosis. Social History: Lives with her daughter, ambulates at home with a cane. No smoking or alcohol. Family History: Her family history is positive for a stroke in her brother. Otherwise, it is noncontributory. Physical Exam: ADMISSION PHYSICAL EXAM: VS:T 97.9 BP 131/88 HR 103 RR 20 93% on 3L GENERAL: Frail, elderly woman in no acute distress HEENT: NC/AT, PERRL, EOMI, sclerae mildly icteric, oropharynx clear. NECK: Supple, no JVD. HEART: S1, S2, no murmurs auscultated. LUNGS: CTA bilaterally to anterior auscultation. ABDOMEN: Soft, distended, diffusely tender to palpation, no masses or HSM, no rebound/guarding. EXTREMITIES: WWP, no edema, 2+ peripheral pulses. SKIN: No rashes or lesions. LYMPH: No cervical LAD. NEURO: Awake, A&Ox3, CNs III-XII grossly intact, muscle strength [**5-26**] throughout, patellar reflexes 2+. LABS: See below. . DISCHARGE PHYSICAL EXAM: VS: 97.0 130/60 58 18 96% RA Gen: No acute distress HEENT: PERRL, EOMI, sclerae anicteric, OP clear CV: RRR, nl S1 S2, no MRG Resp: CTA bilaterally Abd: soft, mildly distended, non-tender. No rebound or guarding. No HSM. Ext: WWP, 1+ pitting edema to knee. No decrease in ROM (passive or active) in right hip. No pain on movement of any of the extremities. Psych: calm, appropriate, A&O x3 Neuro: CN II-XII grossly intact, strength 4+/5 throughout Pertinent Results: Admission Labs: [**2135-9-29**] 06:55PM WBC-8.2 RBC-3.17* HGB-10.3* HCT-30.5* MCV-96 MCH-32.5* MCHC-33.7 RDW-13.8 [**2135-9-29**] 06:55PM NEUTS-91.9* LYMPHS-4.2* MONOS-3.3 EOS-0.4 BASOS-0.2 [**2135-9-29**] 06:55PM PT-12.2 PTT-25.0 INR(PT)-1.0 [**2135-9-29**] 06:55PM GLUCOSE-113* UREA N-19 CREAT-0.6 SODIUM-128* POTASSIUM-4.4 CHLORIDE-95* TOTAL CO2-21* ANION GAP-16 [**2135-9-29**] 06:55PM ALT(SGPT)-265* AST(SGOT)-239* CK(CPK)-63 ALK PHOS-956* TOT BILI-4.3* [**2135-9-29**] 06:55PM cTropnT-0.08* [**2135-9-29**] 06:55PM CK-MB-9 cTropnT-0.07* [**2135-9-29**] 06:55PM MAGNESIUM-1.7 [**2135-9-29**] 09:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN-2* PH-5.5 LEUK-NEG [**2135-9-29**] 09:40PM URINE RBC-1 WBC-2 BACTERIA-NONE YEAST-NONE EPI-<1 . [**Hospital3 **]: [**2135-10-1**] 07:30AM BLOOD WBC-10.7 RBC-2.76* Hgb-9.1* Hct-26.0* MCV-94 MCH-32.8* MCHC-34.9 RDW-14.4 Plt Ct-300 [**2135-10-1**] 11:24AM BLOOD Hct-19.9* [**2135-10-1**] 12:55PM BLOOD Hct-25.3*# [**2135-10-1**] 07:18PM BLOOD Hgb-9.9* Hct-28.2* [**2135-10-4**] 01:42PM BLOOD Hct-30.2* [**2135-10-11**] 04:40PM BLOOD Hct-27.8* . [**2135-10-1**] 07:30AM BLOOD Glucose-59* UreaN-31* Creat-0.9 Na-135 K-2.8* Cl-104 HCO3-18* AnGap-16 [**2135-10-1**] 11:24AM BLOOD UreaN-32* Creat-0.9 Na-134 K-2.2* Cl-104 HCO3-19* AnGap-13 [**2135-10-1**] 07:18PM BLOOD Glucose-74 UreaN-31* Creat-0.9 Na-138 K-3.1* Cl-108 HCO3-18* AnGap-15 . [**2135-9-30**] 06:15AM BLOOD ALT-287* AST-342* LD(LDH)-341* CK(CPK)-112 AlkPhos-1062* TotBili-5.0* [**2135-10-1**] 07:30AM BLOOD ALT-196* AST-155* AlkPhos-857* TotBili-1.9* [**2135-10-1**] 12:55PM BLOOD CK(CPK)-157 Amylase-13 [**2135-10-1**] 12:55PM BLOOD Albumin-1.6* Calcium-6.2* Phos-3.2 Mg-1.6 [**2135-10-2**] 03:12AM BLOOD ALT-139* AST-80* LD(LDH)-304* CK(CPK)-124 AlkPhos-645* TotBili-1.2 [**2135-10-8**] 08:40AM BLOOD ALT-97* AST-212* AlkPhos-1144* TotBili-2.5* [**2135-10-9**] 06:35AM BLOOD ALT-139* AST-300* AlkPhos-1328* TotBili-2.1* [**2135-10-10**] 06:33AM BLOOD ALT-113* AST-136* AlkPhos-1163* TotBili-1.7* [**2135-10-11**] 06:40AM BLOOD ALT-117* AST-255* AlkPhos-1195* TotBili-3.8* [**2135-10-11**] 04:40PM BLOOD ALT-124* AST-234* AlkPhos-1419* TotBili-4.2* [**2135-10-12**] 08:28AM BLOOD ALT-129* AST-267* AlkPhos-1379* TotBili-5.2* [**2135-10-13**] 06:15AM BLOOD ALT-96* AST-108* AlkPhos-1019* TotBili-1.5 [**2135-10-14**] 07:05AM BLOOD ALT-78* AST-49* AlkPhos-962* TotBili-1.3 [**2135-10-15**] 06:40AM BLOOD ALT-63* AST-34 AlkPhos-761* TotBili-1.0 . [**2135-9-30**] 06:15AM BLOOD CK-MB-20* MB Indx-17.9* cTropnT-0.34* [**2135-9-30**] 12:50PM BLOOD CK-MB-15* MB Indx-17.9* cTropnT-0.42* [**2135-10-1**] 12:55PM BLOOD CK-MB-18* MB Indx-11.5* cTropnT-0.50* . [**2135-10-1**] 11:35AM BLOOD Type-ART pO2-64* pCO2-31* pH-7.41 calTCO2-20* Base XS--3 . Discharge Labs: [**2135-10-16**] 07:00AM BLOOD WBC-5.7 RBC-2.82* Hgb-9.2* Hct-28.0* MCV-99* MCH-32.4* MCHC-32.7 RDW-16.8* Plt Ct-556* [**2135-10-16**] 07:00AM BLOOD Glucose-103* UreaN-17 Creat-0.5 Na-137 K-3.3 Cl-103 HCO3-26 AnGap-11 [**2135-10-16**] 07:00AM BLOOD ALT-62* AST-40 AlkPhos-678* TotBili-1.0 [**2135-10-16**] 07:00AM BLOOD Calcium-7.1* Phos-2.9 Mg-1.7 . Microbiology: [**2135-10-1**] URINE CULTURE-negative [**2135-9-30**] BLOOD CULTURE-negative [**2135-9-30**] BLOOD CULTURE-negative . Imaging: RIGHT UPPER QUADRANT ULTRASOUND: There is marked intra- and extra-hepatic biliary ductal dilation, as seen on recent CT. The common bile duct measures up to 1.2 cm. Gallbladder is distended, likely reflecting biliary obstruction. There are no stones within the gallbladder, nor is there sludge identified. There is no gallbladder wall thickening or pericholecystic fluid. There is trace fluid in Morison's pouch, without generalized ascites. The pancreas could not be well visualized due to significant bowel gas in the midline. . IMPRESSION: 1. Intra- and extra-hepatic biliary ductal dilation, as seen on recent CT. Further evaluation with ERCP or MRCP is recommended. 2. Distended gallbladder, likely reflecting biliary obstruction, without cholelithiasis or son[**Name (NI) 493**] evidence of acute cholecystitis. . ERCP Impression ([**9-30**]): - The major papilla appeared like ''fish-mouth''. There was copious thick mucin extruding out. - The minor papilla was bulging. There was some thick mucin extruding out. - Immediately below the minor papilla there was a small opening suspicious for fistula. - A diffuse dilation was seen at the CBD and intrahepatic ducts with the CBD measuring 15-16 mm. - Copious amount of mucin was extracted successfully using a 15 mm RX balloon. - Spyglass cholangioscope showed large amount of mucin in CBD and no discrete lesion was found. - PD was cannulated from the major papilla and small amount of contrast was injected. There was one filling defect in the proximal main PD suspicious for intraductal neoplasm. The guidewire was not able to traverse. - The Santorini duct was cannulated from the minor papilla and small amount of contrast was injected. There was one filling defect in the proximal main PD suspicious for intraductal neoplasm. - Cytology samples were obtained for histology using a brush in the CBD. - Because of the severely dilated CBD and large amount of mucin, a 5cm by 10FR double pig tail biliary stent was placed successfully in the CBD. Then a 7cm by 10FR Cotton [**Doctor Last Name **] biliary stent was placed side-by-side successfully in the CBD. - Otherwise normal ercp to third part of the duodenum. . KUB ([**10-3**]): IMPRESSION: No evidence of obstruction with a large amount of gas in the bowel which may be indicative of ileus. . CXR ([**10-4**]): FINDINGS: There is progressive increase in diffuse bilateral parenchymal opacities, consistent with rapid accumulation of moderate-to-severe pulmonary edema. More focal areas of opacity including within the right apex may represent asymmetric edema versus superimposed aspiration/consolidation. Elevation of the right minor fissue is suggestive of volume loss/atelectasis in the right upper lobe. Bilateral pleural effusions are present and appear progressed with associated bibasilar atelectasis. No pneumothorax is seen. The heart size is top normal. There are calcifications of the aortic arch. A left-sided central line is unchanged with tip in the low SVC. . Echo ([**10-3**]): The left atrium is mildly dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral leaflets are mildly thickened. No mitral valve prolapse is seen. An eccentric, anteriorly directed jet of severe (3+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Moderate to severe mitral regurgitation. Pulmonary artrery hypertension. . ERCP ([**10-10**]): The major papilla appeared like ''fish-mouth''. There was some thick mucin extruding out. The minor papilla was bulging. There was some thick mucin extruding out. Two previously placed biliary stents were seen at the major papilla. One stent partially migrated distally. Both stents were removed with a snare. Cannulation of the biliary duct was successful and deep with a sphincterotome. A straight tip 0.035 in dreamwire was placed. A diffuse dilation was seen at the CBD and intrahepatic ducts with the CBD measuring 15-16 mm. Because patient developed obstruction with plastic stents and patient and family agreed with the metal stent placement, a 8cm by 10mm Wallflex fully covered biliary stent (Ref: 7054; Lot: [**Numeric Identifier 81030**]) was placed successfully in the CBD. The bile flow was good. Otherwise normal ercp to third part of the duodenum. . ERCP ([**10-12**]): Copious amount of mucin was seen at the major and minor papilla. The major papilla appeared like ''fishmouth''. The previously placed FCSE metal stent was seen at the major papilla. It largely migrated distally. It was removed with a snare. Cannulation of the biliary duct was successful and deep with a balloon catheter. A straight tip .035in guidewire was placed. Because of the copious amount of mucin causing obstruction, small amount of contrast was injected. There was filling defect (mucin) at the CBD. CBD measured 15-16 mm. Large amount of mucin was extracted successfully with a balloon. Because patient has failed plastic stents and FCSE metal stent, a 8cm by 10mm Uncovered Wallflex biliary stent (Ref: 7065; Lot: [**Numeric Identifier 81031**]) was placed successfully in the CBD. The bile flow was good. Otherwise normal ercp to third part of the duodenum. Brief Hospital Course: 89 y/o F with Hx dCHF, recent NSTEMI ([**6-1**]) presents with cholangitis and new-onset A fib with RVR, found to have signs of IPMN and adenocarcinoma. . 1. Biliary obstruction/cholangitis: The patient's CT and RUQ ultrasound both suggestive of biliary obstruction. She was evaluated via ERCP on [**9-30**], which revealed substantial obstruction of the bile ducts secondary to copious mucin. Two plastic stents were placed. The patient was given prophylactic antibiotics with Zosyn prior to and immediately following the procedure. Her abdominal distension slowly resolved and her LFTs normalized. One week following the procedure, she was found to have rising LFTs and increased abdominal distension. On [**10-10**] she underwent repeat ERCP to replace the plastic stents with a metal stent, as the previous stent had slipped. This did not successfully stay in place, and required replacement on [**10-12**]. Despite this replacement, it is possible that the blockage will recur, in which case repeat ERCP would be indicated to replace the stents. On discharge, her LFTs were stable for 48 hours and abdominal exam remained benign. . 2. Adenocarcinoma: The findings on the ERCP, combined with the papillary mass found on CT, were highly suggestive of IPMN. Cytology brushings revealed adenocarcinoma cells, likely malignant. The patient indicated prior to the ERCP that she would not wish to undertake therapy for any cancer found as a result of the procedure. She is not a surgical candidate. There may be chemotherapeutic options. The patient may also prefer a comfort care/hospice approach. An appointment with a medical oncologist was set for her following discharge. . 3. New onset atrial fibrillation: On admission, the patient was found to be in Afib with RVR. She was successfully rate controlled with IV and PO metoprolol. Cardiology was consulted and attributed her symptoms to demand ischemia. She was monitored and continued on beta blocker throughout her stay. As her CHADS score is 3, she is a candidate for long-term anti-coagulation. However, her primary care physician felt that this was not appropriate therapy given her risk of bleeding. She will continue metoprolol for rate control. . 4. Hypotension: resolved. The patient was found to be somnolent and hypotensive on [**10-1**] following an episode of coffee ground emesis. She was transferred to the MICU for pressor support. This was thought secondary to Afib with bradycardia. She was in the ICU overnight and on pressors for roughly 8 hours. She did not require ventilation report. Following immediate management, she was maintained in NSR with metoprolol and had no recurrence of the hypotension. Her hematocrit was stable and there was no further sign of bleeding. . 5. Diastolic heart failure: The patient has a history of diastolic HF, but at home required no oxygen support. On admission she was found to have some demand ischemia with troponin 0.4-0.5. Her hypoxia responded to diuresis, indicating heart failure as the etiology. She was resumed on home lasix 20 mg daily, and was felt to be euvolemic on discharge. . 6. Delirium with hallucination: resolved. The patient experienced waxing and [**Doctor Last Name 688**] orientation following her return from ICU. She also experienced visual hallucinations. This was attributed to hospital-associated delirium. Any exacerbating medications were discontinued, and the patient was managed according to the [**Doctor First Name **] protocol. . Inactive issues: 7. CAD: Continued aspirin 8. Back pain: Held home tizanidine. 9. Hypertension: Continue home lisinopril. 10. Urinary incontinence: Held home oxybutynin. 11. Glaucoma: Continue home timolol. . Code: DNR/DNI . Transitional Issues: - Please monitor liver function tests (AST, ALT, Alkaline phosphatase, Total bilirubin) daily until normalized. If there is an increase, or if her abdominal exam worsens, call the ERCP team for follow-up as stents may have slipped. - Once liver function tests have normalized, you may wish to restart Zocor, tizanidine, and oxybutynin. - Please monitor electrolytes and consider restarting KCl if necessary. - If respiratory function improves, nebulizers can be d/c. The patient does not have obstructive disease at baseline. - Oncology appointment to review cytology and determine possible treatment options, discuss prognosis, and select a path forward. This may lead to treatment or to a comfort care/hospice option. Medications on Admission: ASA 325mg daily Calcium 600 + D 1 tab daily oxybutynin 0.5 QHS Lasix 20mg QAM lisinopril 5mg daily MVI KCl SR 10mEq daily timolol 0.5% drops 1 drop to right eye [**Hospital1 **] tizanidine 4mg [**Hospital1 **] vit D 1000unit 1 tab daily Zocor 10mg QHS omeprazole 20mg daily Immodium, MoM, [**Name (NI) **] PRN Discharge Medications: 1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebulized Inhalation every six (6) hours as needed for SOB, wheezing. 2. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB/Wheezing. 3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 5. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet Sig: One (1) Tablet PO once a day. 8. Multi-Day Tablet Sig: One (1) Tablet PO once a day. 9. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 11. ampicillin-sulbactam 1.5 gram Recon Soln Sig: One (1) Recon Soln Injection Q6H (every 6 hours): 1.5 g Q6H end on [**10-17**]. 12. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain: max 3 g/day. 13. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pruritis: HOLD for mental status changes. 14. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 15. senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day. 16. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 17. Outpatient Lab Work Please obtain daily chemistry 7 panel along with daily AST, ALT, alkaline phosphatase, and total bilirubin. Please call results to Dr. [**Last Name (STitle) **],[**First Name3 (LF) 1730**] P. [**Telephone/Fax (1) 19980**] Discharge Disposition: Extended Care Facility: [**Hospital 11851**] Healthcare & Rehabilitation Center - [**Location (un) 620**] Discharge Diagnosis: Primary: obstructive cholangitis Secondary: adenocarcinoma (likely pancreatic), atrial fibrillation, diastolic heart failure Discharge Condition: Mental Status: Confused - sometimes. Activity Status: Out of Bed with assistance to chair or wheelchair. Level of Consciousness: Alert and interactive. Discharge Instructions: Dear Mrs [**Known lastname 6483**], . You came to our [**Hospital3 **] with nausea, vomiting, abdominal pain, and jaundice. A CT scan showed dilated bile ducts, most likely due to an obstruction. You were transferred to our [**Hospital 86**] hospital for ERCP (endoscopic retrograde cholangiopancreatography) to investigate the cause of this blockage and to relieve it. Stents were placed to hold open the bile ducts. Samples of the wall of the bile duct were taken; these were shown to be cancerous. . During your recovery from the ERCP, you experienced a rapid, irregular heart rate. On [**10-1**] your blood pressure dropped to a dangerously low level, and you were transferred to our ICU. You returned to the medical floor on [**10-2**]. For several days you needed additional oxygen support due to fluid in your lungs. You were given medications to control your heart rate, keep your blood pressure in the normal range, and reduce any extra fluid in your body. As these medications took effect, you were able to reduce your need for extra oxygen. During your stay on the medical floor, you were found to be confused at times and to have some visual hallucinations. This is a [**Last Name **] problem when people are in the hospital, and you were able to recover from this confusion as your health improved. . A week after your ERCP, we determined that one of the stents had slipped out of place, allowing the duct to close. You underwent a repeat ERCP on [**10-10**] to replace this stent. You required an additional ERCP on [**10-12**] to replace the stents once again. Following this 3rd procedure the stent appeared to remain in place. You will have daily bloodwork at rehab for liver function tests to ensure that everything is stable. . Our physical therapy team worked with you and determined you were weakened from the long hospital stay. You were transferred to a rehab facility to build your strength. . We made the following changes to your medications: STOP oxybutynin STOP Potassium Chloride (may restart depending on electrolyte monitoring) STOP tizanidine (may restart once liver function normalizes) STOP Zocor (may restart once liver function normalizes) . INCREASE lisinopril from 5mg to 10mg daily for better blood pressure control . START albuterol nebulizer treatments PRN to ease breathing START iprotropium nebulizer treatments PRN to ease breathing START metoprolol XR 100mg daily for A fib rate control and blood pressure management START hydoxyzine 25mg Q6H PRN itching for rash . Please follow-up with your primary care physician when you are discharged from rehab to determine any further medication changes. . Please also follow-up with an Oncologist to discuss your new diagnosis, your treatment choices, and how you wish to proceed. We have made an appointment for you in [**Location (un) 620**] on Monday. Followup Instructions: Please follow-up with your primary care physician following your discharge from rehab. . Name: [**First Name8 (NamePattern2) **] [**Name8 (MD) 3274**], MD Specialty: Hematology/Oncology Location: [**Hospital **] Hospital - [**Hospital 620**] Campus [**Street Address(2) 3001**], [**Location (un) 1773**], [**Location (un) 620**], Ma Phone: [**Telephone/Fax (1) 38619**] When: MONDAY [**2135-10-17**] at 3:00 PM

157,576,428,578,V498,458,427,553,414,412,401,596,625,721,733,790,780,365,724

{'Malignant neoplasm of other specified sites of pancreas,Obstruction of bile duct,Acute on chronic diastolic heart failure,Hematemesis,Do not resuscitate status,Other iatrogenic hypotension,Atrial fibrillation,Other ventral hernia without mention of obstruction or gangrene,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Unspecified essential hypertension,Neurogenic bladder NOS,Stress incontinence, female,Cervical spondylosis without myelopathy,Osteoporosis, unspecified,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Other alteration of consciousness,Unspecified glaucoma,Lumbago'}

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: Nausea, vomiting, abdominal tenderness PRESENT ILLNESS: The patient rpeorts that he symtpoms began yesterday when she began to experience nausea and had several episodes of vomiting. She has also been noticing that he belly has been distended recently. She complains of on-and-off-diarrhea every five weeks or so, but has not experienced any diarrhea this week. The patient says that her abdomen hurts only when people push on it; alone and undisturbed, her abdomen is non-tender. The patient has no history of gallbladder or liver disease that she knows of. She further denies any RUQ pain. She has not experienced and hematuria or dysuria. (Per reports from [**Location (un) 620**], the patient may not have been accurate in my interview. There she was brought in with complaints of LLQ pain and jaundice.) At [**Location (un) 620**], the patient received metoprolol IV 5 mg, Zofran, and 3 liters of fluid. . In the Emergency Department, a CT scan showed "Severe intra/extrahepatic biliary dilatation; severe pancreatic duct dilatation with pancreatic atrophy; nodular enhancement at ampulla suggests possible malignancy. 2. Distended gallbladder with wall edema and perihepatic ascites, likely [**2-23**] severe biliary dilatation. 3. Stool distending the entire colon; distended small bowel likely [**2-23**] to the stool. L spigelian hernia contains a colon loop and free fluid, but no obstruction is seen at the level of the hernia, and no bowel wall thickening. 4. AVN of L femoral head again seen." The Emergency Department had discussed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] and arranged direct admit to surgical floor and possible ERCP evaluation, but then they noted that she was in AFib RVR 120's. Also has [**Apartment Address(1) **] mm in lead III, and ST depressions in V [**2-27**], worse since prior EKG. Has had a silent NSTEMI in past. Cardiology saw the patient and felt that negative stress from 8 months ago made Mi very unlikely. The patient was given metoprolol both PO and IV and a dose of Zosyn. . On the floor, the patient was tired but denied any specific abdominal pain. She denies being nauseated. She also denied feeling any palpitations. MEDICAL HISTORY: hypertension, cataracts with a recent iridectomy in [**10/2133**], hyperreflexic bladder, degenerative arthritis of her neck and back, and osteoporosis. MEDICATION ON ADMISSION: ASA 325mg daily Calcium 600 + D 1 tab daily oxybutynin 0.5 QHS Lasix 20mg QAM lisinopril 5mg daily MVI KCl SR 10mEq daily timolol 0.5% drops 1 drop to right eye [**Hospital1 **] tizanidine 4mg [**Hospital1 **] vit D 1000unit 1 tab daily Zocor 10mg QHS omeprazole 20mg daily Immodium, MoM, [**Name (NI) **] PRN ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: ADMISSION PHYSICAL EXAM: VS:T 97.9 BP 131/88 HR 103 RR 20 93% on 3L GENERAL: Frail, elderly woman in no acute distress HEENT: NC/AT, PERRL, EOMI, sclerae mildly icteric, oropharynx clear. NECK: Supple, no JVD. HEART: S1, S2, no murmurs auscultated. LUNGS: CTA bilaterally to anterior auscultation. ABDOMEN: Soft, distended, diffusely tender to palpation, no masses or HSM, no rebound/guarding. EXTREMITIES: WWP, no edema, 2+ peripheral pulses. SKIN: No rashes or lesions. LYMPH: No cervical LAD. NEURO: Awake, A&Ox3, CNs III-XII grossly intact, muscle strength [**5-26**] throughout, patellar reflexes 2+. LABS: See below. . DISCHARGE PHYSICAL EXAM: VS: 97.0 130/60 58 18 96% RA Gen: No acute distress HEENT: PERRL, EOMI, sclerae anicteric, OP clear CV: RRR, nl S1 S2, no MRG Resp: CTA bilaterally Abd: soft, mildly distended, non-tender. No rebound or guarding. No HSM. Ext: WWP, 1+ pitting edema to knee. No decrease in ROM (passive or active) in right hip. No pain on movement of any of the extremities. Psych: calm, appropriate, A&O x3 Neuro: CN II-XII grossly intact, strength 4+/5 throughout FAMILY HISTORY: Her family history is positive for a stroke in her brother. Otherwise, it is noncontributory. SOCIAL HISTORY: Lives with her daughter, ambulates at home with a cane. No smoking or alcohol. ### Response: {'Malignant neoplasm of other specified sites of pancreas,Obstruction of bile duct,Acute on chronic diastolic heart failure,Hematemesis,Do not resuscitate status,Other iatrogenic hypotension,Atrial fibrillation,Other ventral hernia without mention of obstruction or gangrene,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Unspecified essential hypertension,Neurogenic bladder NOS,Stress incontinence, female,Cervical spondylosis without myelopathy,Osteoporosis, unspecified,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Other alteration of consciousness,Unspecified glaucoma,Lumbago'}

CHIEF COMPLAINT: lightheadedness PRESENT ILLNESS: Mr. [**Known firstname **] [**Last Name (NamePattern1) 7518**] is an 85 y/o male with COPD, HTN, AF on coumadin admitted to NEBH [**2-8**] with atrial fibrillation s/p CV developed tachy/brady syndrome s/p AF ablation on [**2-14**] discharged on CCB, metoprolol and dofetilide now presents with presyncope and sinus bradycardia. On [**2-14**] patient underwent EP study which showed several atrial tachycardias and two were ablated. The plan was for cardioversion following ablation but patient converted to NSR and remained in NSR with only 2 brief episodes of AF on telemetry. Since discharge from the hospital on [**2-15**] the patient has been feeling well. He has not had any chest pain, lightheadedness or dizziness until this morning. This AM had minimal appetite at breakfast. Then attempted to have a bowel movement several times with straining and each time felt lightheaded and dizzy with associated diaphoresis. He has been constipated over the past four days. His children were with him, helped him back to bed and called Dr. [**Last Name (STitle) **] who referred him to the Emergency Room. The patient did not ever lose consciousness. He reports that he has been complaint with all of his medications. He denies any associated chest pain or shortness of breath. Patient has history of bradycardia in past when on metoprolol and cardizem (HR ranging from 40-100 bpm). . During the patient's last hospitalization he underwent AF ablation however according to d/c summary only 2 of 4 arrhythmias were ablated. He was in sinus rhythm prior to discharge and was discharged on lopressor, cardizem and dofetilide. . In the ED, initial vitals were HR: 45-55 BP: 78/39, O2sat 96% on RA. Exam notable for patient with good mentation. EKG was initially sinus bradycardia. Patient received 2 g Calcium gluconate and 1L IVF. Symptoms and EKG changes felt to be consistent with too much medication. . On arrival to the CCU, the patient feels "better". He is fatigued but overall improved from this afternoon. HR 50s. BP 111/70. He denies chest pain, shortness of breath, palpitations, cough, abdominal pain, orthopnea, ankle edema and PND. He does report some persistent groin pain, R>L which has improved over the past several days. MEDICAL HISTORY: Atrial fibrillation s/p CV [**2126**] on coumadin hypertension COPD/Bronchiectasis congestive heart failure (unknown ef) gastroesophageal reflux disease, benign prostatic hypertrophy, , anemia, status post bilateral total knee replacements, shoulder arthroplasty . Cardiac Risk Factors: - Diabetes, - Dyslipidemia, + Hypertension MEDICATION ON ADMISSION: Dofetilide 500 mcg PO Q12H Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [**Hospital1 **] Fluticasone 50 mcg/Actuation Spray daily Pantoprazole 40 mg Tablet PO Q24H Ferrous Sulfate 325 mg daily Cyanocobalamin 100 mcg Tablet 5 Tablet PO DAILY Warfarin 1 mg Tablet PO Once Daily at 4PM Metoprolol Tartrate 50 mg Tablet PO BID Cardizem CD 120 mg 1 capsule daily Lovenox 80 mg/0.8 mL ALLERGIES: Horse Blood Extract PHYSICAL EXAM: VS: HR 56, BP 111/52, 100% on 2L Gen: Elderly male NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. FAMILY HISTORY: Significant for heart disease in father (mi [**89**] yo), mother (mi [**08**] yo), and brother (mi [**67**] yo). No diabetes in the family. SOCIAL HISTORY: Social history is significant for the absence of current tobacco use. Former smoker but quit in [**2095**] with 40 pack yr hx. There is no history of alcohol abuse. No illicit drug use. Widowed. Lives alone in [**Location (un) 2312**] and completes all his ADLs. Former fire-fighter but retired 30 years. Has 4 children and 4 grandkids.

Other specified cardiac dysrhythmias,Hematoma complicating a procedure,Cellulitis and abscess of trunk,Acute posthemorrhagic anemia,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Syncope and collapse,Coronary vasodilators causing adverse effects in therapeutic use,Sympatholytics [antiadrenergics] causing adverse effects in therapeutic use,Knee joint replacement,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Esophageal reflux,Congestive heart failure, unspecified,Bronchiectasis without acute exacerbation,Unspecified essential hypertension,Long-term (current) use of anticoagulants

Cardiac dysrhythmias NEC,Hematoma complic proc,Cellulitis of trunk,Ac posthemorrhag anemia,Abn react-surg proc NEC,Syncope and collapse,Adv eff coronary vasodil,Adv eff sympatholytics,Joint replaced knee,BPH w/o urinary obs/LUTS,Esophageal reflux,CHF NOS,Bronchiectas w/o ac exac,Hypertension NOS,Long-term use anticoagul

Admission Date: [**2135-2-17**] Discharge Date: [**2135-2-24**] Service: MEDICINE Allergies: Horse Blood Extract Attending:[**Doctor First Name 1402**] Chief Complaint: lightheadedness Major Surgical or Invasive Procedure: right groin hematoma evacuation and repair History of Present Illness: Mr. [**Known firstname **] [**Last Name (NamePattern1) 7518**] is an 85 y/o male with COPD, HTN, AF on coumadin admitted to NEBH [**2-8**] with atrial fibrillation s/p CV developed tachy/brady syndrome s/p AF ablation on [**2-14**] discharged on CCB, metoprolol and dofetilide now presents with presyncope and sinus bradycardia. On [**2-14**] patient underwent EP study which showed several atrial tachycardias and two were ablated. The plan was for cardioversion following ablation but patient converted to NSR and remained in NSR with only 2 brief episodes of AF on telemetry. Since discharge from the hospital on [**2-15**] the patient has been feeling well. He has not had any chest pain, lightheadedness or dizziness until this morning. This AM had minimal appetite at breakfast. Then attempted to have a bowel movement several times with straining and each time felt lightheaded and dizzy with associated diaphoresis. He has been constipated over the past four days. His children were with him, helped him back to bed and called Dr. [**Last Name (STitle) **] who referred him to the Emergency Room. The patient did not ever lose consciousness. He reports that he has been complaint with all of his medications. He denies any associated chest pain or shortness of breath. Patient has history of bradycardia in past when on metoprolol and cardizem (HR ranging from 40-100 bpm). . During the patient's last hospitalization he underwent AF ablation however according to d/c summary only 2 of 4 arrhythmias were ablated. He was in sinus rhythm prior to discharge and was discharged on lopressor, cardizem and dofetilide. . In the ED, initial vitals were HR: 45-55 BP: 78/39, O2sat 96% on RA. Exam notable for patient with good mentation. EKG was initially sinus bradycardia. Patient received 2 g Calcium gluconate and 1L IVF. Symptoms and EKG changes felt to be consistent with too much medication. . On arrival to the CCU, the patient feels "better". He is fatigued but overall improved from this afternoon. HR 50s. BP 111/70. He denies chest pain, shortness of breath, palpitations, cough, abdominal pain, orthopnea, ankle edema and PND. He does report some persistent groin pain, R>L which has improved over the past several days. Past Medical History: Atrial fibrillation s/p CV [**2126**] on coumadin hypertension COPD/Bronchiectasis congestive heart failure (unknown ef) gastroesophageal reflux disease, benign prostatic hypertrophy, , anemia, status post bilateral total knee replacements, shoulder arthroplasty . Cardiac Risk Factors: - Diabetes, - Dyslipidemia, + Hypertension Social History: Social history is significant for the absence of current tobacco use. Former smoker but quit in [**2095**] with 40 pack yr hx. There is no history of alcohol abuse. No illicit drug use. Widowed. Lives alone in [**Location (un) 2312**] and completes all his ADLs. Former fire-fighter but retired 30 years. Has 4 children and 4 grandkids. Family History: Significant for heart disease in father (mi [**89**] yo), mother (mi [**08**] yo), and brother (mi [**67**] yo). No diabetes in the family. Physical Exam: VS: HR 56, BP 111/52, 100% on 2L Gen: Elderly male NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with no appreciable JVP. CV: Bradycardic. s1, s2. No m/r/g. No thrills, lifts. No S3 or S4. Soft 2/6 systolic ejection murmur at USB. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Resonant to percussion. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: Bilateral groin hematomas, right side is firm without ooze, nontender to palpation, no bruit. Left side is soft, less ecchymotic. Trace edema bilaterally. No femoral bruits b/l. . Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: [**2135-2-17**] 10:10PM GLUCOSE-194* UREA N-22* CREAT-1.0 SODIUM-137 POTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-27 ANION GAP-11 [**2135-2-17**] 10:10PM CK(CPK)-139 [**2135-2-17**] 10:10PM cTropnT-0.09* [**2135-2-17**] 10:10PM CK-MB-3 [**2135-2-17**] 10:10PM WBC-6.9 RBC-2.77* HGB-8.2* HCT-23.8* MCV-86 MCH-29.4 MCHC-34.3 RDW-15.2 [**2135-2-17**] 10:10PM NEUTS-92* BANDS-0 LYMPHS-6* MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2135-2-17**] 10:10PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2135-2-17**] 10:10PM PLT SMR-NORMAL PLT COUNT-197 [**2135-2-17**] 10:10PM PT-16.4* PTT-32.0 INR(PT)-1.5* . [**2-18**] Large bilateral groin hematomas demonstrated, without evidence of pseudoaneurysm seen. . [**2-20**] Femoral U/S: 1. Increase in size of large right groin hematoma extending into the medial thigh. No evidence for pseudoaneurysm or arteriovenous fistula. 2. Small left groin hematoma. Brief Hospital Course: Patient is an 85 year old male with history of AF s/p CV at OSH with resultant tachy/brady s/p AF ablation on [**2-14**] started on dofetilide, CCB and beta blocker now presents with presyncope and bradycardia likely related to medication. Now off dilt and metoprolol and on dofetilide and acebutolol with symptomatic improvement. This hospitalization is complicated by ongoing fall in HCT with expansion of his bilat groin hematomas R>L now s/p r hematoma evacuation. . ## Bilateral groin hematomas: He had bilateral groin hematomas, and had a hematocrit drop betwee his ablation and this admission from about 30 --> 24. He had groin ultrasound that showed bilateral hematomas but no pseudoaneurysm. S/p drainage and hematoma evacuation by vascular surgery [**2135-2-20**]. Now with one JP drain in place. Pt denies pain. No transfusions since [**2-21**]. Following vascular recs, he will follow up in 2 weeks with Dr. [**Last Name (STitle) **]. HCT remained stable at time of discharge. . ## Rhythm: He does have AF s/p CV c/b bradycardia and tachycardia recently here for AF ablation on [**2-14**] with 2 of 4 atrial arrhythmias ablated. Discharged on [**2-15**] on Dofetelide, Cardizem and Metoprolol in normal sinus rhythm. Returns with near syncopal episodes and sinus bradycardia, likely medication related. Symptoms are likely exacerbated in setting of anemia. Cardizem and metoprolol discontinued and he was discahrged on acebutolol and dofetilide for rate and rhythm control which he tolerated. HOLD coumadin with lovenox for now pending HCT stabilization. Should be restarted at follow up with Dr. [**Last Name (STitle) **] of vascular surgery. He was monitored on telemetry. . ## Pump: Patient with known history of CHF per chart. Euvolemic on exam. Monitored I/Os, goal even. . ## CAD: No known CAD. No ischemic sxs currently. . ## Cellulitis: Pt had mild erythema R groin near well-healing incision. had low grade fever with pancultures sent. He was started on cephalexin to complete 10 day course. His culture data had no growth at time of discharge and he remained afebrile>48 hours prior to discharge. . ## Anemia: Likely related to blood loss in groin based on exam findings of bilateral hematomas. Baseline approximately 30. Tranfused total 6 units. Last transfused [**2135-2-21**]. Continue iron supplementation, B12. Mgmt as above for hematomas. . ## GERD: Continued ppi . ## COPD: Continued inhalers . ##General Care: pneumoboots, ppi, Code status: FULL CODE confirmed with patient, Communication: [**Name (NI) **] [**Name (NI) **] (son) [**Telephone/Fax (1) 111656**]. Discharged when cleared by PT. Medications on Admission: Dofetilide 500 mcg PO Q12H Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [**Hospital1 **] Fluticasone 50 mcg/Actuation Spray daily Pantoprazole 40 mg Tablet PO Q24H Ferrous Sulfate 325 mg daily Cyanocobalamin 100 mcg Tablet 5 Tablet PO DAILY Warfarin 1 mg Tablet PO Once Daily at 4PM Metoprolol Tartrate 50 mg Tablet PO BID Cardizem CD 120 mg 1 capsule daily Lovenox 80 mg/0.8 mL Discharge Medications: 1. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 4. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 5. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Dofetilide 500 mcg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 7. Acebutolol 200 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Cephalexin 250 mg Capsule Sig: One (1) Capsule PO three times a day for 8 days. Disp:*24 Capsule(s)* Refills:*0* 10. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H () as needed for pain. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Acute Blood Loss Anemia Bilateral groin Hematomas Chronic Congestive Heart Failure Atrial Fibrillation s/p Ablation Hypertension Discharge Condition: stable. Discharge Instructions: You had bleeding from the right groin site that required surgery and evacuation of the blood. A drain was placed and will stay in until you see Dr. [**Last Name (STitle) 3407**] on [**3-8**]. You can walk with this drain but do not take a shower or bath until after you see Dr. [**Last Name (STitle) 3407**]. Please keep the dressing clean and dry. You were started on an antibiotic because the right groin site was warm and red, please take this antibiotic for a total of 10 days. The visiting nurse will help with the drain. New medicines: 1. Ceflexin: an antibiotic to treat the local skin infection near the surgery site. 2. Acebutalol: a beta blocker to take instead of the metoprolol . 1. Do not take any coumadin or Lovenox until Dr. [**Last Name (STitle) 3407**] or Dr. [**Last Name (STitle) **] tells you it is OK. 2. Stop taking Cartia XT and metoprolol . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet . Please call Dr. [**Last Name (STitle) **] or Dr. [**Last Name (STitle) 3407**] if you have any further bleeding, increasing swelling, pain or redness, fevers or any other concerning symptoms. Followup Instructions: Vascular Surgery: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2135-3-8**] 10:30 Cardiology: [**Last Name (LF) **],[**First Name3 (LF) **] J. [**Telephone/Fax (1) 7960**] Date/Time:

427,998,682,285,E878,780,E942,E941,V436,600,530,428,494,401,V586

{'Other specified cardiac dysrhythmias,Hematoma complicating a procedure,Cellulitis and abscess of trunk,Acute posthemorrhagic anemia,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Syncope and collapse,Coronary vasodilators causing adverse effects in therapeutic use,Sympatholytics [antiadrenergics] causing adverse effects in therapeutic use,Knee joint replacement,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Esophageal reflux,Congestive heart failure, unspecified,Bronchiectasis without acute exacerbation,Unspecified essential hypertension,Long-term (current) use of anticoagulants'}

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: lightheadedness PRESENT ILLNESS: Mr. [**Known firstname **] [**Last Name (NamePattern1) 7518**] is an 85 y/o male with COPD, HTN, AF on coumadin admitted to NEBH [**2-8**] with atrial fibrillation s/p CV developed tachy/brady syndrome s/p AF ablation on [**2-14**] discharged on CCB, metoprolol and dofetilide now presents with presyncope and sinus bradycardia. On [**2-14**] patient underwent EP study which showed several atrial tachycardias and two were ablated. The plan was for cardioversion following ablation but patient converted to NSR and remained in NSR with only 2 brief episodes of AF on telemetry. Since discharge from the hospital on [**2-15**] the patient has been feeling well. He has not had any chest pain, lightheadedness or dizziness until this morning. This AM had minimal appetite at breakfast. Then attempted to have a bowel movement several times with straining and each time felt lightheaded and dizzy with associated diaphoresis. He has been constipated over the past four days. His children were with him, helped him back to bed and called Dr. [**Last Name (STitle) **] who referred him to the Emergency Room. The patient did not ever lose consciousness. He reports that he has been complaint with all of his medications. He denies any associated chest pain or shortness of breath. Patient has history of bradycardia in past when on metoprolol and cardizem (HR ranging from 40-100 bpm). . During the patient's last hospitalization he underwent AF ablation however according to d/c summary only 2 of 4 arrhythmias were ablated. He was in sinus rhythm prior to discharge and was discharged on lopressor, cardizem and dofetilide. . In the ED, initial vitals were HR: 45-55 BP: 78/39, O2sat 96% on RA. Exam notable for patient with good mentation. EKG was initially sinus bradycardia. Patient received 2 g Calcium gluconate and 1L IVF. Symptoms and EKG changes felt to be consistent with too much medication. . On arrival to the CCU, the patient feels "better". He is fatigued but overall improved from this afternoon. HR 50s. BP 111/70. He denies chest pain, shortness of breath, palpitations, cough, abdominal pain, orthopnea, ankle edema and PND. He does report some persistent groin pain, R>L which has improved over the past several days. MEDICAL HISTORY: Atrial fibrillation s/p CV [**2126**] on coumadin hypertension COPD/Bronchiectasis congestive heart failure (unknown ef) gastroesophageal reflux disease, benign prostatic hypertrophy, , anemia, status post bilateral total knee replacements, shoulder arthroplasty . Cardiac Risk Factors: - Diabetes, - Dyslipidemia, + Hypertension MEDICATION ON ADMISSION: Dofetilide 500 mcg PO Q12H Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [**Hospital1 **] Fluticasone 50 mcg/Actuation Spray daily Pantoprazole 40 mg Tablet PO Q24H Ferrous Sulfate 325 mg daily Cyanocobalamin 100 mcg Tablet 5 Tablet PO DAILY Warfarin 1 mg Tablet PO Once Daily at 4PM Metoprolol Tartrate 50 mg Tablet PO BID Cardizem CD 120 mg 1 capsule daily Lovenox 80 mg/0.8 mL ALLERGIES: Horse Blood Extract PHYSICAL EXAM: VS: HR 56, BP 111/52, 100% on 2L Gen: Elderly male NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. FAMILY HISTORY: Significant for heart disease in father (mi [**89**] yo), mother (mi [**08**] yo), and brother (mi [**67**] yo). No diabetes in the family. SOCIAL HISTORY: Social history is significant for the absence of current tobacco use. Former smoker but quit in [**2095**] with 40 pack yr hx. There is no history of alcohol abuse. No illicit drug use. Widowed. Lives alone in [**Location (un) 2312**] and completes all his ADLs. Former fire-fighter but retired 30 years. Has 4 children and 4 grandkids. ### Response: {'Other specified cardiac dysrhythmias,Hematoma complicating a procedure,Cellulitis and abscess of trunk,Acute posthemorrhagic anemia,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Syncope and collapse,Coronary vasodilators causing adverse effects in therapeutic use,Sympatholytics [antiadrenergics] causing adverse effects in therapeutic use,Knee joint replacement,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Esophageal reflux,Congestive heart failure, unspecified,Bronchiectasis without acute exacerbation,Unspecified essential hypertension,Long-term (current) use of anticoagulants'}

CHIEF COMPLAINT: Hypotension, shortness of breath. PRESENT ILLNESS: This is a 59 year old male with a history of hypertension, diabetes, mellitus, hypercholesterolemia, coronary artery disease, congestive heart failure and chronic obstructive pulmonary disease who presented to an outside hospital on [**9-21**], two days prior to transfer, with shortness of breath times two weeks. The patient had been seen by his primary care physician and treated with Solu-Medrol dose pak and Bactrim and had had a chest x-ray consistent with question of pneumonia. The patient had had increasing shortness of breath and on arrival to the Emergency Room for further evaluation complained of some productive cough. The patient was noted to have elevation of his cardiac enzymes and the patient was treated with Heparin initially and Integrilin added when the troponins were noted to be elevated at the outside hospital. The patient became more short of breath, failed noninvasive positive pressure ventilation (NPPV) and required intubation. After intubation, the patient's blood pressure transiently dropped and Dopamine was started to improve his pressures. The patient, however, became tachycardiac and flipped into atrial fibrillation. The patient was treated with Lopressor and Digoxin intravenously and changed to Neo-Synephrine with good blood pressure control. The patient was also receiving Propofol for division. As well the patient received an insulin drip. Foley catheter was placed with some difficulty by the urologist at the outside hospital and noted to have some blood-tinged urine. Of note, the patient's intubation was very difficult. The patient was transferred to [**Hospital6 1760**] for further evaluation. MEDICAL HISTORY: 1. Diabetes mellitus; 2. Hypertension; 3. Hypercholesterolemia; 4. Coronary artery disease; 5. Congestive heart failure; 6. Chronic obstructive pulmonary disease; 7. Peripheral neuropathy. MEDICATION ON ADMISSION: ALLERGIES: Penicillin. PHYSICAL EXAM: FAMILY HISTORY: History of coronary artery disease. SOCIAL HISTORY:

Acute respiratory failure,Congestive heart failure, unspecified,Pneumonia, organism unspecified,Atrial fibrillation,Alkalosis,Chronic obstructive asthma, unspecified,Unspecified septicemia,Acute kidney failure with lesion of tubular necrosis

Acute respiratry failure,CHF NOS,Pneumonia, organism NOS,Atrial fibrillation,Alkalosis,Chronic obst asthma NOS,Septicemia NOS,Ac kidny fail, tubr necr

Admission Date: [**2193-9-23**] Discharge Date: [**2193-9-29**] Date of Birth: [**2134-9-20**] Sex: M Service: Medical Intensive Care Unit - [**Location (un) **] Team CHIEF COMPLAINT: Hypotension, shortness of breath. HISTORY OF PRESENT ILLNESS: This is a 59 year old male with a history of hypertension, diabetes, mellitus, hypercholesterolemia, coronary artery disease, congestive heart failure and chronic obstructive pulmonary disease who presented to an outside hospital on [**9-21**], two days prior to transfer, with shortness of breath times two weeks. The patient had been seen by his primary care physician and treated with Solu-Medrol dose pak and Bactrim and had had a chest x-ray consistent with question of pneumonia. The patient had had increasing shortness of breath and on arrival to the Emergency Room for further evaluation complained of some productive cough. The patient was noted to have elevation of his cardiac enzymes and the patient was treated with Heparin initially and Integrilin added when the troponins were noted to be elevated at the outside hospital. The patient became more short of breath, failed noninvasive positive pressure ventilation (NPPV) and required intubation. After intubation, the patient's blood pressure transiently dropped and Dopamine was started to improve his pressures. The patient, however, became tachycardiac and flipped into atrial fibrillation. The patient was treated with Lopressor and Digoxin intravenously and changed to Neo-Synephrine with good blood pressure control. The patient was also receiving Propofol for division. As well the patient received an insulin drip. Foley catheter was placed with some difficulty by the urologist at the outside hospital and noted to have some blood-tinged urine. Of note, the patient's intubation was very difficult. The patient was transferred to [**Hospital6 1760**] for further evaluation. On transfer to the [**Hospital6 256**] the patient's Propofol was changed to Ativan for sedation. The patient's insulin drip was discontinued. The patient continued to be on Neo-Synephrine, heparin and Integrilin drips for control. On arrival the patient was sedated with some Ativan on transfer and this was changed to a drip. At the outside hospital the patient also had a pneumonia which was treated with Levaquin. PAST MEDICAL HISTORY: 1. Diabetes mellitus; 2. Hypertension; 3. Hypercholesterolemia; 4. Coronary artery disease; 5. Congestive heart failure; 6. Chronic obstructive pulmonary disease; 7. Peripheral neuropathy. ALLERGIES: Penicillin. HOME MEDICATIONS: Lescol 80 mg p.o. q.d.; Lisinopril 20 mg p.o. q.d.; Albuterol inhaler; Medrol dose pak; Bactrim; Lasix 20 b.i.d.; Metformin 500 b.i.d.; Actos; insulin 70/30 62 q. AM, 68 units q. PM ? unclear FAMILY HISTORY: History of coronary artery disease. REVIEW OF SYSTEMS: At the outside hospital the patient denied fevers, chills, and had some shortness of breath and cough. PHYSICAL EXAMINATION: Temperature 98.7, blood pressure 124/68, 138 kg. The patient was sating 100%, central venous pressure 12, fingersticks of 94. The patient was ventilated on assist control 650 times 12/100% FIO2 with PIPs of 36, plateaus of 27 and a positive end-expiratory pressure of 5%. In general, this was an obese man in no apparent distress. Endotracheal tube was in place and he was sedated. Head, eyes, ears, nose and throat: The patient was normocephalic, atraumatic. Pupils equal, round and reactive to light, oropharynx clear. Neck: Obese, no lymphadenopathy, right subclavian was in place. Lungs: Decreased breathsounds at the bases, bibasilar crackles noted. Cardiovascular: The patient had distant heartsounds, irregular, atrial fibrillation. Abdominal: The patient was very obese, distended, nontender with decreased bowel sounds. Extremities: 2+ pitting edema. Neurological: The patient was not responding to verbal tactile stimuli and moving all four extremities well. LABORATORY DATA: Pertinent for white count of 10.9 with differential of 75% polys, 16% lymphs, and 6% monos, hematocrit of 30.5, platelets 533. Bicarbonate 24, creatinine 1.5, BUN 51, INR 1.1. Calcium 8.4, magnesium 1.5, albumin 2.3, alkaline phosphatase 295, total bilirubin 0.2, ALT 23, AST 20. Creatinine kinase 170, MB 6, troponin 0.22. Urinalysis greater than 50 red blood cells, [**1-16**] white blood cells, occasional bacteria. Electrocardiogram: Atrial fibrillation with a rate of 84, regular rate and rhythm, T wave inversions in V1 to V4, [**Street Address(2) 28585**] depressions in V3 and .[**Street Address(2) 1755**] depression in V4 to V5, not significantly changes from the outside hospital. Chest x-ray: Question of congestive heart failure and left retrocardiac opacity. Arterial blood gases: 7.44/pCO2 42, pO2 212 on the current vent settings, as described above, lactate 0.8. HOSPITAL COURSE: 1. Respiratory failure - The patient was maintained on ventilator given his hospital course for multifactorial respiratory failure in the setting of chronic obstructive pulmonary disease flare, congestive heart failure on examination and x-ray and pneumonia on x-ray. The patient was maintained on a ventilator, assist control and subsequently weaned off of pressure support as tolerated. 2. Congestive heart failure - The patient was thought to be in congestive heart failure contributing the respiratory failure. Unclear etiology, whether this was due in the setting of acute coronary syndrome with a troponin leak versus atrial fibrillation with history of hypertension. The Cardiology Team was consulted regarding the care of this patient and they felt that the troponin leak was not due to acute coronary syndrome but was instead due to sepsis versus demand ischemia in this patient with atrial fibrillation. The patient was subsequently started on Lasix drip with improvement of his diuresis on hospital day #6, after several attempts at diuresis, and the patient subsequently had significant diuresis with both the Lasix drip and Acetazolamide that was initiated for his worsening alkalosis. 3. Chronic obstructive pulmonary disease - The patient had significant wheezing on examination, history of chronic obstructive pulmonary disease and question of asthma. The patient was started on intravenous steroids and tapered to p.o. by hospital day #6. Around-the-clock nebulizers and with metered dose inhalers, Atrovent and Albuterol, were started for the remainder of his hospital course with the improvement of his wheezing. 4. Pneumonia - The patient had evidence of left retrocardiac opacity on chest x-ray on admission. The patient was started on Levofloxacin for a total 10 day course and also was subsequently continued to spike on hospital day #3 and Ceftazidime was added for events of associated pneumonia given the temperature spike. The patient remained afebrile throughout the remainder of the course with a decrease in his white blood cell count. 5. Troponin leak - The patient had positive enzymes at the outside hospital and here. Creatinine kinase was trended. There was consideration of acute coronary syndrome but the electrocardiogram showed no dynamic changes since outside hospital films. Again Cardiology was consulted as above and they felt this troponin leak was not due to acute coronary syndrome. The patient, however, was maintained on Aspirin, statin, during this admission. Once the patient was off of pressors, beta blocker was started as was the ACE inhibitor. The patient was initially on Integrilin on transfer to the hospital here and this was discontinued after Cardiology's recommendation that this was not likely to be acute coronary syndrome. 6. Hypotension - The patient initially presented with sepsis-like picture and the patient was maintained on Neo-Synephrine for pressure support, subsequently weaned off on hospital day #3 with improvement of his mean arterial pressures to greater than 50 degrees. 7. Atrial fibrillation - The patient resolved spontaneously on hospital day #2 from his atrial fibrillation and was in normal sinus rhythm for the remainder of his hospital course. It was felt that this was new and possibly due to paroxysmal atrial fibrillation and question side effect of Dopamine as per outside hospital records. The patient was maintained on beta blocker once off pressure for rate control and maintained on Telemetry without further event. The patient was not on heparin in the setting of genitourinary bleed. 8. Acute renal failure - The patient had elevation of BUN and creatinine, slightly resolved with intravenous fluids and subsequently improved with hydration. However, slight bump on hospital day #4 was likely due to worsening congestive heart failure at which point Lasix drip was initiated with improvement of his renal status. There is a question of hyperperfusion as a cause compounded with acute tubular necrosis. This was also in the setting of complete, continued bleeding from the bladder from traumatic Foley catheter. The patient was maintained on continuous bladder irrigation for removal of clots with the assistance of Urology's recommendation and care. 9. Decreased hematocrit - In the setting of genitourinary bleed, and heparin and Integrilin on transfer to the hospital after traumatic Foley catheter placement, the patient was consented for blood type and screen and received packed red cells during this hospital admission for maintained of his hematocrit. By hospital day #5, the patient's hematocrit was stable with resolution of the genitourinary bleed. 10. Fluids, electrolytes and nutrition - The patient was maintained on tube feeds during his hospital administration while intubated. 11. Code status - The patient was full code. Communication was with the family, wife [**Name (NI) 1439**]. 12. Prophylaxis - The patient was maintained on pneuma boots for deep vein thrombosis prophylaxis and proton pump inhibitor for gastrointestinal prophylaxis. DISPOSITION: To be determined by the next intern who will dictate the remainder of this [**Hospital 228**] hospital course in the Medicine Intensive Care Unit. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**], M.D. [**MD Number(1) 2438**] Dictated By:[**Last Name (NamePattern1) 5227**] MEDQUIST36 D: [**2193-9-29**] 14:23 T: [**2193-9-29**] 18:41 JOB#: [**Job Number 50724**] Name: [**Known lastname 9420**], [**Known firstname 9421**] Unit No: [**Numeric Identifier 9422**] Admission Date: [**2193-9-23**] Discharge Date: [**2193-10-4**] Date of Birth: [**2134-9-20**] Sex: M Service: ADDENDUM: This report covers the [**Hospital 1325**] hospital stay from [**10-2**] until [**10-4**] following his being called out from the Medical Intensive Care Unit. In brief, this is a 59 year old male with a history of hypertension, diabetes mellitus, multiple cardiac risk factors, chronic obstructive pulmonary disease, and congestive heart failure, who presented to an outside hospital on [**2193-9-21**] following a two week history of shortness of breath. At the outside hospital the patient presented with increasing shortness of breath, cough, elevated cardiac enzymes requiring intubations and pressors for hypotension with subsequent transfer to [**Hospital1 960**] for further management. The patient was admitted to the Medical Intensive Care Unit and initially treated for respiratory failure in the setting of chronic obstructive pulmonary disease with possible pneumonia, congestive heart failure exacerbation and elevated cardiac enzymes of unclear etiology, seemed less likely to be acute coronary syndrome, but rather sepsis or atrial fibrillation with tachycardia causing demand ischemia. Also treated for chronic obstructive pulmonary disease, now on a Prednisone taper; pneumonia treated with Levaquin and ceftazidine both of which courses were completed in the Intensive Care Unit with resolved hypotension and atrial fibrillation. Current management at the time of his discharge from the Medical Intensive Care Unit on [**2193-10-2**], included improving respiratory status, continued chronic obstructive pulmonary disease and congestive heart failure treatment, continued following for a chronic genitourinary bleed and blood glucose management in the setting of diabetes mellitus. REVIEW OF HOSPITAL COURSE BY PROBLEM: 1. CONGESTIVE HEART FAILURE: Well compensated. The patient was auto diuresing and was continued on Carvedilol and Lisinopril. 2. CORONARY ARTERY DISEASE: The patient showed no evidence of continued ischemia and was back to his baseline. He was continued on aspirin and beta blocker therapy. 3. CHRONIC OBSTRUCTIVE PULMONARY DISEASE: The patient was continued on a Prednisone taper discontinued with MDI and inhalers. He had completed his course of antibiotics for a suspected pneumonia. 4. HYPERGLYCEMIA: The patient initially had blood sugars in the 300 to 400s. This was while on a Prednisone taper. [**First Name8 (NamePattern2) **] [**Last Name (un) 616**] recommendations, his NPH and insulin regimen was increased and he was also continued on a Humalog sliding scale. The patient was to be discharged with close follow-up with his primary care physician following discharge to follow his blood sugars with the understanding that the sugars would be more easily managed on discontinuing of the Prednisone taper. 5. HEMATURIA: The patient was scheduled to follow-up with Urology for persistent hematuria following Foley catheterization. The patient also reported a long history of intermittent hematuria that was painless. This would be worked up additionally as an outpatient. The patient was hemodynamically stable without significant blood loss by discharge. DISCHARGE MEDICATIONS: 1. Atorvastatin 40 mg p.o. q. day. 2. Aspirin 81 mg p.o. q. day. 3. Bupropion 150 mg p.o. twice a day. 4. Albuterol metered dose inhaler 90 mcg, two puffs q. four hours as needed. 5. Ipratroprium 18 mcg four puffs inhalation four times a day. 6. Colace 100 mg p.o. twice a day. 7. Pantoprazole 40 mg p.o. q. day. 8. Ambien 5 mg p.o. q. h.s. at bed time. 9. Carvedilol 6.25 mg p.o. twice a day. 10. Lisinopril 5 mg p.o. q. day. 11. Insulin NPH 68 units in the a.m. and 26 units in the p.m. 12. Humalog sliding scale. 13. Prednisone taper starting at 20 mg over the course of the next three to four days. DISCHARGE DIAGNOSES: 1. Diabetes mellitus. 2. Chronic obstructive pulmonary disease. 3. Congestive heart failure / diastolic dysfunction. 4. Respiratory failure. 5. Anemia. 6. Hematuria. 7. Hyperglycemia. 8. Paroxysmal atrial fibrillation. 9. Pneumonia. 10. Non-ST elevation myocardial infarction in the setting of sepsis. CONDITION AT DISCHARGE: The patient was stable on discharge. He was breathing comfortably on room air, ambulating without difficulty. Reports that he is at his baseline in terms of shortness of breath and function. DISCHARGE STATUS: The patient was discharged home with [**Hospital6 1346**] services for follow-up in his home setting. DISCHARGE INSTRUCTIONS: 1. The patient was to follow-up with Dr. [**First Name (STitle) **] at the Cornerstone Family Practice at [**Telephone/Fax (1) 7907**] on Monday, [**10-7**], at 10:30 a.m. 2. It was discussed that the patient will need scheduling for an outpatient stress test, diabetes mellitus and continued hematuria work-up. 3. The patient was scheduled to follow-up with Dr. [**Last Name (STitle) 9423**] of Urology at [**Telephone/Fax (1) 7907**] for persistent hematuria. The patient was instructed to call for an appointment. ADDENDUM: Please note that in the Discharge Summary recorded on POE that the insulin dosing is incorrect. The insulin dosing reads NPH SS-Regular insulin 50/50, 68 units in the a.m. and 26 units in the p.m.; this is incorrect. The actual dosing should be NPH insulin 68 units in the a.m. and 26 units in the p.m. It was brought to the attention of this physician that the patient was discharged on an incorrect dose of insulin. The patient was subsequently contact[**Name (NI) **] at home and made aware of this situation; Pharmacy was consulted as well as well as the primary care physician. [**Name10 (NameIs) **] patient reported no adverse event following the incorrectly prescribed insulin dose. The patient was able to fill his prescriptions at the correct dose which was 68 units of NPH in the a.m. and 26 units in the p.m. with a Humalog sliding scale that was given to the patient over the phone. The patient was scheduled for follow-up and was able to make his appointment two days following discharge with his primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **]. [**Name6 (MD) **] [**Last Name (NamePattern4) 424**], M.D. [**MD Number(1) 425**] Dictated By:[**Last Name (NamePattern1) 4517**] MEDQUIST36 D: [**2193-11-5**] 14:16 T: [**2193-11-5**] 14:39 JOB#: [**Job Number 9424**]

518,428,486,427,276,493,038,584

{'Acute respiratory failure,Congestive heart failure, unspecified,Pneumonia, organism unspecified,Atrial fibrillation,Alkalosis,Chronic obstructive asthma, unspecified,Unspecified septicemia,Acute kidney failure with lesion of tubular necrosis'}

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: Hypotension, shortness of breath. PRESENT ILLNESS: This is a 59 year old male with a history of hypertension, diabetes, mellitus, hypercholesterolemia, coronary artery disease, congestive heart failure and chronic obstructive pulmonary disease who presented to an outside hospital on [**9-21**], two days prior to transfer, with shortness of breath times two weeks. The patient had been seen by his primary care physician and treated with Solu-Medrol dose pak and Bactrim and had had a chest x-ray consistent with question of pneumonia. The patient had had increasing shortness of breath and on arrival to the Emergency Room for further evaluation complained of some productive cough. The patient was noted to have elevation of his cardiac enzymes and the patient was treated with Heparin initially and Integrilin added when the troponins were noted to be elevated at the outside hospital. The patient became more short of breath, failed noninvasive positive pressure ventilation (NPPV) and required intubation. After intubation, the patient's blood pressure transiently dropped and Dopamine was started to improve his pressures. The patient, however, became tachycardiac and flipped into atrial fibrillation. The patient was treated with Lopressor and Digoxin intravenously and changed to Neo-Synephrine with good blood pressure control. The patient was also receiving Propofol for division. As well the patient received an insulin drip. Foley catheter was placed with some difficulty by the urologist at the outside hospital and noted to have some blood-tinged urine. Of note, the patient's intubation was very difficult. The patient was transferred to [**Hospital6 1760**] for further evaluation. MEDICAL HISTORY: 1. Diabetes mellitus; 2. Hypertension; 3. Hypercholesterolemia; 4. Coronary artery disease; 5. Congestive heart failure; 6. Chronic obstructive pulmonary disease; 7. Peripheral neuropathy. MEDICATION ON ADMISSION: ALLERGIES: Penicillin. PHYSICAL EXAM: FAMILY HISTORY: History of coronary artery disease. SOCIAL HISTORY: ### Response: {'Acute respiratory failure,Congestive heart failure, unspecified,Pneumonia, organism unspecified,Atrial fibrillation,Alkalosis,Chronic obstructive asthma, unspecified,Unspecified septicemia,Acute kidney failure with lesion of tubular necrosis'}

CHIEF COMPLAINT: Progressive dyspnea on exertion PRESENT ILLNESS: 58 year-old gentleman who has had progressive dyspnea on exertion. He also had a prior history of aortic stenosis and underwent cardiac catheterization in [**Month (only) 547**] which showed no significant coronary artery disease with severe aortic stenosis and mitral regurgitation. Echocardiogram performed on [**2131-1-31**] showed posterior mitral valve leaflet prolapse with moderate-to-severe MR, severe aortic stenosis with aortic valve area of 0.6 cm2 (peak gradient of 39 mm and mean gradient of 22 mm), and ejection fraction of 55%.Dr.[**Last Name (STitle) **] was consulted for surgical intervention and valvular replacement. MEDICAL HISTORY: metabolic syndrome, hypertension, non-insulin-dependent diabetes mellitus, mitral regurgitation, aortic stenosis, aortic insufficiency, obstructive sleep apnea, chronic obstructive pulmonary disease, and pulmonary hypertension. MEDICATION ON ADMISSION: Quinaretic 20/25 mg daily, Cartia XT 180 mg daily, Cozaar 100 mg daily, Simvastatin 80 mg daily, TriCor 48 mg daily, Aspirin 325 mg daily, Glucotrol 5 mg daily, Metformin 500 mg q.a.m. and 1000 mg q.p.m., Lasix 40 mg daily, Albuterol Inhalers, and Flovent Inhalers two puffs twice a day. ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: On exam, his heart rate is 73, respiratory rate 16, and blood pressure of 103/74. He is well developed and well nourished in no apparent distress. Skin was unremarkable and intact. His EOMs were intact. His pupils were equally round and reactive to light and accommodation. Neck was supple with full range of motion and no JVD or carotid bruitswere appreciated. Lungs were clear bilaterally. Heart revealsa regular rate and rhythm with a grade II/VI holosystolic murmur. Abdomen was soft, nontender, and nondistended with positive bowel sounds. Extremities were warm and well perfused without any edema or varicosities. He was alert and oriented x3. He is moving all extremities and had a nonfocal neurologic exam. FAMILY HISTORY: His father had coronary artery bypass surgery in his 50s and died in his early 60s. A strong family history is also present of diabetes. SOCIAL HISTORY: He works as a contractor. His last dental examination was two months ago. He denies using tobacco currently but has used it occasionally in the past. However, he does have significant alcohol problem as he admits to six to nine beers per day...patient states he was quit drinking ETOH over the last month.

Mitral valve insufficiency and aortic valve stenosis,Cardiac complications, not elsewhere classified,Atrioventricular block, complete,Congestive heart failure, unspecified,Other chronic pulmonary heart diseases,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Chronic obstructive asthma, unspecified,Dysmetabolic syndrome X,Paroxysmal tachycardia, unspecified,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Accidents occurring in residential institution

Mitral insuf/aort stenos,Surg compl-heart,Atriovent block complete,CHF NOS,Chr pulmon heart dis NEC,DMII wo cmp nt st uncntr,Chronic obst asthma NOS,Dysmetabolic syndrome x,Parox tachycardia NOS,Abn react-artif implant,Accid in resident instit

Admission Date: [**2131-5-23**] Discharge Date: [**2131-6-9**] Date of Birth: [**2072-7-22**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Progressive dyspnea on exertion Major Surgical or Invasive Procedure: Aortic Valve Replacement (#21mm St.[**Male First Name (un) 923**] Mechanical)/Mitral Valve Replacement (#29mm St.[**Male First Name (un) 923**] Mechanical)-[**5-23**] History of Present Illness: 58 year-old gentleman who has had progressive dyspnea on exertion. He also had a prior history of aortic stenosis and underwent cardiac catheterization in [**Month (only) 547**] which showed no significant coronary artery disease with severe aortic stenosis and mitral regurgitation. Echocardiogram performed on [**2131-1-31**] showed posterior mitral valve leaflet prolapse with moderate-to-severe MR, severe aortic stenosis with aortic valve area of 0.6 cm2 (peak gradient of 39 mm and mean gradient of 22 mm), and ejection fraction of 55%.Dr.[**Last Name (STitle) **] was consulted for surgical intervention and valvular replacement. Past Medical History: metabolic syndrome, hypertension, non-insulin-dependent diabetes mellitus, mitral regurgitation, aortic stenosis, aortic insufficiency, obstructive sleep apnea, chronic obstructive pulmonary disease, and pulmonary hypertension. Social History: He works as a contractor. His last dental examination was two months ago. He denies using tobacco currently but has used it occasionally in the past. However, he does have significant alcohol problem as he admits to six to nine beers per day...patient states he was quit drinking ETOH over the last month. Family History: His father had coronary artery bypass surgery in his 50s and died in his early 60s. A strong family history is also present of diabetes. Physical Exam: On exam, his heart rate is 73, respiratory rate 16, and blood pressure of 103/74. He is well developed and well nourished in no apparent distress. Skin was unremarkable and intact. His EOMs were intact. His pupils were equally round and reactive to light and accommodation. Neck was supple with full range of motion and no JVD or carotid bruitswere appreciated. Lungs were clear bilaterally. Heart revealsa regular rate and rhythm with a grade II/VI holosystolic murmur. Abdomen was soft, nontender, and nondistended with positive bowel sounds. Extremities were warm and well perfused without any edema or varicosities. He was alert and oriented x3. He is moving all extremities and had a nonfocal neurologic exam. He had 2+ bilateral femoral DP, PT, and radial pulses. Pertinent Results: [**2131-6-8**] 05:10AM BLOOD PT-24.3* PTT-87.7* INR(PT)-2.3* [**2131-6-7**] 05:30AM BLOOD PT-24.8* PTT-63.7* INR(PT)-2.4* [**2131-6-6**] 06:10AM BLOOD PT-20.4* PTT-64.6* INR(PT)-1.9* [**2131-6-5**] 06:05AM BLOOD PT-19.0* PTT-58.9* INR(PT)-1.7* [**2131-6-4**] 08:55AM BLOOD PT-19.9* PTT-77.4* INR(PT)-1.8* [**2131-5-23**] 05:46PM BLOOD WBC-7.7 RBC-3.02*# Hgb-8.6*# Hct-25.1*# MCV-83 MCH-28.4 MCHC-34.2 RDW-13.6 Plt Ct-120* [**2131-5-23**] 05:46PM BLOOD PT-15.0* PTT-33.2 INR(PT)-1.3* [**2131-5-26**] 02:11AM BLOOD Calcium-8.1* Phos-2.3* Mg-2.2 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT Done [**2131-5-29**] at 2:30:00 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. [**Hospital1 18**], Division of Cardiothorac [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2072-7-22**] Age (years): 58 M Hgt (in): 68 BP (mm Hg): 119/81 Wgt (lb): 205 HR (bpm): 75 BSA (m2): 2.07 m2 Indication: H/O cardiac surgery with 21mm [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] AVR, and [**First Name8 (NamePattern2) 70723**] [**Male First Name (un) 923**] MVR. ICD-9 Codes: V43.3, 424.1, 424.0 Test Information Date/Time: [**2131-5-29**] at 14:30 Interpret MD: [**First Name11 (Name Pattern1) 553**] [**Last Name (NamePattern4) 4133**], MD Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) 4134**] [**Last Name (NamePattern1) 4135**], RDCS Doppler: Full Doppler and color Doppler Test Location: [**Location 13333**]/[**Hospital Ward Name 121**] 6 Contrast: None Tech Quality: Suboptimal Tape #: 2009W051-0:18 Machine: Vivid [**5-28**] Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: >= 60% >= 55% Aortic Valve - Peak Velocity: *2.8 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: *30 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 15 mm Hg Mitral Valve - Peak Velocity: 1.6 m/sec Mitral Valve - Mean Gradient: 5 mm Hg Mitral Valve - E Wave: 1.6 m/sec Mitral Valve - A Wave: 1.1 m/sec Mitral Valve - E/A ratio: 1.45 Mitral Valve - E Wave deceleration time: 209 ms 140-250 ms TR Gradient (+ RA = PASP): *30 mm Hg <= 25 mm Hg Findings LEFT VENTRICLE: Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. Low normal LVEF. No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. Paradoxic septal motion consistent with prior cardiac surgery. AORTIC VALVE: Bileaflet aortic valve prosthesis (AVR). Normal AVR gradient. No AR. MITRAL VALVE: Bileaflet mitral valve prosthesis (MVR). Normal MVR gradient. Trivial MR. [Due to acoustic shadowing, the severity of MR may be significantly UNDERestimated.] TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Mild PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor parasternal views. Suboptimal image quality - bandages, defibrillator pads or electrodes. Conclusions Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. A bileaflet aortic valve prosthesis is present and appears well-seated. The transaortic gradient is normal for this prosthesis. No aortic regurgitation is seen. A bileaflet mitral valve prosthesis is present and appears well-seated. The transmitral gradient is normal for this prosthesis. Trivial mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Electronically signed by [**First Name11 (Name Pattern1) 553**] [**Last Name (NamePattern4) 4133**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2131-5-29**] 17:33 Brief Hospital Course: [**5-23**] Mr.[**Known lastname 82119**] went to the operating room and underwent Aortic Valve Replacement (#21mm St.[**Male First Name (un) 923**] Mechanical)/Mitral Valve Replacement (#29mm St.[**Male First Name (un) 923**] Mechanical).Cross clamp time=126 minutes. Cardiopulmonary Bypass time=148 minutes. Please refer to Dr[**Last Name (STitle) **] operative report for further details. He tolerated the procedure well and was transferred to the CVICU in critical but stable condition, requiring pressors and inotrope to optimize cardiac output. He awoke neurologically intact and was extubated without difficulty. All drips were weaned to off. Beta-blocker was initially held off due to a first degree AV block. Anticoagulation was started with Coumadin, and bridged with a Heparin drip for therapeutic INR with mechanical valves. [**Last Name (un) **] was consulted for glucose control. Low dose Beta-blocker was ultimately started due to his increased heart rate. His rate blocked down, beta-blocker discontinued , and Electrophysiology was consulted. POD#9 PPM was placed secondary to heart block. EP interrogated the PPM and continued to follow. The remainder of his postoperative course was essentially uneventful. Discharge was dependent upon therapeutic INR. On POD# 17/8 Mr.[**Known lastname 82119**] was cleared by Dr.[**Last Name (STitle) **] for discharge to home with VNA. All follow up appointments were advised. Coumadin/INR to be followed by his PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 74648**]. Medications on Admission: Quinaretic 20/25 mg daily, Cartia XT 180 mg daily, Cozaar 100 mg daily, Simvastatin 80 mg daily, TriCor 48 mg daily, Aspirin 325 mg daily, Glucotrol 5 mg daily, Metformin 500 mg q.a.m. and 1000 mg q.p.m., Lasix 40 mg daily, Albuterol Inhalers, and Flovent Inhalers two puffs twice a day. Discharge Medications: 1. Outpatient Lab Work Dr. [**Last Name (STitle) **] will follow INR (confirmed with [**Doctor First Name **] in office) (P) [**Telephone/Fax (1) 82120**], (F) [**Telephone/Fax (1) 81987**]. VNA to fax results to office for titration. 2. Zocor 80 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*0* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Tablet, Delayed Release (E.C.)(s) 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 8. Fenofibrate Micronized 48 mg Tablet Sig: One (1) Tablet PO daily () as needed for hyperlipidemia. Disp:*30 Tablet(s)* Refills:*0* 9. Glipizide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*0* 10. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 12. Warfarin 2.5 mg Tablet Sig: as directed Tablet PO once a day: Please take 7.5 mg daily. INR will be checked monday by VNA and your doctor will call you with dose changes as needed. Disp:*90 Tablet(s)* Refills:*0* 13. Warfarin 1 mg Tablet Sig: as directed Tablet PO once a day: Please take 7.5 mg daily. INR will be checked monday by VNA and your doctor will call you with dose changes as needed. Disp:*50 Tablet(s)* Refills:*0* 14. Insulin Glargine 100 unit/mL Solution Sig: 15 units Subcutaneous at bedtime. Disp:*qs qs* Refills:*0* 15. Insulin Lispro 100 unit/mL Solution Sig: as directed Subcutaneous every six (6) hours: see discharge instructions for scale. Disp:*qs qs* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] [**Location (un) 14663**] Discharge Diagnosis: mitral regurgitation aortic stenosis s/p AVR, MVR this admission Discharge Condition: good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] H. [**Telephone/Fax (1) 4688**]-in 1 week please call for appointment Dr. [**Last Name (STitle) **] will follow INR, confirmed with [**Hospital1 **] VNA to draw PT/INR Mon. [**2131-6-11**] and call results to Dr. [**Last Name (STitle) **] Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse ([**Telephone/Fax (1) 3071**] Completed by:[**2131-6-9**]

396,997,426,428,416,250,493,277,427,E878,E849

{'Mitral valve insufficiency and aortic valve stenosis,Cardiac complications, not elsewhere classified,Atrioventricular block, complete,Congestive heart failure, unspecified,Other chronic pulmonary heart diseases,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Chronic obstructive asthma, unspecified,Dysmetabolic syndrome X,Paroxysmal tachycardia, unspecified,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Accidents occurring in residential institution'}

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: Progressive dyspnea on exertion PRESENT ILLNESS: 58 year-old gentleman who has had progressive dyspnea on exertion. He also had a prior history of aortic stenosis and underwent cardiac catheterization in [**Month (only) 547**] which showed no significant coronary artery disease with severe aortic stenosis and mitral regurgitation. Echocardiogram performed on [**2131-1-31**] showed posterior mitral valve leaflet prolapse with moderate-to-severe MR, severe aortic stenosis with aortic valve area of 0.6 cm2 (peak gradient of 39 mm and mean gradient of 22 mm), and ejection fraction of 55%.Dr.[**Last Name (STitle) **] was consulted for surgical intervention and valvular replacement. MEDICAL HISTORY: metabolic syndrome, hypertension, non-insulin-dependent diabetes mellitus, mitral regurgitation, aortic stenosis, aortic insufficiency, obstructive sleep apnea, chronic obstructive pulmonary disease, and pulmonary hypertension. MEDICATION ON ADMISSION: Quinaretic 20/25 mg daily, Cartia XT 180 mg daily, Cozaar 100 mg daily, Simvastatin 80 mg daily, TriCor 48 mg daily, Aspirin 325 mg daily, Glucotrol 5 mg daily, Metformin 500 mg q.a.m. and 1000 mg q.p.m., Lasix 40 mg daily, Albuterol Inhalers, and Flovent Inhalers two puffs twice a day. ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: On exam, his heart rate is 73, respiratory rate 16, and blood pressure of 103/74. He is well developed and well nourished in no apparent distress. Skin was unremarkable and intact. His EOMs were intact. His pupils were equally round and reactive to light and accommodation. Neck was supple with full range of motion and no JVD or carotid bruitswere appreciated. Lungs were clear bilaterally. Heart revealsa regular rate and rhythm with a grade II/VI holosystolic murmur. Abdomen was soft, nontender, and nondistended with positive bowel sounds. Extremities were warm and well perfused without any edema or varicosities. He was alert and oriented x3. He is moving all extremities and had a nonfocal neurologic exam. FAMILY HISTORY: His father had coronary artery bypass surgery in his 50s and died in his early 60s. A strong family history is also present of diabetes. SOCIAL HISTORY: He works as a contractor. His last dental examination was two months ago. He denies using tobacco currently but has used it occasionally in the past. However, he does have significant alcohol problem as he admits to six to nine beers per day...patient states he was quit drinking ETOH over the last month. ### Response: {'Mitral valve insufficiency and aortic valve stenosis,Cardiac complications, not elsewhere classified,Atrioventricular block, complete,Congestive heart failure, unspecified,Other chronic pulmonary heart diseases,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Chronic obstructive asthma, unspecified,Dysmetabolic syndrome X,Paroxysmal tachycardia, unspecified,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Accidents occurring in residential institution'}

CHIEF COMPLAINT: Food Impaction PRESENT ILLNESS: Ms. [**Known lastname 91418**] is an 84 y/o F with a h/o AF on coumadin, recent hip fracture s/p repair three weeks ago who presented to [**Hospital1 **] [**Location (un) 620**] from rehab on [**2175-9-26**] with worsening dysphagia after swallowing pills that morning. She has a history of chronic dysphagia, but has never had an EGD prior to her admission to [**Location (un) 620**]. On presentation to [**Location (un) 620**] she was complaining of the sensation of something stuck in her throat, along with difficulty swallowing her secretions. She denies any pain when she swallows, but did complain of a constant pain in her throat. At [**Hospital1 **] [**Location (un) 620**] she underwent an EGD which showed a possible Zenker's diverticulum with food impaction. The GI doctors were [**Name5 (PTitle) 460**] to pass the scope but were not able to clear the impaction. Peri procedure she went into AF with RVR to the 140's, but with stable systolic blood pressures. She was given IV metoprolol with improvement in her heart rate to the 100's. As GI was unable to remove the food impaction it was decided that she would be transferred to [**Hospital1 18**] for ENT evaluation and removal of the food impaction. . On arrival to the ICU her initial VS were: 98.1, 103, 157/86, 16, 100% on 2LNC. She currently feels well, not having any chest pain, palpitations, difficulty with her secretions or abdominal pain. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. MEDICAL HISTORY: Atrial fibrillation on Coumadin Diabetes Hypertension Hyperlipidemia Hip fracture History of elbow fracture MEDICATION ON ADMISSION: Diltiazem 120 mg daily Fentanyl topical 12 mcg every 72 hours Folic acid 1 mg daily Lasix 40 mg daily Metformin 1000 twice a day Metoprolol 50 mg daily MiraLAX powder Potassium chloride supplement 20 mEq daily Pravachol 20 mg at bedtime Vitamin B12 1000 mcg daily Vitamin B6 50 mg daily Dulcolax suppository and Fleet enemas Januvia 100 mg once a day Coumadin between 3 and 5 mg daily Lactulose as needed for constipation Percocet for pain Tramadol 50 mg b.i.d. p.r.n. Zofran 4 mg every 6 hours p.r.n. ALLERGIES: azithromycin PHYSICAL EXAM: Admission Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema FAMILY HISTORY: Non-contributory SOCIAL HISTORY: Recently in rehab but before that was living at home, was independent of ADLs. Denies smoking or alcohol.

Dysphagia, unspecified,Atrial fibrillation,Long-term (current) use of anticoagulants,Anemia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Osteoporosis, unspecified,Do not resuscitate status

Dysphagia NOS,Atrial fibrillation,Long-term use anticoagul,Anemia NOS,DMII wo cmp nt st uncntr,Osteoporosis NOS,Do not resusctate status

Admission Date: [**2175-9-27**] Discharge Date: [**2175-9-30**] Date of Birth: [**2091-5-25**] Sex: F Service: MEDICINE Allergies: azithromycin Attending:[**First Name3 (LF) 2782**] Chief Complaint: Food Impaction Major Surgical or Invasive Procedure: Direct laryngoscopy, direct rigid and flexible esophagoscopy, balloon dilation esophagus. History of Present Illness: Ms. [**Known lastname 91418**] is an 84 y/o F with a h/o AF on coumadin, recent hip fracture s/p repair three weeks ago who presented to [**Hospital1 **] [**Location (un) 620**] from rehab on [**2175-9-26**] with worsening dysphagia after swallowing pills that morning. She has a history of chronic dysphagia, but has never had an EGD prior to her admission to [**Location (un) 620**]. On presentation to [**Location (un) 620**] she was complaining of the sensation of something stuck in her throat, along with difficulty swallowing her secretions. She denies any pain when she swallows, but did complain of a constant pain in her throat. At [**Hospital1 **] [**Location (un) 620**] she underwent an EGD which showed a possible Zenker's diverticulum with food impaction. The GI doctors were [**Name5 (PTitle) 460**] to pass the scope but were not able to clear the impaction. Peri procedure she went into AF with RVR to the 140's, but with stable systolic blood pressures. She was given IV metoprolol with improvement in her heart rate to the 100's. As GI was unable to remove the food impaction it was decided that she would be transferred to [**Hospital1 18**] for ENT evaluation and removal of the food impaction. . On arrival to the ICU her initial VS were: 98.1, 103, 157/86, 16, 100% on 2LNC. She currently feels well, not having any chest pain, palpitations, difficulty with her secretions or abdominal pain. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: Atrial fibrillation on Coumadin Diabetes Hypertension Hyperlipidemia Hip fracture History of elbow fracture Social History: Recently in rehab but before that was living at home, was independent of ADLs. Denies smoking or alcohol. Family History: Non-contributory Physical Exam: Admission Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admission Labs: [**2175-9-27**] 08:35PM BLOOD WBC-6.3 RBC-3.17* Hgb-10.1* Hct-29.1* MCV-92 MCH-31.8 MCHC-34.6 RDW-13.8 Plt Ct-333 [**2175-9-27**] 08:35PM BLOOD PT-25.7* PTT-36.8* INR(PT)-2.4* [**2175-9-27**] 08:35PM BLOOD Glucose-90 UreaN-6 Creat-0.4 Na-141 K-3.2* Cl-104 HCO3-25 AnGap-15 [**2175-9-27**] 08:35PM BLOOD Calcium-8.7 Phos-2.9 Mg-1.9 Discharge LABS: see below HCt 29.4.3, normal WBC Chem7 WNL INR 3.6 1,25 Vit D pending Microbiology: none . Imaging: CXR ([**9-28**]): FINDINGS: Single portable frontal view of the chest shows an apparent widening of the mediastinum. This is concerning for postoperative pneumomediastinum. There is air seen superior to the left main stem bronchus which was also seen in the previous film. No pneumothorax or pleural effusion. Heart size is large. IMPRESSION: Widening of the mediastinum. Followup within one to two hours with a PA and lateral film is recommended. . . CXR ([**9-28**]): FINDINGS: In comparison with the study of earlier in this date, the prominence of the superior mediastinum is less, probably due to the PA technique. Air along the lower left side of the trachea and left main stem bronchus again is seen. This again could possibly represent pneumomediastinum or represent an artifact from overlying structures. If there is serious concern, CT could be considered. . CXR ([**9-29**]): Previously seen equivocal lucency in the left lower paratracheal region is not evident on the present x-ray. It was probably an artifact. There is no evidence of a pneumomediastinum on the present radiograph. Both lungs are low volume and there are no lung opacities concerning for pneumonic consolidation. A small lucent area in the fifth intercostal space posteriorly is probably contributed from margins of ribs and the vascular structure and is very unlikely to be a true lung cavity. Heart size and mediastinal contours are unchanged. There is no effusion/pneumothorax. . CXR ([**9-29**]): Since the most recent radiograph from [**9-29**] acquired at 5:47 a.m., there are no significant relevant changes in the lung findings. There is no evidence of pneumomediastinum/pneumothorax. Pleural effusion, if any, is minimal on the left side. Heart, mediastinal and hilar contours are unchanged. . Operative Report (ENT [**9-28**]) After protecting the upper dentition a standard [**Last Name (un) **] laryngoscope was inserted into the patient's oral cavity. The patient's esophageal inlet was found and found to be narrow. No food impaction was found at this time, though the cricopharyngeus was found to be tight. The laryngoscope was brought into suspension using a standard [**Last Name (un) 309**] suspension system. Serial dilations were performed with esophageal dilation balloons up to 18 mm. After this the esophageal inlet was found to be larger with no undue mucosal tears. After esophageal dilation was performed, rigid esophagoscopy was performed up to approximately 20 cm. This showed normal mucosa, although there was some minimal trauma secondary to the esophageal dilation. In order to view the entire length of the esophagus a flexible esophagoscopy was performed. The esophagoscope was passed into the patient's oral cavity and into the esophageal inlet. This was advanced to the gastroesophageal junction and the stomach. The stomach was insufflated and the scope retroflexed. The GE junction looked normal from the gastric side. The esophagus was then examined in its entirety from distal to proximal. The area of previous stricture was found just distal to the esophageal inlet and that was previously dilated. The flexible esophagoscope was then withdrawn from the patient's oral cavity. The patient was then awakened and extubated without complications. Sponge count correct. ESTIMATED BLOOD LOSS: Negligible. SPECIMEN TO PATHOLOGY: None . Brief Hospital Course: Hospital Course: 84F h/o afib on coumadin, s/p recent hip fracture with nailing at [**Hospital1 **] [**Location (un) 620**] 1 month ago and then sent to rehab who developed worsening dysphagia 1d prior to admission. She described having difficulty swallowing pills and her saliva so was sent to [**Hospital1 **] [**Location (un) 8062**] ED where EGD showed concern for food impaction that was unable to be cleared with flex endoscopy and also notable for question of zenker's diverticulum. She also had afib with RVR treatedwith IV [**Location (un) 18990**] and BB. She was sent to [**Hospital1 **] ICU on [**9-27**] for ENT evaluation. She was given FFP and her coumadin was held prior to proceeding with laryngoscope and rigid endoscope with esophageal baloon dilation on [**9-28**] that showed a narrow esophagus. A standard post-procedure CXR had a prelim read notable for pneumomediastinum, but she remained clincially stable, and a repeat CXR on [**9-29**] did not show any evidence of pneumomediastinum and ENT felt comfortable beginning a PO diet. She tolerated mechanical soft diet on [**9-29**] and had no symptoms of dyspnea, cough, vomitting, dysphagia, or neck pain. She has been ambulating with the aide of a walker. Plan for active issues: #Dysphagia: improved Per ENT, the anatomy looked "tight" but there was no focal stricture or malignant appearing mucosa --Barium Swallow as outpatient per ENT --f/u with Dr. [**Last Name (STitle) 91419**] (ENT and swallowing specialist) [**Telephone/Fax (1) 9312**] after discharge --advance diet as tolerated to regulars today #Hip repair: now ambulating with assistance of walker --return to rehab for further rehab with PT and f/u with orthopedics #Afib: relatively well controlled on dual [**Name (NI) 18990**] and BB, anticoagulated with coumadin. her period of RVR was likely due to acute stress from difficulty swallowing INR values: 2.4, 3.0, 2.3, 2.8, 3.6 ([**9-27**]), no vit K given. --decreased dose of toprol XL to 25mg and resumed home dose of diltiazem 120mg qd metoprolol and diltiazem, resume long acting --hold coumadin on [**9-30**] for level of 3.6 and monitor INR, resume Coumadin as per rehab physicians #Anemia: no evidence of hemolysis. no hemodynamic compromise or change in vitals. --repeat CBC after discharge . #Diabetes 2: uncomplicated, controlled --resume metformin on [**9-30**]. She can resume januvia as well in the future. . #Osteoperosis: probable: Patient reports prior vertebral fracture from fall and now had R hip fracture. She will benefit from initiation of Bisphosphanate to reduce risk of future fractures. Given her difficulties with swallowing pills, it would be reasonable to consider Zoledronic Acid 5mg IV once a year as first line therapy for her. --f/u vitamin D level sent on [**9-30**] --Upon baseline measure of Vitamin D, can begin Bisphosphanate --Ca and Vitamin D POs started as inpatient #Code Status: DNR/DNI (confirmed) Medications on Admission: Diltiazem 120 mg daily Fentanyl topical 12 mcg every 72 hours Folic acid 1 mg daily Lasix 40 mg daily Metformin 1000 twice a day Metoprolol 50 mg daily MiraLAX powder Potassium chloride supplement 20 mEq daily Pravachol 20 mg at bedtime Vitamin B12 1000 mcg daily Vitamin B6 50 mg daily Dulcolax suppository and Fleet enemas Januvia 100 mg once a day Coumadin between 3 and 5 mg daily Lactulose as needed for constipation Percocet for pain Tramadol 50 mg b.i.d. p.r.n. Zofran 4 mg every 6 hours p.r.n. Discharge Disposition: Extended Care Facility: [**Hospital 11851**] Healthcare & Rehabilitation Center - [**Location (un) 620**] Discharge Diagnosis: dysphagia 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: #Med Changes: rehab --dose of toprol xl decreased to 25, but can be adjusted at rehab --d/c'd januvia and can resume based on FSBG, continue metformin --started Ca and Vit D --d/c'd vit B6, to minimize number of pills --held lasix because of a few days of NPO status --stopped fentanyl patch and percocet and tramadol as pain controlled TRANSITIONAL CARE: []f/u with Dr. [**Last Name (STitle) **] (ENT and swallowing specialist) [**Telephone/Fax (1) 9312**] after discharge []Barium Swallow as outpatient with ENT []adjust coumadin dose per INR []adjust diabetic meds based on FSBG []f/u Vitamin D level (pending at discharge) []need to decide on bisphonsphanate treatment for likely osteoperosis (h/o hip and vertebral fracture) []repeat cbc for mild anemia Followup Instructions: Call Dr. [**Last Name (STitle) **] (ENT and swallowing specialist at [**Hospital1 18**] ) [**Telephone/Fax (1) 91420**] after discharge Discuss hip fracture repair with ortho F/u afib, osteoperosis, and DM with your internists at rehab and your PCP

787,427,V586,285,250,733,V498

{'Dysphagia, unspecified,Atrial fibrillation,Long-term (current) use of anticoagulants,Anemia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Osteoporosis, unspecified,Do not resuscitate 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: Food Impaction PRESENT ILLNESS: Ms. [**Known lastname 91418**] is an 84 y/o F with a h/o AF on coumadin, recent hip fracture s/p repair three weeks ago who presented to [**Hospital1 **] [**Location (un) 620**] from rehab on [**2175-9-26**] with worsening dysphagia after swallowing pills that morning. She has a history of chronic dysphagia, but has never had an EGD prior to her admission to [**Location (un) 620**]. On presentation to [**Location (un) 620**] she was complaining of the sensation of something stuck in her throat, along with difficulty swallowing her secretions. She denies any pain when she swallows, but did complain of a constant pain in her throat. At [**Hospital1 **] [**Location (un) 620**] she underwent an EGD which showed a possible Zenker's diverticulum with food impaction. The GI doctors were [**Name5 (PTitle) 460**] to pass the scope but were not able to clear the impaction. Peri procedure she went into AF with RVR to the 140's, but with stable systolic blood pressures. She was given IV metoprolol with improvement in her heart rate to the 100's. As GI was unable to remove the food impaction it was decided that she would be transferred to [**Hospital1 18**] for ENT evaluation and removal of the food impaction. . On arrival to the ICU her initial VS were: 98.1, 103, 157/86, 16, 100% on 2LNC. She currently feels well, not having any chest pain, palpitations, difficulty with her secretions or abdominal pain. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. MEDICAL HISTORY: Atrial fibrillation on Coumadin Diabetes Hypertension Hyperlipidemia Hip fracture History of elbow fracture MEDICATION ON ADMISSION: Diltiazem 120 mg daily Fentanyl topical 12 mcg every 72 hours Folic acid 1 mg daily Lasix 40 mg daily Metformin 1000 twice a day Metoprolol 50 mg daily MiraLAX powder Potassium chloride supplement 20 mEq daily Pravachol 20 mg at bedtime Vitamin B12 1000 mcg daily Vitamin B6 50 mg daily Dulcolax suppository and Fleet enemas Januvia 100 mg once a day Coumadin between 3 and 5 mg daily Lactulose as needed for constipation Percocet for pain Tramadol 50 mg b.i.d. p.r.n. Zofran 4 mg every 6 hours p.r.n. ALLERGIES: azithromycin PHYSICAL EXAM: Admission Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema FAMILY HISTORY: Non-contributory SOCIAL HISTORY: Recently in rehab but before that was living at home, was independent of ADLs. Denies smoking or alcohol. ### Response: {'Dysphagia, unspecified,Atrial fibrillation,Long-term (current) use of anticoagulants,Anemia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Osteoporosis, unspecified,Do not resuscitate status'}

CHIEF COMPLAINT: Poor wound healing, admitted from wound clinic PRESENT ILLNESS: S/p AVR/CABG on [**12-5**] c/b superficial sternal wound infection. Discharged home on Vancomycin, at followup visit wound did not appear to be healing and patient was readmitted for debridement and evaluation by plastic surgery. MEDICAL HISTORY: s/p AVR/CABG, Hypertension, Hyperlipidemia, CLL, s/p T&A, s/p Umbilical Hernia repair, s/p Cholecystectomy, s/p total hip replacement, s/p varicose vein ligation, s/y hysterectomy MEDICATION ON ADMISSION: Colace 100" ASA 81' Percocet 5/325 Lipitor 10' Zantac 150" Amiodarone 200' Lopressor 50" Lasix 40' Captopril 12.5''' Vancomycin 750" ALLERGIES: Ciprofloxacin Er / Lisinopril / Diovan PHYSICAL EXAM: Admission: Gen: NAD Cor: RRR, no murmur Pulm: Diminished Left base Skin: sternal incision open 5x3x1 inch with fibrinous slough in base. Yeast under breasts bilat. FAMILY HISTORY: Non-contributory SOCIAL HISTORY: Quit smoking 44 years years ago (15yr smoking hx). Denies ETOH.

Other postoperative infection,Chronic lymphoid leukemia, without mention of having achieved remission,Unspecified pleural effusion,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortic valve disorders,Sinoatrial node dysfunction,Unspecified essential hypertension,Pure hypercholesterolemia,Anemia, unspecified,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus,Heart valve replaced by other means,Hip joint replacement,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

Other postop infection,Ch lym leuk wo achv rmsn,Pleural effusion NOS,Cor ath unsp vsl ntv/gft,Aortic valve disorder,Sinoatrial node dysfunct,Hypertension NOS,Pure hypercholesterolem,Anemia NOS,Other staphylococcus,Heart valve replac NEC,Joint replaced hip,Abn react-anastom/graft

Admission Date: [**2175-1-12**] Discharge Date: [**2175-1-21**] Date of Birth: [**2098-6-14**] Sex: F Service: CARDIOTHORACIC Allergies: Ciprofloxacin Er / Lisinopril / Diovan Attending:[**First Name3 (LF) 1283**] Chief Complaint: Poor wound healing, admitted from wound clinic Major Surgical or Invasive Procedure: Sternal wound debridement, wire removal, omental flap closure History of Present Illness: S/p AVR/CABG on [**12-5**] c/b superficial sternal wound infection. Discharged home on Vancomycin, at followup visit wound did not appear to be healing and patient was readmitted for debridement and evaluation by plastic surgery. Past Medical History: s/p AVR/CABG, Hypertension, Hyperlipidemia, CLL, s/p T&A, s/p Umbilical Hernia repair, s/p Cholecystectomy, s/p total hip replacement, s/p varicose vein ligation, s/y hysterectomy Social History: Quit smoking 44 years years ago (15yr smoking hx). Denies ETOH. Family History: Non-contributory Physical Exam: Admission: Gen: NAD Cor: RRR, no murmur Pulm: Diminished Left base Skin: sternal incision open 5x3x1 inch with fibrinous slough in base. Yeast under breasts bilat. Discharge: VS 97.2 94SR 132/58 18 93%RA 107.2 kg Neuro: non focal Pulm: CTA bilat CV: RRR, no murmur Abdm: soft, NT/NABS Ext: warm, well perfused. no edema Skin: Sternal and abdominal incisions with staples. no erythema. JP drain x1 with serosang fluid Pertinent Results: [**2175-1-12**] 06:44PM GLUCOSE-107* UREA N-13 CREAT-0.9 SODIUM-143 POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-29 ANION GAP-15 [**2175-1-12**] 06:44PM WBC-18.8* RBC-3.65* HGB-10.1* HCT-31.1* MCV-85 MCH-27.8 MCHC-32.6 RDW-15.1 [**2175-1-12**] 06:44PM PLT COUNT-308 [**2175-1-12**] 06:44PM PT-12.1 PTT-20.3* INR(PT)-1.0 [**2175-1-20**] 03:31AM BLOOD WBC-24.3* RBC-3.67* Hgb-10.0* Hct-31.9* MCV-87 MCH-27.3 MCHC-31.4 RDW-15.7* Plt Ct-300 [**2175-1-20**] 03:31AM BLOOD Plt Ct-300 [**2175-1-20**] 03:31AM BLOOD PT-13.6* PTT-27.9 INR(PT)-1.2* [**2175-1-20**] 03:31AM BLOOD Glucose-115* UreaN-20 Creat-0.9 Na-141 K-3.7 Cl-109* HCO3-25 AnGap-11 [**2175-1-19**] 05:48AM BLOOD Vanco-12.3 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname 4092**] [**Hospital1 18**] [**Numeric Identifier 74641**] (Complete) Done [**2175-1-15**] at 9:43:06 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] Division of Cardiothoracic [**Doctor First Name **] [**First Name (Titles) **] [**Last Name (Titles) **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] [**Last Name (LF) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 1426**] Plastic Surgery, PC [**Apartment Address(1) 1414**] [**Location (un) **], [**Numeric Identifier 1415**] Status: Inpatient DOB: [**2098-6-14**] Age (years): 76 F Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Abnormal ECG. Aortic valve disease. Coronary artery disease. H/O cardiac surgery. Pericardial effusion. ICD-9 Codes: 440.0, 424.1 Test Information Date/Time: [**2175-1-15**] at 09:43 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5209**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2007AW2-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 40% to 45% >= 55% Aortic Valve - Peak Gradient: 11 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 8 mm Hg Pericardium - Effusion Size: 0.2 cm Findings LEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast in the body of the LA. No spontaneous echo contrast or thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No spontaneous echo contrast in the body of the RA. No ASD by 2D or color Doppler. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Mild symmetric LVH. Normal LV cavity size. Mildly depressed LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Simple atheroma in aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). Minimally increased gradient c/w minimal AS. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular calcification. Calcified tips of papillary muscles. Trivial MR. TRICUSPID VALVE: Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The patient received antibiotic prophylaxis. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. patient. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions 1. The left atrium is mildly dilated. No spontaneous echo contrast is seen in the body of the left atrium. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. 2. No spontaneous echo contrast is seen in the body of the right atrium. No atrial septal defect is seen by 2D or color Doppler. 3. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (LVEF= 45%). 4. Right ventricular chamber size and free wall motion are normal. 5. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 6. A bioprosthetic aortic valve prosthesis is present and well-seated. . There is a minimally increased gradient consistent with minimal aortic valve stenosis. Trace aortic regurgitation is seen. There is no paravalvular leak. 7. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. 8. There is a trivial/physiologic pericardial effusion. 9. There is a moderate sized pleural effusion on both sides. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2175-1-15**] 11:32 Brief Hospital Course: Admitted from wound clinic on [**1-12**] and treated with IV antibiotics. Plastic surgery was consulted and on [**1-16**] she was brought to operating room for debridement with pectoral and omental flap closure. She tolerated this well and was brought to the cardiac surgery ICU after the surgery in stable condition. She stayed in the CVICU for two days then was transferred to the cardiac surgery floor for continued care. She was gently diuresed for a right pleural effusion. Beta blockade was titrated and her ACE inhibitor was restarted. She did well, her activity level was advanced with physical therapy and it was decided she was stable and ready for discharge home with VNA on [**1-21**]. Medications on Admission: Colace 100" ASA 81' Percocet 5/325 Lipitor 10' Zantac 150" Amiodarone 200' Lopressor 50" Lasix 40' Captopril 12.5''' Vancomycin 750" Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. Disp:*45 Tablet(s)* Refills:*0* 2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for chest wound. Disp:*1 bottle* Refills:*0* 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed. 5. Cefepime 2 gram Recon Soln Sig: Two (2) gms Injection Q12H (every 12 hours) for 6 weeks. Disp:*168 gms* Refills:*0* 6. Vancomycin 500 mg Recon Soln Sig: 1250 (1250) mg Intravenous Q 24H (Every 24 Hours) for 6 weeks. Disp:*[**Numeric Identifier **] mg* Refills:*0* 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks. Disp:*7 Tablet(s)* Refills:*0* 8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 1 weeks. Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 9. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO three times a day. Disp:*45 Tablet(s)* Refills:*0* 10. Zinc Sulfate 220 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 11. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0* 12. Outpatient Lab Work Qweekly draws on wednesdays CBC with Diff, BUN, Cr, LFT, Vanco trough Results to Dr [**First Name8 (NamePattern2) 4035**] [**Last Name (NamePattern1) 976**] fax [**Telephone/Fax (1) 1419**] Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: S/P sternal debridement and omental flap closure [**1-16**] PMH: s/p AVR/CABG [**12-5**], AS, CAD, HTN, ^chol, CLL, Hernia repair, CCY, Total hip replacement, varicose vein ligation, Hyst, T&A Discharge Condition: good Discharge Instructions: keep wounds clean and dry. OK to shower, no bathing or swimming. Take all medications as prescribed. Call for any fever, redness or drainage from wounds. Followup Instructions: Dr [**First Name (STitle) **]([**Telephone/Fax (1) 1429**]pt to call for Monday AM for appt next week Dr [**Last Name (STitle) **]([**Telephone/Fax (1) 1504**]) in [**4-17**] weeks, pt to call for appt Completed by:[**2175-1-27**]

998,204,511,414,424,427,401,272,285,041,V433,V436,E878

{'Other postoperative infection,Chronic lymphoid leukemia, without mention of having achieved remission,Unspecified pleural effusion,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortic valve disorders,Sinoatrial node dysfunction,Unspecified essential hypertension,Pure hypercholesterolemia,Anemia, unspecified,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus,Heart valve replaced by other means,Hip joint replacement,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'}

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: Poor wound healing, admitted from wound clinic PRESENT ILLNESS: S/p AVR/CABG on [**12-5**] c/b superficial sternal wound infection. Discharged home on Vancomycin, at followup visit wound did not appear to be healing and patient was readmitted for debridement and evaluation by plastic surgery. MEDICAL HISTORY: s/p AVR/CABG, Hypertension, Hyperlipidemia, CLL, s/p T&A, s/p Umbilical Hernia repair, s/p Cholecystectomy, s/p total hip replacement, s/p varicose vein ligation, s/y hysterectomy MEDICATION ON ADMISSION: Colace 100" ASA 81' Percocet 5/325 Lipitor 10' Zantac 150" Amiodarone 200' Lopressor 50" Lasix 40' Captopril 12.5''' Vancomycin 750" ALLERGIES: Ciprofloxacin Er / Lisinopril / Diovan PHYSICAL EXAM: Admission: Gen: NAD Cor: RRR, no murmur Pulm: Diminished Left base Skin: sternal incision open 5x3x1 inch with fibrinous slough in base. Yeast under breasts bilat. FAMILY HISTORY: Non-contributory SOCIAL HISTORY: Quit smoking 44 years years ago (15yr smoking hx). Denies ETOH. ### Response: {'Other postoperative infection,Chronic lymphoid leukemia, without mention of having achieved remission,Unspecified pleural effusion,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortic valve disorders,Sinoatrial node dysfunction,Unspecified essential hypertension,Pure hypercholesterolemia,Anemia, unspecified,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus,Heart valve replaced by other means,Hip joint replacement,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'}

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is a 61 year-old female with a past medical history for type 2 diabetes, obesity, hypertension, and known coronary artery disease. The patient had coronary artery stenting in [**2122-11-29**] and was in her usual state of health until she awoke with coughing, wheezing, chest heaviness and dull pain to the shoulder blades. The patient took two nitroglycerin tablets without relief and was transported by EMS system to the Emergency Department. Cardiac workup was begun in the Emergency Department and the patient was given 40 mg of intravenous Lasix, supplemental oxygen and nitroglycerin drip. The patient was also beta blocked with Metoprolol 10 mg intravenous times one and begun on Integrilin as well as heparin. MEDICAL HISTORY: 1. Type 2 diabetes. 2. Hypertension. 3. Coronary artery disease. MEDICATION ON ADMISSION: ALLERGIES: Penicillin. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

Other complications due to other cardiac device, implant, and graft,Coronary atherosclerosis of native coronary artery,Pneumonitis due to inhalation of food or vomitus,Blood in stool,Paroxysmal ventricular tachycardia,Congestive heart failure, unspecified,Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension

Comp-oth cardiac device,Crnry athrscl natve vssl,Food/vomit pneumonitis,Blood in stool,Parox ventric tachycard,CHF NOS,DMII ophth nt st uncntrl,Hypertension NOS

Admission Date: [**2123-1-20**] Discharge Date: [**2123-1-31**] Date of Birth: [**2061-1-6**] Sex: F Service: ADMISSION DIAGNOSIS: Chest pain. DISCHARGE DIAGNOSES: 1. Coronary artery disease. 2. Status post coronary artery bypass graft times three. HISTORY OF PRESENT ILLNESS: The patient is a 61 year-old female with a past medical history for type 2 diabetes, obesity, hypertension, and known coronary artery disease. The patient had coronary artery stenting in [**2122-11-29**] and was in her usual state of health until she awoke with coughing, wheezing, chest heaviness and dull pain to the shoulder blades. The patient took two nitroglycerin tablets without relief and was transported by EMS system to the Emergency Department. Cardiac workup was begun in the Emergency Department and the patient was given 40 mg of intravenous Lasix, supplemental oxygen and nitroglycerin drip. The patient was also beta blocked with Metoprolol 10 mg intravenous times one and begun on Integrilin as well as heparin. PAST MEDICAL HISTORY: 1. Type 2 diabetes. 2. Hypertension. 3. Coronary artery disease. MEDICATIONS: Aspirin 325 mg po q day, atenolol 50 mg po q day, Lipitor 10 mg po q day, Isosorbide mononitrate 30 mg q day, Plavix 75 mg po q day, Lasix 20 mg q.d., Rosiglitazone 50 mg q.d., Glyburide 5 mg po q day, Metformin 1000 mg b.i.d., Lisinopril 40 mg q day, Vitamin B-12 100 micrograms q day, iron sulfate 325 mg t.i.d. ALLERGIES: Penicillin. PHYSICAL EXAMINATION: The patient is an elderly woman in some distress. Her vital signs are heart rate 94. Blood pressure 113/54. Respirations 12. Oxygen saturation 99% on 3 liters nasal cannula. HEENT throat is clear. Neck is supple, midline. No carotid bruit. Chest is significant for slight crackles at the bases. Cardiovascular is regular rate and rhythm without murmurs, rubs or gallops. Abdomen is soft, nontender, nondistended and obese. No masses or organomegaly. Extremities are warm, noncyanotic, nonedematous times four. Neurological is grossly intact. LABORATORIES ON ADMISSION: CBC 9, 34.1, 194, urinalysis is negative. Chem 7 is 140, 5.1, 103, 24, 44, 1.1, 211. CKs 241 with MB of 6 and troponin I of 4.0. HOSPITAL COURSE: The patient was admitted to the Emergency Department and taken on an emergent basis to the cardiac catheterization laboratory. The patient had 100% occlusion of the right coronary artery, 70% of left anterior descending coronary artery and 70% of the circumflex. Recommendations made for urgent revascularization procedure. Plavix was held for the procedure and the patient was continued on aspirin, beta blocker, statin and ace inhibitor. The patient ruled out for myocardial infarction post catheterization. On [**2123-1-21**] the patient received 1 unit of packed red blood cells for a hematocrit of 26. The patient tolerated this well without problems. The patient did well on the floor while waiting her bypass procedure. She was heparinized and did receive a 2 unit of red blood cells on [**2123-1-24**] for a hematocrit of 29.3. The patient was appropriately preoped and taken to the Operating Room on [**2123-1-25**]. At that time she had a coronary artery bypass graft times three using the left internal mammary coronary artery and saphenous vein graft. The patient tolerated this without complications. Postoperatively, the patient was taken to the Intensive Care Unit for close monitoring. She was maintained on Propofol and a Protonin drips, as well as an insulin drip for elevated blood sugars. Nitroglycerin drip was used intermittently for her hypertension. This was titrated to keep mean arterial pressure between 60 and 90. The patient was extubated on postoperative day number two and subsequently transferred to the floor. She was transfused an additional 2 units of packed red blood cells. On the floor, the patient did well without any acute issues. She was seen by physical therapy for conditioning and gait training. Chest tubes and pacer wires were discontinued on postoperative day number three. Cardiac medications were titrated to effect for heart rate and blood pressure. The patient had an otherwise uneventful course except for on the early morning of [**2123-1-30**] when the patient had a short run of seven beat ventricular tachycardia. The patient was kept for 24 hours after this for monitoring. Since there was no significant repeat or other arrhythmia at this time, the patient was discharged to home on postoperative day number six tolerating a regular diet and taking adequate pain control on po pain medications and having no more anginal equivalents or arrhythmias on telemetry. PHYSICAL EXAMINATION ON DISCHARGE: Vital signs are stable, afebrile. Temperature 98.3, heart rate 84, blood pressure 143/70, respirations 20, oxygen saturation 94% on room air. Chest was clear to auscultation bilaterally. Sternal incision was clean and dry with no drainage. Cardiovascular is regular rate and rhythm without murmurs, rubs or gallops. Abdomen is soft, nontender, nondistended. Extremities warm and well perfuse without cyanosis or edema. Neurologically intact. LABORATORY ON DISCHARGE: CBC 7.8, 32.6, 208. Chemistries 137, 4.7, 101, 27, 26, 7.8, 129, magnesium 1.8. MEDICATIONS ON DISCHARGE: Lasix 20 mg po b.i.d. times seven days, potassium chloride 20 milliequivalents b.i.d. times seven days. Colace 100 mg po b.i.d., aspirin 325 mg q day, percocet 5/325 one to two tablets q 4 hours prn. Glyburide 5 mg q.d., iron complex 150 mg q.d., Lipitor 10 mg po q day, cyanocobalamin 50 micrograms q day, Metformin 1000 mg b.i.d., Rosiglitazone 2 mg q.d., Lopressor 25 mg b.i.d. DISCHARGE CONDITION: Good. DISPOSITION: To home. DIET: Cardiac, diabetic. DISCHARGE INSTRUCTIONS: The patient is to follow up with her cardiologist in one to two weeks. Diuresis and adjustment of cardiac medications should be addressed at that time. The patient should follow up with Dr. [**Last Name (STitle) 70**] in four weeks time. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Last Name (NamePattern1) 14041**] MEDQUIST36 D: [**2123-1-31**] 04:14 T: [**2123-2-2**] 05:54 JOB#: [**Job Number 14042**]

996,414,507,578,427,428,250,401

{'Other complications due to other cardiac device, implant, and graft,Coronary atherosclerosis of native coronary artery,Pneumonitis due to inhalation of food or vomitus,Blood in stool,Paroxysmal ventricular tachycardia,Congestive heart failure, unspecified,Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension'}

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 61 year-old female with a past medical history for type 2 diabetes, obesity, hypertension, and known coronary artery disease. The patient had coronary artery stenting in [**2122-11-29**] and was in her usual state of health until she awoke with coughing, wheezing, chest heaviness and dull pain to the shoulder blades. The patient took two nitroglycerin tablets without relief and was transported by EMS system to the Emergency Department. Cardiac workup was begun in the Emergency Department and the patient was given 40 mg of intravenous Lasix, supplemental oxygen and nitroglycerin drip. The patient was also beta blocked with Metoprolol 10 mg intravenous times one and begun on Integrilin as well as heparin. MEDICAL HISTORY: 1. Type 2 diabetes. 2. Hypertension. 3. Coronary artery disease. MEDICATION ON ADMISSION: ALLERGIES: Penicillin. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: ### Response: {'Other complications due to other cardiac device, implant, and graft,Coronary atherosclerosis of native coronary artery,Pneumonitis due to inhalation of food or vomitus,Blood in stool,Paroxysmal ventricular tachycardia,Congestive heart failure, unspecified,Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension'}

CHIEF COMPLAINT: PRESENT ILLNESS: This 58-year-old white male has a history of mitral regurgitation, has been followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] with several echocardiograms over the past three years. He reports a history of shortness of breath, which he attributes to his bronchial asthma. He was referred to Dr. [**Last Name (Prefixes) **] for surgical evaluation. He denies chest pain or pressure. He had an echocardiogram done in [**7-22**], which revealed severe 4+ MR and a normal EF of 60%. He had a cardiac catheterization on [**2101-2-14**], which revealed an EF of 61%, 40% proximal RCA lesion, and normal left system. There was severe 4+ mitral regurgitation, and he is now admitted for elective MV repair. MEDICAL HISTORY: 1. Significant for mitral regurgitation. 2. History of bronchial asthma for 30 years. 3. History of hypertension. 4. Status post removal of skin cancer on his face and right arm. MEDICATION ON ADMISSION: 1. Moduretic 5/50 mg half a tablet p.o. q.d. 2. K tabs q.d. 3. Univasc 7.5 mg p.o. q.d. 4. Multivitamin one p.o. q.d. 5. Accolate 20 mg p.o. b.i.d. 6. Vitamin C 250 mg p.o. q.d. 7. Aspirin 325 mg p.o. q.d. 8. Flovent two puffs p.o. b.i.d. 9. Proventil prn. 10. Prednisone 5 mg prn during emergency asthma attacks only. ALLERGIES: He has no known allergies. PHYSICAL EXAM: On physical exam, he is a well-developed and well-nourished white male in no apparent distress. Vital signs are stable, afebrile. HEENT exam: Normocephalic, atraumatic. Extraocular movements are intact. Oropharynx is benign. Neck is supple, full range of motion, no lymphadenopathy or thyromegaly. Carotids are 2+ and equal bilaterally without bruits. Lungs had poor air exchange bilaterally without wheezes, rhonchi, or rales. Cardiovascular: Regular rate and rhythm with a [**1-22**] murmur heard best at the apex radiating to the left axilla. Abdomen was soft, nontender, and mildly obese with normoactive bowel sounds, no masses or hepatosplenomegaly. Extremities were without clubbing, cyanosis, or edema. Neurologic examination was nonfocal. Pulses were 2+ and equal bilaterally throughout. FAMILY HISTORY: Unremarkable. SOCIAL HISTORY: He is a bus driver. He lives with his wife in [**Name (NI) 189**]. Quit smoking 34 years ago. Smoked a pack a day for 15 years prior to that. Drinks 1-2 drinks a week.

Mitral valve insufficiency and aortic valve insufficiency,Asthma, unspecified type, unspecified,Unspecified essential hypertension,Personal history of other malignant neoplasm of skin

Mitral/aortic val insuff,Asthma NOS,Hypertension NOS,Hx-skin malignancy NEC

Admission Date: [**2101-2-21**] Discharge Date: [**2101-2-25**] Date of Birth: [**2042-12-8**] Sex: M Service: HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: This 58-year-old white male has a history of mitral regurgitation, has been followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] with several echocardiograms over the past three years. He reports a history of shortness of breath, which he attributes to his bronchial asthma. He was referred to Dr. [**Last Name (Prefixes) **] for surgical evaluation. He denies chest pain or pressure. He had an echocardiogram done in [**7-22**], which revealed severe 4+ MR and a normal EF of 60%. He had a cardiac catheterization on [**2101-2-14**], which revealed an EF of 61%, 40% proximal RCA lesion, and normal left system. There was severe 4+ mitral regurgitation, and he is now admitted for elective MV repair. PAST MEDICAL HISTORY: 1. Significant for mitral regurgitation. 2. History of bronchial asthma for 30 years. 3. History of hypertension. 4. Status post removal of skin cancer on his face and right arm. MEDICATIONS ON ADMISSION: 1. Moduretic 5/50 mg half a tablet p.o. q.d. 2. K tabs q.d. 3. Univasc 7.5 mg p.o. q.d. 4. Multivitamin one p.o. q.d. 5. Accolate 20 mg p.o. b.i.d. 6. Vitamin C 250 mg p.o. q.d. 7. Aspirin 325 mg p.o. q.d. 8. Flovent two puffs p.o. b.i.d. 9. Proventil prn. 10. Prednisone 5 mg prn during emergency asthma attacks only. ALLERGIES: He has no known allergies. His last dental exam was six months ago and he was cleared for surgery. FAMILY HISTORY: Unremarkable. SOCIAL HISTORY: He is a bus driver. He lives with his wife in [**Name (NI) 189**]. Quit smoking 34 years ago. Smoked a pack a day for 15 years prior to that. Drinks 1-2 drinks a week. REVIEW OF SYSTEMS: Is as above. PHYSICAL EXAM: On physical exam, he is a well-developed and well-nourished white male in no apparent distress. Vital signs are stable, afebrile. HEENT exam: Normocephalic, atraumatic. Extraocular movements are intact. Oropharynx is benign. Neck is supple, full range of motion, no lymphadenopathy or thyromegaly. Carotids are 2+ and equal bilaterally without bruits. Lungs had poor air exchange bilaterally without wheezes, rhonchi, or rales. Cardiovascular: Regular rate and rhythm with a [**1-22**] murmur heard best at the apex radiating to the left axilla. Abdomen was soft, nontender, and mildly obese with normoactive bowel sounds, no masses or hepatosplenomegaly. Extremities were without clubbing, cyanosis, or edema. Neurologic examination was nonfocal. Pulses were 2+ and equal bilaterally throughout. He was admitted on [**2101-2-21**] and underwent a minimally invasive mitral valve repair with a 30 mm [**Doctor Last Name 405**] annuloplasty band. The cross-clamp time was 110 minutes. Total bypass time 132 minutes. He was transferred to the CSRU in stable condition and was transiently on Neo-Synephrine. He was extubated, and had a stable postoperative night. On postoperative day one, he had his chest tube D/C'd. He did have a temperature of 101 and then was transferred to the floor in stable condition. He continued to have a stable postoperative course with the exception of temperature elevations to 101. His chest x-ray was clear. His urine culture was negative, and his white count was normal. He would usually have one or two spikes per day, but otherwise his temperature was around 99. On postoperative day #4, he was discharged home in stable condition. LABORATORIES ON DISCHARGE: Hematocrit 30.6, white count 9.2, platelets 207,000. Sodium 140, potassium 4.2, chloride 102, CO2 33, BUN 16, creatinine 0.8, blood sugar 116. MEDICATIONS ON DISCHARGE: 1. Lasix 20 mg p.o. q.d. for seven days. 2. Potassium 20 mEq p.o. b.i.d. for seven days. 3. Aspirin 325 mg p.o. q.d. 4. Percocet 1-2 tablets p.o. q.4-6h. prn pain. 5. Accolate one p.o. b.i.d. 6. Flovent two puffs b.i.d. 7. Lopressor 75 mg p.o. b.i.d. DISCHARGE DIAGNOSES: 1. Mitral regurgitation. 2. Hypertension. 3. Asthma. FO[**Last Name (STitle) **]P INSTRUCTIONS: He will follow up with Dr. [**Last Name (STitle) 43109**] in [**11-19**] weeks, Dr. [**First Name (STitle) **] in [**12-21**] weeks, and Dr. [**Last Name (Prefixes) **] in four weeks. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern1) 6516**] MEDQUIST36 D: [**2101-2-25**] 10:56 T: [**2101-2-25**] 11:15 JOB#: [**Job Number 94973**]

396,493,401,V108

{'Mitral valve insufficiency and aortic valve insufficiency,Asthma, unspecified type, unspecified,Unspecified essential hypertension,Personal history of other malignant neoplasm of skin'}

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: This 58-year-old white male has a history of mitral regurgitation, has been followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] with several echocardiograms over the past three years. He reports a history of shortness of breath, which he attributes to his bronchial asthma. He was referred to Dr. [**Last Name (Prefixes) **] for surgical evaluation. He denies chest pain or pressure. He had an echocardiogram done in [**7-22**], which revealed severe 4+ MR and a normal EF of 60%. He had a cardiac catheterization on [**2101-2-14**], which revealed an EF of 61%, 40% proximal RCA lesion, and normal left system. There was severe 4+ mitral regurgitation, and he is now admitted for elective MV repair. MEDICAL HISTORY: 1. Significant for mitral regurgitation. 2. History of bronchial asthma for 30 years. 3. History of hypertension. 4. Status post removal of skin cancer on his face and right arm. MEDICATION ON ADMISSION: 1. Moduretic 5/50 mg half a tablet p.o. q.d. 2. K tabs q.d. 3. Univasc 7.5 mg p.o. q.d. 4. Multivitamin one p.o. q.d. 5. Accolate 20 mg p.o. b.i.d. 6. Vitamin C 250 mg p.o. q.d. 7. Aspirin 325 mg p.o. q.d. 8. Flovent two puffs p.o. b.i.d. 9. Proventil prn. 10. Prednisone 5 mg prn during emergency asthma attacks only. ALLERGIES: He has no known allergies. PHYSICAL EXAM: On physical exam, he is a well-developed and well-nourished white male in no apparent distress. Vital signs are stable, afebrile. HEENT exam: Normocephalic, atraumatic. Extraocular movements are intact. Oropharynx is benign. Neck is supple, full range of motion, no lymphadenopathy or thyromegaly. Carotids are 2+ and equal bilaterally without bruits. Lungs had poor air exchange bilaterally without wheezes, rhonchi, or rales. Cardiovascular: Regular rate and rhythm with a [**1-22**] murmur heard best at the apex radiating to the left axilla. Abdomen was soft, nontender, and mildly obese with normoactive bowel sounds, no masses or hepatosplenomegaly. Extremities were without clubbing, cyanosis, or edema. Neurologic examination was nonfocal. Pulses were 2+ and equal bilaterally throughout. FAMILY HISTORY: Unremarkable. SOCIAL HISTORY: He is a bus driver. He lives with his wife in [**Name (NI) 189**]. Quit smoking 34 years ago. Smoked a pack a day for 15 years prior to that. Drinks 1-2 drinks a week. ### Response: {'Mitral valve insufficiency and aortic valve insufficiency,Asthma, unspecified type, unspecified,Unspecified essential hypertension,Personal history of other malignant neoplasm of skin'}

CHIEF COMPLAINT: shortness of breath PRESENT ILLNESS: 62 year old male with a history of htn who has had dyspnea on exertion after climbing up a flight of stairs or when he has to execute quickly a physically demanding task for the past year. He had an positive ETT and underwent cardiac cath today which revealed tight left main disease and LAD and LCX disease as well. MEDICAL HISTORY: Hypertension GERD MEDICATION ON ADMISSION: FLUTICASONE 50 mcg Spray, Suspension - 1 (One) intranasally twice daily HYDROCHLOROTHIAZIDE - 25 mg 1 (One) Tablet(s) by mouth once a day OMEPRAZOLE MAGNESIUM 20 mg one Tablet(s) by mouth daily ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Pulse: 69S Resp: 20 O2 sat: 95% RA B/P Right: 96/80 Left: Height: 5' 11" Weight: 213 lbs. FAMILY HISTORY: + cancer SOCIAL HISTORY: Lives with: wife Occupation: supervisor for [**Name (NI) 85221**] Tobacco: never ETOH: occasional

Coronary atherosclerosis of native coronary artery,Intermediate coronary syndrome,Unspecified essential hypertension,Esophageal reflux

Crnry athrscl natve vssl,Intermed coronary synd,Hypertension NOS,Esophageal reflux

Admission Date: [**2185-9-9**] Discharge Date: [**2185-9-14**] Date of Birth: [**2123-3-22**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: [**2185-9-10**] 1. Coronary bypass grafting x4: Left internal mammary artery to left anterior descending coronary; reverse saphenous vein single graft from aorta to first diagonal coronary; reverse saphenous vein single graft from aorta to first obtuse marginal coronary artery; reverse saphenous vein graft from aorta to the second obtuse marginal coronary artery. 2. Epiaortic duplex scanning. 3. Endoscopic right greater saphenous vein harvesting. History of Present Illness: 62 year old male with a history of htn who has had dyspnea on exertion after climbing up a flight of stairs or when he has to execute quickly a physically demanding task for the past year. He had an positive ETT and underwent cardiac cath today which revealed tight left main disease and LAD and LCX disease as well. Past Medical History: Hypertension GERD Social History: Lives with: wife Occupation: supervisor for [**Name (NI) 85221**] Tobacco: never ETOH: occasional Family History: + cancer Physical Exam: Pulse: 69S Resp: 20 O2 sat: 95% RA B/P Right: 96/80 Left: Height: 5' 11" Weight: 213 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 + [] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [] Neuro: Grossly intact Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ PT [**Name (NI) 167**]: 2+ Left: 2+ Radial Right: cath site Left: 2+ Carotid Bruit Right: no Left: no Pertinent Results: Intra-op TEE [**2185-9-10**] Conclusions Pre CPB: No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. There is no aortic valve stenosis. Trace aortic regurgitation is seen. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. Dr. [**Last Name (STitle) 914**] was notified in person of the results. Post CPB: The patient is being atrial paced. There is trace MR. [**First Name (Titles) **] [**Last Name (Titles) 50255**] systolic function is preserved. The visible contours of the thoracic aorta are intact. [**Known lastname **],[**Known firstname **] JR [**Medical Record Number 87408**] M 62 [**2123-3-22**] Radiology Report CHEST (PORTABLE AP) Study Date of [**2185-9-11**] 11:25 AM [**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] CSRU [**2185-9-11**] 11:25 AM CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 87409**] Reason: eval for ptx Final Report CHEST ON [**9-11**] HISTORY: Question pneumothorax. FINDINGS: The endotracheal tube has been removed. There is right IJ line with tip in the SVC. There is volume loss in the left lower lung. Left-sided chest tube has been removed. There is no pneumothorax. DR. [**First Name (STitle) **] [**Doctor Last Name **] [**2185-9-13**] 04:55AM BLOOD Hct-30.5* [**2185-9-12**] 06:10AM BLOOD WBC-12.2* RBC-3.79* Hgb-11.4* Hct-32.9* MCV-87 MCH-30.2 MCHC-34.7 RDW-13.3 Plt Ct-136* [**2185-9-12**] 06:10AM BLOOD Glucose-107* UreaN-25* Creat-0.7 Na-137 K-4.0 Cl-101 HCO3-31 AnGap-9 Brief Hospital Course: The patient was brought to the operating room on [**2185-9-10**] where the patient underwent CABG x 4 (LIMA-LAD, RSVG-OM1, RSVG-OM2, RSVG-Diag). Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. Vancomycin was used for surgical antibiotic prophylaxis. 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. 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#4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to home in stable condition on POD#4. Medications on Admission: FLUTICASONE 50 mcg Spray, Suspension - 1 (One) intranasally twice daily HYDROCHLOROTHIAZIDE - 25 mg 1 (One) Tablet(s) by mouth once a day OMEPRAZOLE MAGNESIUM 20 mg one Tablet(s) by mouth daily Discharge Medications: 1. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 5 days. Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. 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:*2* 4. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 6. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. Disp:*90 Tablet(s)* Refills:*0* 7. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 5 days. Disp:*10 Tablet(s)* Refills:*0* 8. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 **] VNA, [**Hospital1 1559**] Discharge Diagnosis: coronary artery disease PMH: Hypertension GERD Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions 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. [**Last Name (STitle) 914**] [**2185-10-4**] @ 2:30 PM Cardiologist: Dr. [**Last Name (STitle) 1911**] [**2185-10-10**] @ 2 PM Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) **] in [**3-7**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2185-9-14**]

414,411,401,530

{'Coronary atherosclerosis of native coronary artery,Intermediate coronary syndrome,Unspecified essential hypertension,Esophageal reflux'}

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: shortness of breath PRESENT ILLNESS: 62 year old male with a history of htn who has had dyspnea on exertion after climbing up a flight of stairs or when he has to execute quickly a physically demanding task for the past year. He had an positive ETT and underwent cardiac cath today which revealed tight left main disease and LAD and LCX disease as well. MEDICAL HISTORY: Hypertension GERD MEDICATION ON ADMISSION: FLUTICASONE 50 mcg Spray, Suspension - 1 (One) intranasally twice daily HYDROCHLOROTHIAZIDE - 25 mg 1 (One) Tablet(s) by mouth once a day OMEPRAZOLE MAGNESIUM 20 mg one Tablet(s) by mouth daily ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Pulse: 69S Resp: 20 O2 sat: 95% RA B/P Right: 96/80 Left: Height: 5' 11" Weight: 213 lbs. FAMILY HISTORY: + cancer SOCIAL HISTORY: Lives with: wife Occupation: supervisor for [**Name (NI) 85221**] Tobacco: never ETOH: occasional ### Response: {'Coronary atherosclerosis of native coronary artery,Intermediate coronary syndrome,Unspecified essential hypertension,Esophageal reflux'}

CHIEF COMPLAINT: nausea/vomiting PRESENT ILLNESS: 38 y/o man, well known to dept. Medicine, with DMI and severe gastroparesis and hypertension, [**Name6 (MD) 2091**] on RRT (o/p HD tiw) frequently admitted for abdominal pain crises with n/v, resulting in uncontrolled HTN given fact that cannot take po meds during these episodes. Has had innumerate admissions for the same here. He presents overnight with 1 day of nausea and several epsiodes of vomitting. Sxs are typical of prior episodes. Denies CP/SOB/diarrhea/f/c/URIsx. . In the ED he was found to be afebrile, hr 70-80s, hypertensive to 160s systolic, and sating 99% on RA. EKG was significant for worsening ST elevations in V1-V4, pseudonormalization of TW in v2, v3 and new TWI in v6. Per ED report Interventional cards attending was consulted who felt that this was possibly developing LV aneurysm and declined to bring him to cath. . Of note, during admission from [**Date range (1) 92864**], cardiology was consulted for ST elevations that were seen on his EKG s/p a recent STEMI in [**2186-12-14**] elevations were persistent (possibly due to evolving aneurysm) and that no further work up would be necessary unless there are further changes on future EKGS. They also reviewed his recent echocardiograms which showed akinetic segments of his LV. However, it was decided to defer anticoagulation since his EF was relatively preserved. . In the ED, labs were significant for a potassium of 6.7, repeat of 6.4. He received calcium gluc, kayexalate, labetalol 20mg, ativan 2mg IV x 2, dilaudid 2mg IV x 2 and 4U Reg Insulin. Renal was consulted and he went to HD. . He was evaluated by Merit at HD. There his BP was slightly low during dialysis and he was very lethargic. It was difficult to get a full story due to drowsiness. MEDICAL HISTORY: #. DMI uncontrolled with complications #. CAD s/p STEMI [**12-21**] in setting of cocaine use, s/p cath with MEDICATION ON ADMISSION: #. Aspirin 325 mg DAILY #. Clopidogrel 75 mg DAILY #. Atorvastatin 80 mg DAILY #. Clonidine 0.2 mg/24 hr Patch Weekly (every Tuesday) #. Clonidine 0.1 mg PO BID #. Lisinopril 40 mg DAILY #. Labetalol 300 mg [**Hospital1 **] #. Prochlorperazine Maleate 10 mg Q6PRN #. Insulin 5U NPH [**Hospital1 **] and RISS for FS>150. #. Metoclopramide 10 mg QIDACHS #. Lorazepam 1 mg Q4H PRN nausea #. Omeprazole 40 mg Daily #. Lanthanum 500 mg 2 tabs TID QAC ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: V: Post HD 97.3, BP 167/114, P78, R16, 99%RA Gen: Drowsy but arousable, middle-aged AA man HEENT: PERRL, OP clear, MMM CV: RRR no m/r/g, HD cath in place with no erythema, warmth or tenderness surrounding Pulm: CTAB Abd: decreased BS, NTND Ext: no edema FAMILY HISTORY: Father deceased of ESRD and DM. Mother aged 50's with hypertension. 2 sisters, one with diabetes. 6 brother, one with diabetes. There is no family history of premature coronary artery disease or sudden death. SOCIAL HISTORY: Patient has a prior history of tobacco and marijauna use, but he does not currently smoke. He has a prior history of alcohol abuse and has been sober for 9 years. He has a past history of cocaine use. He currently denies illicit drugs.

Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Peripheral autonomic neuropathy in disorders classified elsewhere,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Old myocardial infarction,Diabetes with neurological manifestations, type I [juvenile type], uncontrolled,Gastroparesis

Mal hyp kid w cr kid V,End stage renal disease,Aut neuropthy in oth dis,Crnry athrscl natve vssl,Status-post ptca,Old myocardial infarct,DMI neuro uncntrld,Gastroparesis

Admission Date: [**2187-2-26**] Discharge Date: [**2187-2-28**] Date of Birth: [**2148-4-23**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 613**] Chief Complaint: nausea/vomiting Major Surgical or Invasive Procedure: PICC line placement and removal History of Present Illness: 38 y/o man, well known to dept. Medicine, with DMI and severe gastroparesis and hypertension, [**Name6 (MD) 2091**] on RRT (o/p HD tiw) frequently admitted for abdominal pain crises with n/v, resulting in uncontrolled HTN given fact that cannot take po meds during these episodes. Has had innumerate admissions for the same here. He presents overnight with 1 day of nausea and several epsiodes of vomitting. Sxs are typical of prior episodes. Denies CP/SOB/diarrhea/f/c/URIsx. . In the ED he was found to be afebrile, hr 70-80s, hypertensive to 160s systolic, and sating 99% on RA. EKG was significant for worsening ST elevations in V1-V4, pseudonormalization of TW in v2, v3 and new TWI in v6. Per ED report Interventional cards attending was consulted who felt that this was possibly developing LV aneurysm and declined to bring him to cath. . Of note, during admission from [**Date range (1) 92864**], cardiology was consulted for ST elevations that were seen on his EKG s/p a recent STEMI in [**2186-12-14**] elevations were persistent (possibly due to evolving aneurysm) and that no further work up would be necessary unless there are further changes on future EKGS. They also reviewed his recent echocardiograms which showed akinetic segments of his LV. However, it was decided to defer anticoagulation since his EF was relatively preserved. . In the ED, labs were significant for a potassium of 6.7, repeat of 6.4. He received calcium gluc, kayexalate, labetalol 20mg, ativan 2mg IV x 2, dilaudid 2mg IV x 2 and 4U Reg Insulin. Renal was consulted and he went to HD. . He was evaluated by Merit at HD. There his BP was slightly low during dialysis and he was very lethargic. It was difficult to get a full story due to drowsiness. Past Medical History: #. DMI uncontrolled with complications #. CAD s/p STEMI [**12-21**] in setting of cocaine use, s/p cath with bare metal stent to LAD #. Recurrent flash pulmonary edema since STEMI [**12-21**] chronic systolic heart failure #. [**Month/Year (2) 2091**] stage V on HD since [**2-/2184**] (T/Th/Sat), followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1366**] #. Recurrent line sepsis, coag negative staph, klebsiella, enterobacter #. History of esophageal erosion, [**Doctor First Name **]-[**Doctor Last Name **] tear #. History of AV fistula clot Social History: Patient has a prior history of tobacco and marijauna use, but he does not currently smoke. He has a prior history of alcohol abuse and has been sober for 9 years. He has a past history of cocaine use. He currently denies illicit drugs. Family History: Father deceased of ESRD and DM. Mother aged 50's with hypertension. 2 sisters, one with diabetes. 6 brother, one with diabetes. There is no family history of premature coronary artery disease or sudden death. Physical Exam: V: Post HD 97.3, BP 167/114, P78, R16, 99%RA Gen: Drowsy but arousable, middle-aged AA man HEENT: PERRL, OP clear, MMM CV: RRR no m/r/g, HD cath in place with no erythema, warmth or tenderness surrounding Pulm: CTAB Abd: decreased BS, NTND Ext: no edema Pertinent Results: [**2187-2-26**] WBC-8.5# HGB-10.3* HCT-34.6* MCV-82 RDW-18.1* PLT COUNT-343 NEUTS-64.6 LYMPHS-21.3 MONOS-7.0 EOS-6.4* BASOS-0.7 GLUCOSE-292* UREA N-60* CREAT-8.8* SODIUM-137 POTASSIUM-6.3* CHLORIDE-95* TOTAL CO2-24 ANION GAP-24* CALCIUM-10.4* PHOSPHATE-7.5* MAGNESIUM-2.1 CK(CPK)-165 CK-MB-7 cTropnT-0.38* -> 0.37 -> 0.40 -> 0.33 . CXR: no acute process . ECG: Sinus rhythm, ST elevations V1-V4 not significantly changed from previous. TWIs laterally, not significantly changed from previous. Brief Hospital Course: A/P: 38 year old male with DMI, ESRD on HD, gastroparesis, CAD s/p STEMI 2 months ago, presenting with nausea, vomiting similar to prior gastroparesis flares. . # Nausea/Vomiting - Likely secondary to gastroparesis, as with prior admissions. His usual regimen if IV reglan, dilaudid, and ativan was started. This resulted in significant improvement and he was able to tolerate POs by the following morning. He stated he was feeling improved and expressed his intentions to leave on [**2187-2-28**] AM. At this time he denied abdominal pain and was tolerated PO intake well. . # HTN - Hypertensive prior to HD with some hypotension during it. Was also labile on the floors, intermittently with elevated BP but then falling into 100's systolic range. Still able to tolerate HD. Med compliance as an outpatient is complicated by N/V and inability to hold down PO meds. Got IV meds (metoprolol, captopril) overnight, but then able to take in PO meds. Clonidine patch had come off also; that was replaced. No evidence of sepsis or cardiac changes. . # Hyperkalemia - With ESRD. Had HD on the day of admission and then again the following day to keep with schedule. K improved following HD. . # CAD - Recent STEMI s/p stent. He was ruled out for MI here (stable unchanging troponin elevations). EKG with persistent ST changes as above, ? possible evolving aneurysm per past cardiology evaluation. Last echo [**2-3**] still without evidence of aneurysm. Cardiology has previously been involved during admissions; have felt no further workup needed unless acute changes in EKG or symptoms. Case was discussed with cards in the ED. He was scheduled with cardiology as an outpatient. Aspirin, [**Month/Year (2) **], beta blocker and ACE inhibitor were continued. . # DM type I - Given NPH (patient using at home) and regular SS coverage. . # ESRD on HD: Has HD on day of admit and then again the following day to keep him on schedule and to get him to dry weight. Lanthanum was continued. Attempted to obtain urine tox given transplant candidate status, but patient unable to give urine sample (though does void). . # Full code Medications on Admission: #. Aspirin 325 mg DAILY #. Clopidogrel 75 mg DAILY #. Atorvastatin 80 mg DAILY #. Clonidine 0.2 mg/24 hr Patch Weekly (every Tuesday) #. Clonidine 0.1 mg PO BID #. Lisinopril 40 mg DAILY #. Labetalol 300 mg [**Hospital1 **] #. Prochlorperazine Maleate 10 mg Q6PRN #. Insulin 5U NPH [**Hospital1 **] and RISS for FS>150. #. Metoclopramide 10 mg QIDACHS #. Lorazepam 1 mg Q4H PRN nausea #. Omeprazole 40 mg Daily #. Lanthanum 500 mg 2 tabs TID QAC Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 4. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every Monday). 6. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 7. Labetalol 300 mg Tablet Sig: One (1) Tablet PO twice a day. 8. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. 9. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO four times a day: with meals and at bedtime. 10. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for nausea. 11. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 12. Lanthanum 1,000 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO three times a day: with meals. 13. Insulin Insulin as you have been doing at home: NPH 5 units in the morning and evening. Regular insulin for fingerstick sugar above 150 as you have been doing at home. Discharge Disposition: Home Discharge Diagnosis: Nausea/vomiting Gastroparesis Hypertensive urgency Diabetes mellitus End stage renal disease Discharge Condition: Stable Discharge Instructions: You were admitted with nausea, vomiting, abdominal pain, and inability to hold down food or liquids. This was likely due to gastroparesis from diabetes as before. We treated you with pain and nausea medications and you have improved. We have offered to have you stay to ensure that your symptoms do not return, but you have indicated that you would like to leave the hospital at this time. . Please call your doctor or return to the hospital if you have worsening abdominal pain, nausea, vomiting, inability to hold down liquids, chest pain, dizziness, or any new symptoms that you are concerned about. . Please keep all of your appointments with your doctors and take [**Name5 (PTitle) **] of your medications as prescribed. We have not made any changes to you medications since you were admitted. Followup Instructions: You have several upcoming appointments at [**Hospital1 18**]: . 1. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9546**], MD (Neurology) Phone:[**Telephone/Fax (1) 1047**] Date/Time:[**2187-3-13**] 10:00 2. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN, CS (Internal Medicine) Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2187-3-27**] 12:00 3. [**Company 191**] CLINICAL PHARMACIST Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2187-3-27**] 1:00 4. Transplant team (Dr. [**Last Name (STitle) **] and [**First Name4 (NamePattern1) 10801**] [**Last Name (NamePattern1) **]); [**2187-4-9**] starting at 2:00 pm. 5. Dr. [**Last Name (STitle) **] (heart specialist); [**2187-4-9**] at 4:00 pm. . You should continue dialysis as usual on Tuesdays, Thursdays, and Saturdays. . You will also need followup with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 250**]) in the future. In the meantime, you have an appointment with one of the clinic's nurse practitioners ([**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) 3817**]) as above. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Admission Date: [**2187-3-1**] Discharge Date: [**2187-3-5**] Date of Birth: [**2148-4-23**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 30**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: s/p left femoral line placement and removal hemodialysis, PICC line placement and removal History of Present Illness: 38 year old male with a past medical history significant for over 40 admissions in the past year to the hospital, diabetes mellitus type 1 complicated by severe gastroporesis, coronary artery disease status post ST segment elevation myocardial infarction with placement of bare metal stent [**2186-12-17**], endstage renal disease on hemodialysis who presented with a one hour history of sharp cramping generalized abdominal pain which awoke him from sleep. The abdominal pain induced per patient nausa and vomiting; therefore, he called the ambulance to take him to the hospital. Of note for dinner prior to this episode of pain, the patient ate a cheeseburger and soup. Also he was recently discharged from [**Hospital1 18**] [**2187-2-28**] in order to make a court appearance. He states that he has continued to take his antihypertensives and antinausea medications at home. He states that this pain is typical of his abdominal pain crises. He states this is unlike the chest pain he developed in the setting of cocaine use prior to his myocardial infarction in [**12-21**]. Patient had recent post ST segment elevation myocardial infarction in [**12-21**] that presented with L-sided chest tightness radiating to L arm with associated diaphoresis. During that admission he was found to have occlusion of distal left anterior descending artery to D1 with bare metal stent placement. . In the ED: He was found to be hypertensive to 177/123-> 220/134 -> started on a nitro paste, then nitro gtt when a femoral line was placed. He was given ativan 2mg IM x 3 and dilaudid 2mg IM/IV x 3 for nausea. He was given aspirin 325mg. He was transferred to the CCU due to lack of floor beds. . CCU Course: His nitro ggt was weaned off as pain control was achieved with ativan 1mg intravenous 2-4 hours and dilaudid 2mg intravenous every 2-4 hours. His blood pressure medications were gradually restarted with good effect. He underwent hemodialysis [**2187-3-1**] for ultrafiltration of 2.2 liters and the removal of 1.7 liters. Patient was started on Lantus 6 units in the evening and has a BG on 51 in the am that was treated. The patient is schedeuled to undergo placement of a PICC by IR [**2187-3-2**]. . ROS (on transfer): No chest pain, shortness of breath, nausea, vomiting, constipation, diarrhea, pruritis, changes in skin or eye color, diaphoresis. No fevers, chills. +diffuse abdominal pain, non radiating, crampy Past Medical History: DIABETES MELLITUS: -- gastroparesis, complicated by chronic abdominal pain -- end-stage renal disease on hemodialysis since [**2-/2184**] HYPETENSION CAD s/p STEMI on [**2186-12-17**] in setting of cocaine use with bare metal stent placement to the LAD, unable to cross d1 lesion. history of line sepsis, coag negative staph most recently [**2187-1-10**] and priors with klebsiella/enterobacteremia AUTONOMIC DYSFUNCTION -- hypertensive emergency -- orthostatic hypotension history of substance abuse (cocaine, marijuana, alcohol) history of esophageal erosion, [**Doctor First Name **]-[**Doctor Last Name **] tear history of AV fistula clot CVA? Social History: Patient has a prior history of tobacco and marijauna use, but he does not currently smoke. He has a prior history of alcohol abuse and has been sober for 9 years. He has a past history of cocaine use *1 per patient. He states he does not currently use cocaine. Family History: Father deceased of ESRD and DM. Mother aged 50's with hypertension. 2 sisters, one with diabetes. 6 brother, one with diabetes. There is no family history of premature coronary artery disease or sudden death. Physical Exam: VS: 97.1, 143/100, 83, 20, 96% RA, pain [**5-24**], BG 69 . Gen: young male in NAD, resp or otherwise. Oriented x 2 (missed date by one day). Mood, affect appropriate. Pleasant. HEENT: NCAT. anicteric sclera. CNII-XII grossly intact Neck: Supple no JVD, no cervical LAD. CV: RRR, no r/g, SEM best heard RUSB/LUSB, does not radiate to carotids. Chest: Respirations unlabored, no accessory muscle use. No crackles, wheeze, rhonchi. RUQ tunneled HD line dressing c/d/i. Abd: soft, ND, No HSM. No abdominial bruits. No tenderness to palpation, no rebound, no guarding. Ext: Left groin triple lumen catheter c/d/i. 4/5 strength hip flexors, 4+/5 biceps, triceps, deltoids Pertinent Results: CARDIAC CATH [**12-21**] demonstrated: LMCA - no disease, LAD - LAD occluded proximally after D1. The D1 had a chronic total occlusion, LCx was a non-dominant vessel without lesions, RCA was not injected. . ECG (from ED): Sinus tachy at 118. STE V1-V4 unchanged from [**2187-2-26**]. TWIs in I, aVL, V5-V6 unchanged from previous. . [**2187-2-2**] TTE: EF=45%, distal septum, anterial wall, apex HK. The left atrium is elongated. There is mild symmetric LVH. There is mild regional left ventricular systolic dysfunction with hypokinesis of the distal septum, distal anterior wall and apex. (LVEF = 45%). PASP 36. Brief Hospital Course: 38 year old male with diabetes mellitus complicated by gastroparesis, hypertension, autonomic dysfuction, coronary artery disease status post myocardial infarction [**12-21**] with stent placement presents with abdominal pain, nausea, vomiting and discovered to be hypertensive. . 1) Hypertensive: The patient has chronic hypertension and is on clonidine, labetalol, lisinopril. Notes from multiple prior admission indicated that he becomes very hypertensive in the setting of pain. Patient's underlying abdominal pain was treated with ativan iv prn and a dilaudid PCA. On a diabetic and renal diet with the pain control the patient's pain resolved. Patient was continued on his home blood pressure medications including labetalol, clonidine, lisinopril. Patient was transitioned to dilaudid oral and ativan prn. . 2) Diabetes Mellitus: Patient on admit transitioned to Lantus and dose was adjusted. The patient will be discharged home on Lantus and an insulin sliding scale. Patient had one episode where he consumed an entire jug of [**Location (un) 2452**] juice raised his potassium to 6 with flipped Ts V4/V6. Patient was treated with calcium gluconate, kayexelate and insulin. Repeat ECG showed resolution of the flipped t-waves. Patient was discharged home with antiemetics prn for his gastroporesis. . 3) Coronary Artery Disease: status post bare metal stent for anterior ST segment elevation myocardial infarction. Continued patient aspirin, [**Location (un) 4532**] and ace inhibitor. . 4) End Stage Renal Disease: Patient continued on his tuesday, thursday, saturday hemodialysis. Appreciated renal hemodialysis recommendations. . 5) Pain management - Patient has history of diabetic gastroparesis and abdominal pain. His abdominal pain can be attributed to poor food choices prior to this episode. Labile blood pressure appeared to depend upon his level of pain control. The pain service was consulted. Patient has responded well the PCA, standing tylenol and new neurontin and no longer requires ativan. Patient's intravenous dilaudid requirement was transitioned to oral dilaudid. == Patient to go home new standing tylenol, neurontin and dilaudid po. . 6) FEN: diabetic/cardiac/renal diet maintained while in the hospital. . 7) ACCESS: Patient had a femoral line placed for access which was removed when the patient had a PICC placed for access. Patient continues to have hemodialysis catheter for hemodialysis access. . 8) Code: FULL CODE. Medications on Admission: Aspirin 325 mg PO DAILY Clopidogrel 75 mg PO DAILY Atorvastatin 80 mg PO once a day. Clonidine 0.1 mg PO BID Clonidine 0.2 mg/24 hr Patch Weekly QMON (every Monday). Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Labetalol 300 mg Tablet Sig: One (1) Tablet PO twice a day. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO four times a day: with meals and at bedtime. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for nausea. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Lanthanum 1,000 mg Tablet, PO three times a day: with meals. Insulin as you have been doing at home: NPH 5 units in the morning and evening. Regular insulin for fingerstick sugar above 150 as you have been doing at home. Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every Monday). 6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Labetalol 100 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 8. Lanthanum 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 10. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 11. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 12. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for anxiety. Disp:*25 Tablet(s)* Refills:*0* 13. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. 14. Lantus 100 unit/mL Solution Sig: Four (4) units Subcutaneous at bedtime: as directed. 15. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO QTUTHSA ([**Doctor First Name **],MO,WE,FR). 16. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QTUTHSA (TU,TH,SA). 17. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection subcutaneously as previously directed: per insulin sliding scale. 18. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for breakthrough pain. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: hypertensive urgency gastroparesis diabetes mellitus secondary diagnosis: end stage renal disease on hemodialysis coronary artery disease Discharge Condition: stable, ambulating, tolerating po's Discharge Instructions: You were admitted to the hospital for abdominal pain and high blood pressure. You were treated with in intravenous pain medication which was converted to pills so that you could acheive better pain control at home. Upon discharge your blood pressure was under good control; it is important that you take these medications daily. . Please call your primary care physician or call 911 if you experience chest pain, nausea, vomiting, increased abdominal pain, fevers, headache or other concerning symptoms. . Please resume your home medications as previously instructed. Followup Instructions: Please call the [**Hospital 191**] clinic at [**Telephone/Fax (1) 250**] to set up an appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in the next 1-2 weeks to follow-up. If he is not available, ask for the next available appointment. . You have the following previously scheduled appointments: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9546**], MD Phone:[**Telephone/Fax (1) 1047**] Date/Time:[**2187-3-13**] 10:00 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN, CS Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2187-3-27**] 12:00 Provider: [**Name10 (NameIs) 191**] CLINICAL PHARMACIST Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2187-3-27**] 1:00

403,585,337,414,V458,412,250,536

{'Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Peripheral autonomic neuropathy in disorders classified elsewhere,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Old myocardial infarction,Diabetes with neurological manifestations, type I [juvenile type], uncontrolled,Gastroparesis'}

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: nausea/vomiting PRESENT ILLNESS: 38 y/o man, well known to dept. Medicine, with DMI and severe gastroparesis and hypertension, [**Name6 (MD) 2091**] on RRT (o/p HD tiw) frequently admitted for abdominal pain crises with n/v, resulting in uncontrolled HTN given fact that cannot take po meds during these episodes. Has had innumerate admissions for the same here. He presents overnight with 1 day of nausea and several epsiodes of vomitting. Sxs are typical of prior episodes. Denies CP/SOB/diarrhea/f/c/URIsx. . In the ED he was found to be afebrile, hr 70-80s, hypertensive to 160s systolic, and sating 99% on RA. EKG was significant for worsening ST elevations in V1-V4, pseudonormalization of TW in v2, v3 and new TWI in v6. Per ED report Interventional cards attending was consulted who felt that this was possibly developing LV aneurysm and declined to bring him to cath. . Of note, during admission from [**Date range (1) 92864**], cardiology was consulted for ST elevations that were seen on his EKG s/p a recent STEMI in [**2186-12-14**] elevations were persistent (possibly due to evolving aneurysm) and that no further work up would be necessary unless there are further changes on future EKGS. They also reviewed his recent echocardiograms which showed akinetic segments of his LV. However, it was decided to defer anticoagulation since his EF was relatively preserved. . In the ED, labs were significant for a potassium of 6.7, repeat of 6.4. He received calcium gluc, kayexalate, labetalol 20mg, ativan 2mg IV x 2, dilaudid 2mg IV x 2 and 4U Reg Insulin. Renal was consulted and he went to HD. . He was evaluated by Merit at HD. There his BP was slightly low during dialysis and he was very lethargic. It was difficult to get a full story due to drowsiness. MEDICAL HISTORY: #. DMI uncontrolled with complications #. CAD s/p STEMI [**12-21**] in setting of cocaine use, s/p cath with MEDICATION ON ADMISSION: #. Aspirin 325 mg DAILY #. Clopidogrel 75 mg DAILY #. Atorvastatin 80 mg DAILY #. Clonidine 0.2 mg/24 hr Patch Weekly (every Tuesday) #. Clonidine 0.1 mg PO BID #. Lisinopril 40 mg DAILY #. Labetalol 300 mg [**Hospital1 **] #. Prochlorperazine Maleate 10 mg Q6PRN #. Insulin 5U NPH [**Hospital1 **] and RISS for FS>150. #. Metoclopramide 10 mg QIDACHS #. Lorazepam 1 mg Q4H PRN nausea #. Omeprazole 40 mg Daily #. Lanthanum 500 mg 2 tabs TID QAC ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: V: Post HD 97.3, BP 167/114, P78, R16, 99%RA Gen: Drowsy but arousable, middle-aged AA man HEENT: PERRL, OP clear, MMM CV: RRR no m/r/g, HD cath in place with no erythema, warmth or tenderness surrounding Pulm: CTAB Abd: decreased BS, NTND Ext: no edema FAMILY HISTORY: Father deceased of ESRD and DM. Mother aged 50's with hypertension. 2 sisters, one with diabetes. 6 brother, one with diabetes. There is no family history of premature coronary artery disease or sudden death. SOCIAL HISTORY: Patient has a prior history of tobacco and marijauna use, but he does not currently smoke. He has a prior history of alcohol abuse and has been sober for 9 years. He has a past history of cocaine use. He currently denies illicit drugs. ### Response: {'Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Peripheral autonomic neuropathy in disorders classified elsewhere,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Old myocardial infarction,Diabetes with neurological manifestations, type I [juvenile type], uncontrolled,Gastroparesis'}

CHIEF COMPLAINT: Scheduled CoreValve procedure PRESENT ILLNESS: 80yo male with h/o CABG x4, CVA, 100% L carotid occlusion, known aortic stenosis now symptomatic. Patient reports shortness of breath after walking 1 block, must rest after climbing 1 flightof stairs. He admits to 1 witnessed syncopal episode while havingIV's started in an upright position, 1 syncopal episode 6 months ago while getting into shower (also found to have pneumonia). He denies chest pain. Cardiac cath showed three patent grafts.Echocardiogram revealed [**Location (un) 109**] 0.8cm2, mean gradient 36mmHg. Noncontrast chest CT showed heavily calcified aorta prohibitive for conventional surgical AVR. . He was consented for participation in the Corevalve TAVI study. He met all inclusion criteria and did not meet any exclusion criteria. He reported cold-like symptoms of head congestion, no fever. He saw his PCP and [**Name9 (PRE) 40018**] was initiated. His symptoms are improving, he remains fever free and he was cleared by his PCP. [**Name10 (NameIs) **] dose Plavix [**12-14**]. . He underwent succesful CoreValve placement today. His transvenous pacing was placed through the femoral line and the valve was placed through subclavian access. He was sedated with fentanyl and versed and required Neosynephrine for blood pressure supporet at the beginning of the procedure but was weaned off by the end. During balloon dilation he developed LBBB with a paced rhythm. He was given Vancomycin and cefazolin during the procedure. He was extubated prior to arrival to the CCU. He is currently mildly sedated but appropriately responding to commands. . He does have a history of post op N/V from previous surgeries. He also has some residual sensory deficit from prior CVA but no motor deficits. He has a history of esophageal stricture so can not get TEE. . NYHA Class: II MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: - CABG:Coronary artery disease s/p Coronary artery bypass graft x 4 [**2151**] - Aortic stenosis - PERCUTANEOUS CORONARY INTERVENTIONS: none - PACING/ICD: [**Company 1543**] 3. OTHER PAST MEDICAL HISTORY: Past Medical History: - Sepsis secondary to aspiration pneumonia - Lumbar radiculopathy with L4-L5 disc herniation - AAA - Carotid stenosis - CVA from left common carotid occlusion - Esophageal stricture s/p multiple dilatations - Obstructive sleep apnea on CPAP (doesn't use) - GERD - Degenerative joint disease - Pseudomonas bacteremia from UTI - Anxiety - Spinal stenosis - Benign prostatic hypertrophy - Neurogenic pseudo-claudication Past Surgical History: - s/p Left shoulder surgery - s/p Back surgery - s/p Tonsillectomy - s/p Cataract surgery - s/p TURP - s/p Right elbow surgery - s/p Right knee surgery MEDICATION ON ADMISSION: Medications - Prescription AVALOX 400mg daily x 10 days (start date [**12-15**]) AMLODIPINE - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth DAILY EZETIMIBE [ZETIA] - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth DAILY FEXOFENADINE [[**Doctor First Name **]] - (Prescribed by Other Provider) - 60 mg Tablet - 1 (One) Tablet(s) by mouth twice a day PRN allergies HYDROCHLOROTHIAZIDE - (Prescribed by Other Provider) - 12.5 mg Tablet - 1 (One) Tablet(s) by mouth once daily in the morning LOSARTAN - (Prescribed by Other Provider) - 100 mg Tablet - 1 Tablet(s) by mouth once a day OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth twice a day ROPINIROLE [REQUIP] - (Prescribed by Other Provider) - 0.25 mg Tablet - 1.5 (One and a half) Tablet(s) by mouth once a day ROSUVASTATIN [CRESTOR] - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth once a day TAMSULOSIN [FLOMAX] - (Prescribed by Other Provider) - 0.4 mg Capsule, Ext Release 24 hr - 1 Capsule(s) by mouth once a day TRAMADOL [ULTRAM] - (Prescribed by Other Provider) - 50 mg Tablet - 1 Tablet(s) by mouth AS NEEDED FOR PAIN ALLERGIES: Protonix / Accupril / Pravachol / Mevacor PHYSICAL EXAM: ADMISSION EXAM: BP=141/43 HR=61 RR=18 O2 sat= 96% GENERAL: NAD. mildly sedated but responding appropriately to commands. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple, trachea midline,bilat bruits vs referred murmer. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, No MRG. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Anterior exam CTAB, posterior exam deferred. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ FAMILY HISTORY: father deceased secondary to trauma, mother deceased [**Age over 90 **]yo. SOCIAL HISTORY: Lives with wife on upper level of house, daughter lives on lower level (13 stairs).

Aortic valve disorders,Aphasia,Cerebral embolism without mention of cerebral infarction,Chronic diastolic heart failure,Late effects of cerebrovascular disease, hemiplegia affecting dominant side,Aortocoronary bypass status,Fitting and adjustment of cardiac pacemaker,Other left bundle branch block,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Obstructive sleep apnea (adult)(pediatric),Esophageal reflux,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Examination of participant in clinical trial,Peripheral vascular disease, unspecified

Aortic valve disorder,Aphasia,Crbl emblsm wo infrct,Chr diastolic hrt fail,Late ef-hemplga dom side,Aortocoronary bypass,Ftng cardiac pacemaker,Left bb block NEC,Hypertension NOS,Hyperlipidemia NEC/NOS,Obstructive sleep apnea,Esophageal reflux,BPH w/o urinary obs/LUTS,Exam-clincal trial,Periph vascular dis NOS

Admission Date: [**2163-12-19**] Discharge Date: [**2163-12-27**] Date of Birth: [**2083-11-13**] Sex: M Service: MEDICINE Allergies: Protonix / Accupril / Pravachol / Mevacor Attending:[**First Name3 (LF) 1515**] Chief Complaint: Scheduled CoreValve procedure Major Surgical or Invasive Procedure: CoreValve aortic valve replacement History of Present Illness: 80yo male with h/o CABG x4, CVA, 100% L carotid occlusion, known aortic stenosis now symptomatic. Patient reports shortness of breath after walking 1 block, must rest after climbing 1 flightof stairs. He admits to 1 witnessed syncopal episode while havingIV's started in an upright position, 1 syncopal episode 6 months ago while getting into shower (also found to have pneumonia). He denies chest pain. Cardiac cath showed three patent grafts.Echocardiogram revealed [**Location (un) 109**] 0.8cm2, mean gradient 36mmHg. Noncontrast chest CT showed heavily calcified aorta prohibitive for conventional surgical AVR. . He was consented for participation in the Corevalve TAVI study. He met all inclusion criteria and did not meet any exclusion criteria. He reported cold-like symptoms of head congestion, no fever. He saw his PCP and [**Name9 (PRE) 40018**] was initiated. His symptoms are improving, he remains fever free and he was cleared by his PCP. [**Name10 (NameIs) **] dose Plavix [**12-14**]. . He underwent succesful CoreValve placement today. His transvenous pacing was placed through the femoral line and the valve was placed through subclavian access. He was sedated with fentanyl and versed and required Neosynephrine for blood pressure supporet at the beginning of the procedure but was weaned off by the end. During balloon dilation he developed LBBB with a paced rhythm. He was given Vancomycin and cefazolin during the procedure. He was extubated prior to arrival to the CCU. He is currently mildly sedated but appropriately responding to commands. . He does have a history of post op N/V from previous surgeries. He also has some residual sensory deficit from prior CVA but no motor deficits. He has a history of esophageal stricture so can not get TEE. . NYHA Class: II Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: - CABG:Coronary artery disease s/p Coronary artery bypass graft x 4 [**2151**] - Aortic stenosis - PERCUTANEOUS CORONARY INTERVENTIONS: none - PACING/ICD: [**Company 1543**] 3. OTHER PAST MEDICAL HISTORY: Past Medical History: - Sepsis secondary to aspiration pneumonia - Lumbar radiculopathy with L4-L5 disc herniation - AAA - Carotid stenosis - CVA from left common carotid occlusion - Esophageal stricture s/p multiple dilatations - Obstructive sleep apnea on CPAP (doesn't use) - GERD - Degenerative joint disease - Pseudomonas bacteremia from UTI - Anxiety - Spinal stenosis - Benign prostatic hypertrophy - Neurogenic pseudo-claudication Past Surgical History: - s/p Left shoulder surgery - s/p Back surgery - s/p Tonsillectomy - s/p Cataract surgery - s/p TURP - s/p Right elbow surgery - s/p Right knee surgery Social History: Lives with wife on upper level of house, daughter lives on lower level (13 stairs). Family History: father deceased secondary to trauma, mother deceased [**Age over 90 **]yo. Physical Exam: ADMISSION EXAM: BP=141/43 HR=61 RR=18 O2 sat= 96% GENERAL: NAD. mildly sedated but responding appropriately to commands. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple, trachea midline,bilat bruits vs referred murmer. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, No MRG. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Anterior exam CTAB, posterior exam deferred. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ Pertinent Results: ADMISSION LABS: [**2163-12-19**] 11:15AM WBC-8.0 RBC-4.10* HGB-13.4* HCT-37.0* MCV-90 MCH-32.7* MCHC-36.3* RDW-12.4 [**2163-12-19**] 11:15AM PLT COUNT-165 [**2163-12-19**] 11:15AM PT-13.7* PTT-28.0 INR(PT)-1.2* [**2163-12-19**] 11:15AM GLUCOSE-96 UREA N-10 CREAT-1.1 SODIUM-140 POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-30 ANION GAP-12 [**2163-12-19**] 11:15AM estGFR-Using this [**2163-12-19**] 11:15AM ALT(SGPT)-40 AST(SGOT)-33 CK(CPK)-116 ALK PHOS-80 TOT BILI-0.9 [**2163-12-19**] 11:15AM ALBUMIN-4.2 [**2163-12-19**] 12:40PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.009 [**2163-12-19**] 12:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG . Pertinent Labs: [**2163-12-19**] 11:15AM CK-MB-2 proBNP-173 [**2163-12-19**] 01:00PM %HbA1c-5.4 eAG-108 [**2163-12-24**] 07:11AM BLOOD Triglyc-100 HDL-34 CHOL/HD-2.4 LDLcalc-26 [**2163-12-21**] 05:01AM BLOOD CK(CPK)-303 [**2163-12-21**] 01:00AM BLOOD CK-MB-5 . DISCHARGE LABS: [**2163-12-25**] 06:44AM BLOOD Glucose-103* UreaN-14 Creat-1.0 Na-138 K-3.8 Cl-104 HCO3-27 AnGap-11 [**2163-12-25**] 06:44AM BLOOD WBC-7.5 RBC-3.59* Hgb-11.4* Hct-32.8* MCV-91 MCH-31.7 MCHC-34.7 RDW-12.5 Plt Ct-139* . ECHO [**12-20**] Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. An aortic CoreValve prosthesis is present. Mild to moderate ([**1-30**]+) aortic regurgitation is seen. Moderate (2+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is no pericardial effusion. IMPRESSION: CoreValve aortic prosthesis in good position. Posterior, mild to moderate paravalvular aortic regurgitation. . ECHO [**12-23**] The left atrium is mildly dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. There are focal calcifications in the aortic arch. An aortic CoreValve prosthesis is present. The transaortic gradient is normal for this prosthesis. A mild (1+) paravalvular aortic valve leak is present. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2163-12-20**], the aortic regurgitation is reduced. . # # # # # # # # ################################################################ Please enter CTA results # # # # # # # # ################################################################ Brief Hospital Course: 80 yo male with history of CAD s/p CABG x4, L MCA CVA [**3-/2163**] with minimal residual R arm weakness, 100% L carotid occlusion, and previous symptomatic aortic stenosis now s/p CoreValve procedure. . ACTIVE ISSUES: # Severe symptomatic aortic stenosis: Underwent succesful CoreValve procedure. He was initially monitored in the CCU. His vitals were stable and he did not have any complications related to venous access or any conduction abnormalities. He was started on plavix and his aspirin was continued post procedure. . # Possible TIA: On [**12-24**] he had a 20 minute epidose of expressive aphasia without any noted motor or sensory symptoms. MD was made aware after episode resolved and there were no residual deficits on first evaluation. A CTA of the head and neck was performed which showed complete occlusion of left cervical internal carotid artery with partial recanalization of the petrous and cavernous ICA. An MRI was not obtained as the patient has a pacemaker. TTE showed no ventricular thrombus. Neurology consultation recommended starting him on Coumadin with ASA and Rosuvastatin for about 6 months or so and then switch him back to Plavix/ASA/Rosuvastatin. He was started on coumadin the day prior to discharge with goal INR of [**3-2**].5. Plan is to stop plavix when INR is at goal with plan to re-initiate plavix therapy after coumadin discontinued. . # HTN - Blood pressure was initially managed with nitroglycerin gtt. His losartan was continued. The amlodipine and hydrochlorothiazide were stopped as his blood pressure remained normotensive off these meds. . # RHYTHM: [**Company 1543**] PPM, interrogated as per study protocol prior to procedure. Post procedure interogation showed Normal function.The p waves without the QRS are part of the PM programming thatoccasionally does not pace to evaluate PR interval to reduce ventricular pacing . CHRONIC ISSUES: . # CAD: s/p CABG x 4 ([**2151**])- Aspirin was continued and plavix 300mg post procedure and 75mg daily afterwards was started. . # CHF - secondary to severe AS, EF>55% . #Respiratory illness: He completed 10 day course of levofloxacin per PCP, [**Name10 (NameIs) **] day [**12-25**] . # HYPERLIPIDEMIA: He was continued on home crestor/niacin . ISSUES OF TRANSITIONS IN CARE: # CODE STATUS: FULL # CONTACT: [**First Name8 (NamePattern2) **] [**Known lastname 40019**] Relationship: wife Phone number: [**Telephone/Fax (1) 40020**] daughter's cell [**Telephone/Fax (1) 40021**] ([**Doctor First Name 3548**] Ruffini) . # FOLLOW UP REGARDING TIA: transition from Coumadin to Plavix in about 6 months ([**2164-5-29**]). Continue ASA and Rosuvastatin throughout treatment. . #FOLLOW UP HYPERTENSION: Home amlodipine and HCTZ were discontinued in hospital. [**Month (only) 116**] need to re-initiate as outpatient if suboptimal bp control. Medications on Admission: Medications - Prescription AVALOX 400mg daily x 10 days (start date [**12-15**]) AMLODIPINE - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth DAILY EZETIMIBE [ZETIA] - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth DAILY FEXOFENADINE [[**Doctor First Name **]] - (Prescribed by Other Provider) - 60 mg Tablet - 1 (One) Tablet(s) by mouth twice a day PRN allergies HYDROCHLOROTHIAZIDE - (Prescribed by Other Provider) - 12.5 mg Tablet - 1 (One) Tablet(s) by mouth once daily in the morning LOSARTAN - (Prescribed by Other Provider) - 100 mg Tablet - 1 Tablet(s) by mouth once a day OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth twice a day ROPINIROLE [REQUIP] - (Prescribed by Other Provider) - 0.25 mg Tablet - 1.5 (One and a half) Tablet(s) by mouth once a day ROSUVASTATIN [CRESTOR] - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth once a day TAMSULOSIN [FLOMAX] - (Prescribed by Other Provider) - 0.4 mg Capsule, Ext Release 24 hr - 1 Capsule(s) by mouth once a day TRAMADOL [ULTRAM] - (Prescribed by Other Provider) - 50 mg Tablet - 1 Tablet(s) by mouth AS NEEDED FOR PAIN Medications - OTC ASPIRIN [BABY ASPIRIN] - (OTC) - 81 mg Tablet, Chewable - 1 (One) Tablet(s) by mouth once daily in the evening CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D] - (Prescribed by Other Provider) - 1,000 unit Capsule - 1 Capsule(s) by mouth once a day GLUCOSAMINE-CHONDROITIN - (Prescribed by Other Provider) - Dosage uncertain LACTOBACILLUS ACIDOPHILUS [FLORAJEN] - (Prescribed by Other Provider) - 460 mg (20 billion cell) Capsule - 2 Capsule(s) by mouth daily NIACIN - (Prescribed by Other Provider) - 500 mg Capsule, Extended Release - 1 Capsule(s) by mouth once a day Discharge Medications: 1. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 2. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 4. ropinirole 0.25 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime). 5. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 8. losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. niacin 500 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO HS (at bedtime). 10. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. warfarin 2 mg Tablet Sig: 2.5 Tablets PO q evening for 6 months: take as directed pending lab results. Disp:*100 Tablet(s)* Refills:*5* 12. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): STOP WHEN INR>2.0. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: primary diagnosis: coronary artery disease aortic stenosis transient ischemic attack secondary diagnosis: carotid occlusion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Discharge Instructions: Dear Mr. [**Known lastname 40019**], You were admitted for CoreValve procedure. You tolerated the procedure well but you did experience a transient ischemic attack, which is a small stroke. Because of this, you will need to take Coumadin for 6 months. It is important that you follow up with your physicians regarding your Coumadin and regarding your CoreValve. Please note the following changes to your medications: - START Coumadin - START multivitamin - CHANGE Losartan from 100mg daily to 50mg daily - STOP avalox - STOP amlodipine - STOP [**Doctor First Name 130**] - STOP hydrochlorothiazide - STOP tramadol - STOP glucosamine-chondroitin - STOP lactobacillus Please be sure to follow up with your physicians. It was a pleasure taking care of you at [**Hospital1 18**] and we wish you all the best. Followup Instructions: Department: CARDIAC SERVICES When: FRIDAY [**2164-1-20**] at 11:00 AM With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: FRIDAY [**2164-1-20**] at 10:30 AM With: DEVICE CLINIC [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

424,784,434,428,438,V458,V533,426,401,272,327,530,600,V707,443

{'Aortic valve disorders,Aphasia,Cerebral embolism without mention of cerebral infarction,Chronic diastolic heart failure,Late effects of cerebrovascular disease, hemiplegia affecting dominant side,Aortocoronary bypass status,Fitting and adjustment of cardiac pacemaker,Other left bundle branch block,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Obstructive sleep apnea (adult)(pediatric),Esophageal reflux,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Examination of participant in clinical trial,Peripheral vascular 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: Scheduled CoreValve procedure PRESENT ILLNESS: 80yo male with h/o CABG x4, CVA, 100% L carotid occlusion, known aortic stenosis now symptomatic. Patient reports shortness of breath after walking 1 block, must rest after climbing 1 flightof stairs. He admits to 1 witnessed syncopal episode while havingIV's started in an upright position, 1 syncopal episode 6 months ago while getting into shower (also found to have pneumonia). He denies chest pain. Cardiac cath showed three patent grafts.Echocardiogram revealed [**Location (un) 109**] 0.8cm2, mean gradient 36mmHg. Noncontrast chest CT showed heavily calcified aorta prohibitive for conventional surgical AVR. . He was consented for participation in the Corevalve TAVI study. He met all inclusion criteria and did not meet any exclusion criteria. He reported cold-like symptoms of head congestion, no fever. He saw his PCP and [**Name9 (PRE) 40018**] was initiated. His symptoms are improving, he remains fever free and he was cleared by his PCP. [**Name10 (NameIs) **] dose Plavix [**12-14**]. . He underwent succesful CoreValve placement today. His transvenous pacing was placed through the femoral line and the valve was placed through subclavian access. He was sedated with fentanyl and versed and required Neosynephrine for blood pressure supporet at the beginning of the procedure but was weaned off by the end. During balloon dilation he developed LBBB with a paced rhythm. He was given Vancomycin and cefazolin during the procedure. He was extubated prior to arrival to the CCU. He is currently mildly sedated but appropriately responding to commands. . He does have a history of post op N/V from previous surgeries. He also has some residual sensory deficit from prior CVA but no motor deficits. He has a history of esophageal stricture so can not get TEE. . NYHA Class: II MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: - CABG:Coronary artery disease s/p Coronary artery bypass graft x 4 [**2151**] - Aortic stenosis - PERCUTANEOUS CORONARY INTERVENTIONS: none - PACING/ICD: [**Company 1543**] 3. OTHER PAST MEDICAL HISTORY: Past Medical History: - Sepsis secondary to aspiration pneumonia - Lumbar radiculopathy with L4-L5 disc herniation - AAA - Carotid stenosis - CVA from left common carotid occlusion - Esophageal stricture s/p multiple dilatations - Obstructive sleep apnea on CPAP (doesn't use) - GERD - Degenerative joint disease - Pseudomonas bacteremia from UTI - Anxiety - Spinal stenosis - Benign prostatic hypertrophy - Neurogenic pseudo-claudication Past Surgical History: - s/p Left shoulder surgery - s/p Back surgery - s/p Tonsillectomy - s/p Cataract surgery - s/p TURP - s/p Right elbow surgery - s/p Right knee surgery MEDICATION ON ADMISSION: Medications - Prescription AVALOX 400mg daily x 10 days (start date [**12-15**]) AMLODIPINE - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth DAILY EZETIMIBE [ZETIA] - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth DAILY FEXOFENADINE [[**Doctor First Name **]] - (Prescribed by Other Provider) - 60 mg Tablet - 1 (One) Tablet(s) by mouth twice a day PRN allergies HYDROCHLOROTHIAZIDE - (Prescribed by Other Provider) - 12.5 mg Tablet - 1 (One) Tablet(s) by mouth once daily in the morning LOSARTAN - (Prescribed by Other Provider) - 100 mg Tablet - 1 Tablet(s) by mouth once a day OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth twice a day ROPINIROLE [REQUIP] - (Prescribed by Other Provider) - 0.25 mg Tablet - 1.5 (One and a half) Tablet(s) by mouth once a day ROSUVASTATIN [CRESTOR] - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth once a day TAMSULOSIN [FLOMAX] - (Prescribed by Other Provider) - 0.4 mg Capsule, Ext Release 24 hr - 1 Capsule(s) by mouth once a day TRAMADOL [ULTRAM] - (Prescribed by Other Provider) - 50 mg Tablet - 1 Tablet(s) by mouth AS NEEDED FOR PAIN ALLERGIES: Protonix / Accupril / Pravachol / Mevacor PHYSICAL EXAM: ADMISSION EXAM: BP=141/43 HR=61 RR=18 O2 sat= 96% GENERAL: NAD. mildly sedated but responding appropriately to commands. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple, trachea midline,bilat bruits vs referred murmer. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, No MRG. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Anterior exam CTAB, posterior exam deferred. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ FAMILY HISTORY: father deceased secondary to trauma, mother deceased [**Age over 90 **]yo. SOCIAL HISTORY: Lives with wife on upper level of house, daughter lives on lower level (13 stairs). ### Response: {'Aortic valve disorders,Aphasia,Cerebral embolism without mention of cerebral infarction,Chronic diastolic heart failure,Late effects of cerebrovascular disease, hemiplegia affecting dominant side,Aortocoronary bypass status,Fitting and adjustment of cardiac pacemaker,Other left bundle branch block,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Obstructive sleep apnea (adult)(pediatric),Esophageal reflux,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Examination of participant in clinical trial,Peripheral vascular disease, unspecified'}

CHIEF COMPLAINT: PRESENT ILLNESS: Mr. [**Known lastname **] is a 72-year-old man with multiple medical problems including admission to the medical Intensive Care Unit in [**2149-11-8**] to [**2149-12-9**] for urosepsis complicated by myocardial infarction, congestive heart failure, and worsening renal failure resulting in initiation of dialysis. During this admission the patient had a prolonged intubation for hypoxic respiratory failure secondary to his congestive heart failure. The patient had been discharged to [**Hospital1 **] Care Hospital on [**1-2**] where he was noted to have melena for 24 hours with a hematocrit drop from 34 to 28%. He was transfused two units of packed red blood cells with only some compensation of his hematocrit to 31.6. He was sent to the Emergency Room on [**2150-1-12**] for evaluation where he was hypotensive to 70/48 and started on IV fluids and Dopamine. An NG lavage was negative for bright red blood or coffee grounds. Due to his hypotension and history of nosocomial infection, she was given Vancomycin and Ceftazidime and transferred to the medical Intensive Care Unit for further management. MEDICAL HISTORY: Coronary artery disease status post cardiac catheterization with LAD stent on [**2149-12-15**], status post myocardial infarction [**11-8**], congestive heart failure with an EF of 25-30%, type 2 diabetes times 20 years, peripheral vascular disease status post toe amputation times two, atrial fibrillation, pseudomonas urinary tract infection [**2149-11-8**], hypertension, chronic renal insufficiency, now on hemodialysis Monday, Wednesday and Friday, gout, chronic lower extremity edema, obstructive sleep apnea on C-PAP, history of MRSA pneumonia, history of GI bleed with no EGD or colonoscopy report available. MEDICATION ON ADMISSION: ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: The patient quit tobacco 20 years ago and quit alcohol use 4-6 weeks prior to admission. The patient is married and has a daughter.

Unspecified vascular insufficiency of intestine,Congestive heart failure, unspecified,Blood in stool,Acute myocardial infarction of other anterior wall, subsequent episode of care,Candidiasis of other urogenital sites,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled

Vasc insuff intest NOS,CHF NOS,Blood in stool,AMI anterior wall,subseq,Candidias urogenital NEC,DMII oth nt st uncntrld

Admission Date: [**2150-1-12**] Discharge Date: [**2150-1-17**] Date of Birth: [**2077-8-1**] Sex: M Service: Medical Intensive Care Unit with transfer to [**Company 191**] internal medicine firm. HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 72-year-old man with multiple medical problems including admission to the medical Intensive Care Unit in [**2149-11-8**] to [**2149-12-9**] for urosepsis complicated by myocardial infarction, congestive heart failure, and worsening renal failure resulting in initiation of dialysis. During this admission the patient had a prolonged intubation for hypoxic respiratory failure secondary to his congestive heart failure. The patient had been discharged to [**Hospital1 **] Care Hospital on [**1-2**] where he was noted to have melena for 24 hours with a hematocrit drop from 34 to 28%. He was transfused two units of packed red blood cells with only some compensation of his hematocrit to 31.6. He was sent to the Emergency Room on [**2150-1-12**] for evaluation where he was hypotensive to 70/48 and started on IV fluids and Dopamine. An NG lavage was negative for bright red blood or coffee grounds. Due to his hypotension and history of nosocomial infection, she was given Vancomycin and Ceftazidime and transferred to the medical Intensive Care Unit for further management. REVIEW OF SYSTEMS: The patient reported feeling sleepy and lethargic. He denied chest pain, shortness of breath, or abdominal pain. PAST MEDICAL HISTORY: Coronary artery disease status post cardiac catheterization with LAD stent on [**2149-12-15**], status post myocardial infarction [**11-8**], congestive heart failure with an EF of 25-30%, type 2 diabetes times 20 years, peripheral vascular disease status post toe amputation times two, atrial fibrillation, pseudomonas urinary tract infection [**2149-11-8**], hypertension, chronic renal insufficiency, now on hemodialysis Monday, Wednesday and Friday, gout, chronic lower extremity edema, obstructive sleep apnea on C-PAP, history of MRSA pneumonia, history of GI bleed with no EGD or colonoscopy report available. ALLERGIES: No known drug allergies. MEDICATIONS: On admission, Protonix 40 mg po q day, Captopril 12.5 mg po tid, Levaquin 250 mg po q day, Day 8 of 15, Epogen 5,000 units three times per week, Colace 100 mg po bid, Lipitor 40 mg po q h.s., Nephrocaps 1 tablet po q day, NPH 10 units subcu q a.m., 6 units subcu q p.m., Paroxetine 20 mg po q day, Reglan 5 mg po qid, Calcium Carbonate 500 mg po tid, Digoxin .125 mg three times per week. SOCIAL HISTORY: The patient quit tobacco 20 years ago and quit alcohol use 4-6 weeks prior to admission. The patient is married and has a daughter. PHYSICAL EXAMINATION: Temperature 99.8, heart rate 80, blood pressure 131/51, respiratory rate 26, oxygen saturation 97% on four liters. In general this is a lethargic but alert and elderly man in no acute distress. HEENT exam indicated pupils are equal, round and reactive to light, there was a right subconjunctival hemorrhage, had dry oral mucosa. The neck was supple with no jugular venous distention. A Quinton catheter was in place in the right subclavian position. Cardiovascular exam indicated regular rhythm, normal S1 and S2, no murmurs, gallops or rubs. Chest was clear to auscultation bilaterally. On abdominal exam the patient had bruising on his lower abdomen which was soft, nontender, non distended with normal bowel sounds. He had a rectal bag in place with black, running stool. On extremity exam the patient had 2+ peripheral pulses and no edema. He does have a small ulcer on his left lateral shin with an eschar. On his back he had a stage II sacral decubitus ulcer. Neurologically the patient was alert and oriented to place, month, year and current events. He responded to verbal commands and was moving all extremities against gravity. EKG indicated normal sinus rhythm. Chest x-ray indicated an elevated right hemidiaphragm, unchanged from previous study on [**12-29**]. There was no congestive heart failure or infiltrates. Remainder of his laboratory studies were notable for a white blood count of 28.4 with differential of 74% neutrophils and 20% lymphocytes, hematocrit 31.6, BUN 69, creatinine 6.1, glucose 188. Urinalysis indicated specific gravity of greater than 1.030, nitrites positive with 3-5 white blood cells and a few bacteria. Arterial blood gas indicated a PH of 7.31 with a PCO2 40 and PAO2 of 62. Lactate level was 2.3. Blood cultures times two were sent as was a urine culture and a C. diff. HOSPITAL COURSE: The patient was admitted to the Intensive Care Unit for management of a GI bleed. He was continued on Dopamine and slowly weaned off over the course of the first two hospital days. He was transfused one unit of packed red blood cells for a hematocrit of 25.9 on hospital day #2 and was transfused another 2 units of packed red blood cells on hospital day #3. The renal team was consulted and suggested DDAVP and ultrafiltration without Heparin on hospital day #2 as well as initiation of conjugated estrogens. The GI service saw the patient on hospital day #2 and felt that he was not actively bleeding since his blood pressure was stable and his blood counts were stable and it was therefore opted for upper and lower endoscopy when his coagulation parameters were optimized. On the evening of hospital day #2 the patient had development of transient new first degree AV block. Amiodarone and Digoxin were held. On hospital day #3 the patient was transferred to the floor. As all of his cultures were negative antibiotics were discontinued. On hospital day #4 the patient received upper and lower endoscopy. Upper endoscopy indicated normal esophagus, stomach and duodenum with the exception of a small polyp in the stomach which was likely hyperplastic. Colonoscopy indicated localized discontinuous granularity with friable erythematous mucosa in the ascending colon. There was no active bleeding. These findings were thought to be consistent with ischemic colitis. As the patient was not actively bleeding and was status post myocardial infarction on last admission, he was restarted on 81 mg of Aspirin. He was also restarted on his Amiodarone for rate control. The patient was to be seen by physical therapy and occupational therapy whose evaluations are pending at the time of this discharge dictation. He was being screened for placement in an acute rehabilitation facility. The patient was to follow-up with his primary care provider, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Name (STitle) 1683**]. DISCHARGE DIAGNOSIS: 1. Ischemic bowel. 2. Congestive heart failure. 3. Coronary artery disease. 4. End stage renal disease on hemodialysis. 5. Type 2 diabetes mellitus. 6. Peripheral vascular disease. 7. Atrial fibrillation. 8. Hypertension. DISCHARGE MEDICATIONS: Protonix 40 mg po q day, Captopril 12.5 mg po tid, enteric coated Aspirin 81 mg po q day, Epogen 5000 units three times per week with hemodialysis, Colace 100 mg po bid, Lipitor 40 mg po q day, Amiodarone 200 mg po q day, Nephrocaps one tablet po q day, Paxil 20 mg po q day, Reglan 5 mg po qid, TUMS 500 mg po tid, NPH 10 units q a.m., 6 units q p.m. DISPOSITION: The patient was to be discharged to an acute rehabilitation facility. CONDITION ON DISCHARGE: Improved. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8873**] [**Name8 (MD) **], M.D. [**MD Number(1) 8874**] Dictated By:[**Last Name (NamePattern1) 194**] MEDQUIST36 D: [**2150-1-16**] 17:43 T: [**2150-1-16**] 18:31 JOB#: [**Job Number 7718**] Admission Date: [**2150-1-12**] Discharge Date: [**2150-1-21**] Date of Birth: [**2077-8-1**] Sex: M Service: HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 72-year-old man with multiple medical problems who is status post recent medical Intensive Care Unit admission from [**2149-11-8**] through [**2149-12-9**] for urosepsis complicated by myocardial infarction, congestive heart failure, worsening renal failure resulting in initiation of dialysis and prolonged intubation for hypoxemic respiratory failure secondary to congestive heart failure. The patient was discharged to [**Hospital1 **] Care Hospital on [**1-2**]. At [**Hospital1 **] the patient was noted to have melena times 24 hours with a drop in hematocrit from 34 to 28. He was transfused two units of packed red blood cells with a resultant hematocrit of 31.6. He was then sent to the Emergency Room for evaluation where he was noted to be hypotensive at 72/48 on arrival. He received 500 cc of normal saline and was started on a Dopamine drip with an increase in his blood pressure to 160/54. NG lavage in the Emergency Room was negative for blood. The patient was pancultured and given Vancomycin and Ceftazidime. He was transferred from the medical Intensive Care Unit for evaluation. REVIEW OF SYSTEMS: The patient referred to feeling sleepy and lethargic. He denied chest pain, shortness of breath or abdominal pain. PAST MEDICAL HISTORY: Coronary artery disease status post catheterization with left anterior descending artery stent on [**2149-12-15**], status post MI in [**2149-11-8**]. Congestive heart failure with an ejection fraction of 25-30%. Type 2 diabetes mellitus times 20 years. Peripheral vascular disease status post toe amputation times two. Atrial fibrillation. Pseudomonas urinary tract infection in [**2149-11-8**]. Hypertension. Chronic renal insufficiency now on hemodialysis Monday, Wednesday and Friday. Gout. Chronic lower extremity erythema and edema. Obstructive sleep apnea, on C-pap. Anemia of chronic disease on Epogen. History of Methicillin resistant staph aureus pneumonia. History of GI bleed with no documented EGD or colonoscopy. ALLERGIES: No known drug allergies. MEDICATIONS: Protonix 40 mg po q day, Captopril 12.5 mg po tid, Levofloxacin 250 mg po q d, day 8 of 15, Epogen 5,000 units three times per week with hemodialysis, Colace 100 mg po bid, Lipitor 40 mg po q h.s., Nephrocaps one tablet po q day, NPH 10 units q a.m., 6 units q p.m., Paroxetine 20 mg po q day, Reglan 5 mg po qid, Calcium Carbonate 500 mg po tid, Digoxin 0.125 mg po tiw. SOCIAL HISTORY: The patient quit smoking tobacco 20 years ago, he quit drinking alcohol 4-6 weeks prior to admission. PHYSICAL EXAMINATION: Temperature 99.8, heart rate 80, blood pressure 131/51, respiratory rate 26, oxygen saturation 97% on four liters. In general, this is a lethargic but alert elderly gentleman, chronically ill appearing, answering questions. HEENT: Indicated pupils are equal, round and reactive to light. There was a right subconjunctival hemorrhage and dry oral mucosa. The neck was supple with full range of motion. There was no jugulovenous distension. A right subclavian Quinton catheter was in place and the site appeared clean, dry and intact. Cardiovascular exam indicated regular rate and rhythm, normal S1 and S2, no murmurs, gallops or rubs. Lungs were clear to auscultation bilaterally. Abdominal exam indicated bruising on the lower abdomen. The abdomen was soft, nontender, non distended with normal bowel sounds. The patient had a rectal bag in place with black, runny stool. On extremity exam the patient had no edema, he had an ulcer with an eschar over his left lateral shin. Back exam indicated stage 2 sacral decubitus ulcer with no rash and no vertebral body tenderness. Neurologically the patient was alert and oriented to place, month, year and current events. He moved all four extremities against gravity. Reflexes were symmetric. LABORATORY DATA: EKG indicated normal sinus rhythm. Chest x-ray indicated increased right hemidiaphragm, unchanged from [**12-29**]. There was no congestive heart failure or infiltrate. White blood count was 28.4 with 74% polys and 20% lymphs. Hematocrit 31.6. Chem 7 was remarkable for BUN of 61, creatinine 6.1 and glucose 188, LFTs were notable for an alkaline phosphatase of 248. Cardiac enzymes were negative. Urinalysis indicated a specific gravity of 1.030, nitrite positive, [**2-10**] white blood cells and a few bacteria. Arterial blood gases indicated a PH of 7.31, PACO2 40 and PAO2 of 62. Lactate was 2.3. Blood cultures, urine cultures and C. diff cultures were sent and were negative. HOSPITAL COURSE: In the medical Intensive Care Unit the patient was continued on Dopamine drip and slowly weaned off with good hemodynamic stability. He was transfused a total of 3 units of packed red blood cells, following which his hematocrit remained stable. The patient continued hemodialysis three times per week. The patient was also started on conjugated estrogen therapy in the setting of a GI bleed. The patient was evaluated by the GI service on hospital day #2 and felt that he was not actively bleeding since his blood pressure was stable and his blood counts were stable as well. On the night of hospital stay #2 the patient developed a transient, first degree AV block and the Amiodarone and Digoxin were held. On hospital day #3 the patient was transferred to the floor for further work-up of his GI bleed. Upper endoscopy was performed on hospital day #4 and indicated the presence of a polyp in the stomach body which was described as likely hyperplastic. There was no active bleeding. Colonoscopy was also performed and indicated ischemic appearing ascending colon with no evidence of any active bleeding. As all of the patient's culture results came back negative, Vancomycin was discontinued. The patient was also restarted on his Amiodarone and Aspirin given that there was no evidence of a current GI bleed. The patient was evaluated by physical therapy who recommended aggressive daily physical therapy given his degree of deconditioning. On hospital day #5 the patient was noted to be lethargic with decreased responsiveness. A chest x-ray indicated a slight increase in congestive heart failure. Arterial blood gases indicated a PH of 7.29, PACO2 of 49 and PAO2 87. An EKG was obtained which indicated no ischemic changes. Urinalysis was sent which came back consistent with a urinary tract infection. Urine cultures were sent and the patient was started on Ciprofloxacin. Following initiation of antibiotic therapy, the patient's mental status improved dramatically and he remained at baseline for the remainder of his hospital stay. The patient was evaluated by the speech and swallow service who deemed him appropriate for thick liquids and pureed foods. At the time of this dictation the patient was being screened for placement in an acute rehabilitation facility. DISCHARGE DIAGNOSIS: 1. Ischemic bowel, status post ? lower GI bleed. 2. Coronary artery disease. 3. Congestive heart failure with 25% ejection fraction. 4. Type 2 diabetes mellitus. 5. Peripheral vascular disease. 6. Atrial fibrillation. 7. Hypertension. 8. End stage renal disease on hemodialysis. 9. Obstructive sleep apnea. 10. Chronic lower extremity edema. 11. History of MRSA pneumonia. DISCHARGE MEDICATIONS: Cipro 500 mg po q day through [**2150-1-24**], Tylenol 650 mg po q 4-6 hours prn, enteric coated ASA 81 mg po q day, Amiodarone 200 mg po q day, Prevacid slow rate 30 mg po bid, Epogen 5000 units with hemodialysis, Captopril 12.5 mg po tid, Paroxetine 20 mg po q d, Nephrocaps one tablet po q day, Reglan 5 mg po q 6 hours, Calcium Carbonate suspension 500 mg po tid, Lipitor 40 mg po q h.s., NPH 10 units subcu q a.m., 6 units subcu q p.m. The patient was to have hemodialysis three times per week. DISPOSITION: At the time of this dictation it was anticipated that the patient would be discharged to an acute rehabilitation facility. CONDITION ON DISCHARGE: Improved. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8873**] [**Name8 (MD) **], M.D. [**MD Number(1) 8874**] Dictated By:[**Last Name (NamePattern1) 194**] MEDQUIST36 D: [**2150-1-20**] 19:32 T: [**2150-1-20**] 19:54 JOB#: [**Job Number 18077**]

557,428,578,410,112,250

{'Unspecified vascular insufficiency of intestine,Congestive heart failure, unspecified,Blood in stool,Acute myocardial infarction of other anterior wall, subsequent episode of care,Candidiasis of other urogenital sites,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled'}

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: Mr. [**Known lastname **] is a 72-year-old man with multiple medical problems including admission to the medical Intensive Care Unit in [**2149-11-8**] to [**2149-12-9**] for urosepsis complicated by myocardial infarction, congestive heart failure, and worsening renal failure resulting in initiation of dialysis. During this admission the patient had a prolonged intubation for hypoxic respiratory failure secondary to his congestive heart failure. The patient had been discharged to [**Hospital1 **] Care Hospital on [**1-2**] where he was noted to have melena for 24 hours with a hematocrit drop from 34 to 28%. He was transfused two units of packed red blood cells with only some compensation of his hematocrit to 31.6. He was sent to the Emergency Room on [**2150-1-12**] for evaluation where he was hypotensive to 70/48 and started on IV fluids and Dopamine. An NG lavage was negative for bright red blood or coffee grounds. Due to his hypotension and history of nosocomial infection, she was given Vancomycin and Ceftazidime and transferred to the medical Intensive Care Unit for further management. MEDICAL HISTORY: Coronary artery disease status post cardiac catheterization with LAD stent on [**2149-12-15**], status post myocardial infarction [**11-8**], congestive heart failure with an EF of 25-30%, type 2 diabetes times 20 years, peripheral vascular disease status post toe amputation times two, atrial fibrillation, pseudomonas urinary tract infection [**2149-11-8**], hypertension, chronic renal insufficiency, now on hemodialysis Monday, Wednesday and Friday, gout, chronic lower extremity edema, obstructive sleep apnea on C-PAP, history of MRSA pneumonia, history of GI bleed with no EGD or colonoscopy report available. MEDICATION ON ADMISSION: ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: The patient quit tobacco 20 years ago and quit alcohol use 4-6 weeks prior to admission. The patient is married and has a daughter. ### Response: {'Unspecified vascular insufficiency of intestine,Congestive heart failure, unspecified,Blood in stool,Acute myocardial infarction of other anterior wall, subsequent episode of care,Candidiasis of other urogenital sites,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled'}

CHIEF COMPLAINT: s/p fall with altered mental status PRESENT ILLNESS: Ms. [**Known lastname 50992**] is a [**Age over 90 **] yo female with a h/o atrial fibrillation, CHF, hypertension, diastolic dysfunction, DM2, stage V chronic kidney disease and hypothyroidism who is transferred to [**Hospital1 18**] following two falls on [**11-28**]. Daughter states that she sat down earlier in the day on the staircase landing complaining of knee pain. At that time, she hit her head against the wall but was subsequently alert and oriented. Later in the day, around 4 p.m. she fell from the top of the staircase backwards down approximately 10 stairs. She was initially responsive and not complaining of any pain, but was unable to move. Her daughter called EMS. When EMS arrived, she was sitting on a bottom step, conversational. Her head subsequently dropped back and her mouth opened and she became unresponsive. . On initial exam at [**Hospital1 **] [**Location (un) 620**], patient was not responding to questions but opened her eyes to verbal stimuli. A CT of her c-spine was significant for C4/C5 space widening with ? anterior ligamentous sprain due to trauma. CT of her head was reported as negative. She was treated with a dose of ceftriaxone for reported UTI. . She was admitted to the ICU at [**Hospital1 **] [**Location (un) 620**] where she was reported to be fidgeting and moaning in bed, but otherwise nonverbal. BP was elevated to 228/122 and she was given 10 mg of IV labetalol without result. She was started on a nitroglycerin gtt at 0100 for BP control. She was noted to have a surgical right pupil. She was subsequently transferred to the MICU at [**Hospital1 18**] for MRI/MRA of her posterior circulation. MEDICAL HISTORY: 1) Atrial fibrillation 2) Diastolic CHF, EF 60% 3) Hypertension 4) Diabetes mellitus, Type II x 20 years 5) Stage V chronic kidney disease (Cr 4.1 in [**10-9**]), followed by Dr. [**Last Name (STitle) 4090**], were planning for tunneled catheter when the patient becomes sicker and requires dialysis 6) Hypothyroidism 7) Secondary hyperparathyroidism MEDICATION ON ADMISSION: 1. Norvasc 2.5 mg qday 2. Diovan 40 mg daily 3. HCTZ 12.5 mg QOD 4. Lanoxin 6.25 mg daily 5. Lipitor 20 mg daily 6. Lasix 40 mg daily 7. Levoxyl 100 mcg daily 8. Warfarin 2 mg 5day/week, 1 mg Monday & Thursday 9. Toprol XL 125 mg daily 10. Detrol LA 2 mg daily 11. Betamol 0.5% - 1 drop [**Hospital1 **] OU 12. NPH insulin 10 units [**Hospital1 **] 13. Reglan 10 mg PRN nausea 14. Vitamin D 50,000 units per week 14. Phoslo 1334 mg TID 15. Slo-Mag 64 mg daily 16. MVI 17. Tylenol PRN knee/back pain ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: VS: T 97.7, 176/79, HR 79, RR 15, SpO2 95% Gen: elderly WF, in c-collar, lying on right side in fetal position HEENT: normocephalic, atraumatic CV: regular rate, sinus rhythm on telemetry, nl S1 S2 Resp: CTA, normal respiratory effort Abdomen: soft, +BS, no grimace to deep palpation Extrem: no edema, 2+ pulses Skin: superficial abrasions on upper portion of posterior torso Neuro: unable to perform complete neuro exam due to lack of patient cooperation, eyes squeezed shut bilaterally, unable to assess pupil reactivity; cogwheeling of upper right extremity, hypertonic in upper extremities bilaterally; upgoing toes on right, downgoing on left; does not follow commands; some spontaneous movements in all extremities FAMILY HISTORY: non-contributory . SOCIAL HISTORY: Resides with daughter at home. Independent and performs all ADL's at baseline, except requires assistance with bathing. Ambulates with a cane.

Toxic encephalopathy,Concussion with loss of consciousness of unspecified duration,Atrial fibrillation,Chronic kidney disease, Stage V,Chronic diastolic heart failure,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Urinary tract infection, site not specified,Cerebral embolism with cerebral infarction,Diseases of tricuspid valve,Mitral valve disorders,Accidental fall on or from other stairs or steps,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Vascular dementia, uncomplicated,Cerebral atherosclerosis,Unspecified acquired hypothyroidism,Long-term (current) use of anticoagulants,Secondary hyperparathyroidism (of renal origin),Candidiasis of vulva and vagina

Toxic encephalopathy,Concussion w coma NOS,Atrial fibrillation,Chron kidney dis stage V,Chr diastolic hrt fail,Hyp kid NOS w cr kid V,Urin tract infection NOS,Crbl emblsm w infrct,Tricuspid valve disease,Mitral valve disorder,Fall on stair/step NEC,DMII wo cmp nt st uncntr,Vascular dementia,uncomp,Cerebral atherosclerosis,Hypothyroidism NOS,Long-term use anticoagul,Sec hyperparathyrd-renal,Candidal vulvovaginitis

Admission Date: [**2117-1-29**] Discharge Date: [**2117-2-11**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 898**] Chief Complaint: s/p fall with altered mental status Major Surgical or Invasive Procedure: Tunneled Catheter placement Central line placement History of Present Illness: Ms. [**Known lastname 50992**] is a [**Age over 90 **] yo female with a h/o atrial fibrillation, CHF, hypertension, diastolic dysfunction, DM2, stage V chronic kidney disease and hypothyroidism who is transferred to [**Hospital1 18**] following two falls on [**11-28**]. Daughter states that she sat down earlier in the day on the staircase landing complaining of knee pain. At that time, she hit her head against the wall but was subsequently alert and oriented. Later in the day, around 4 p.m. she fell from the top of the staircase backwards down approximately 10 stairs. She was initially responsive and not complaining of any pain, but was unable to move. Her daughter called EMS. When EMS arrived, she was sitting on a bottom step, conversational. Her head subsequently dropped back and her mouth opened and she became unresponsive. . On initial exam at [**Hospital1 **] [**Location (un) 620**], patient was not responding to questions but opened her eyes to verbal stimuli. A CT of her c-spine was significant for C4/C5 space widening with ? anterior ligamentous sprain due to trauma. CT of her head was reported as negative. She was treated with a dose of ceftriaxone for reported UTI. . She was admitted to the ICU at [**Hospital1 **] [**Location (un) 620**] where she was reported to be fidgeting and moaning in bed, but otherwise nonverbal. BP was elevated to 228/122 and she was given 10 mg of IV labetalol without result. She was started on a nitroglycerin gtt at 0100 for BP control. She was noted to have a surgical right pupil. She was subsequently transferred to the MICU at [**Hospital1 18**] for MRI/MRA of her posterior circulation. Past Medical History: 1) Atrial fibrillation 2) Diastolic CHF, EF 60% 3) Hypertension 4) Diabetes mellitus, Type II x 20 years 5) Stage V chronic kidney disease (Cr 4.1 in [**10-9**]), followed by Dr. [**Last Name (STitle) 4090**], were planning for tunneled catheter when the patient becomes sicker and requires dialysis 6) Hypothyroidism 7) Secondary hyperparathyroidism Social History: Resides with daughter at home. Independent and performs all ADL's at baseline, except requires assistance with bathing. Ambulates with a cane. Family History: non-contributory . Physical Exam: VS: T 97.7, 176/79, HR 79, RR 15, SpO2 95% Gen: elderly WF, in c-collar, lying on right side in fetal position HEENT: normocephalic, atraumatic CV: regular rate, sinus rhythm on telemetry, nl S1 S2 Resp: CTA, normal respiratory effort Abdomen: soft, +BS, no grimace to deep palpation Extrem: no edema, 2+ pulses Skin: superficial abrasions on upper portion of posterior torso Neuro: unable to perform complete neuro exam due to lack of patient cooperation, eyes squeezed shut bilaterally, unable to assess pupil reactivity; cogwheeling of upper right extremity, hypertonic in upper extremities bilaterally; upgoing toes on right, downgoing on left; does not follow commands; some spontaneous movements in all extremities Pertinent Results: [**2117-1-29**] 04:20AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-500 GLUCOSE-250 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2117-1-29**] 04:20AM NEUTS-95.9* BANDS-0 LYMPHS-2.4* MONOS-1.1* EOS-0.2 BASOS-0.2 [**2117-1-29**] 04:20AM WBC-18.0*# RBC-4.11* HGB-12.7 HCT-36.7 MCV-89 MCH-30.8 MCHC-34.5 RDW-14.1 [**2117-1-29**] 04:20AM ASA-NEG tricyclic-NEG [**2117-1-29**] 04:20AM TSH-10* [**2117-1-29**] 04:20AM cTropnT-0.04* [**2117-1-29**] 12:00PM CK-MB-7 cTropnT-0.06* [**2117-1-29**] 12:00PM GLUCOSE-198* UREA N-69* CREAT-6.0* SODIUM-132* POTASSIUM-4.8 CHLORIDE-98 TOTAL CO2-21* ANION GAP-18 MR of head [**1-29**]: No evidence of an acute infarct. Possible tiny subacute infarct in the white matter of the left frontal lobe. . MRA of head and neck [**1-29**]: Nonvisualization of the right vertebral artery could be due to thrombosis. . EEG [**1-30**]: This is an abnormal EEG due to the presence of bursts of generalized slowing superimposed upon a slow background. This is most consistent with a moderate encephalopathy of toxic, metabolic, or anoxic etiology. No evidence of ongoing seizure activity was seen, and no focal abnormalities were noted. . CT T spine [**1-29**]:Multilevel degenerative changes w/o evidence of acute fracture or dislocation in the T-spine. . CT L spine [**1-29**]: Compression deformity of L1 with approx. 50% loss of height centrally. Most likely this represents a chronic degenerative process, although acute component difficult to exclude. Brief Hospital Course: 1) Altered mental status: difficult to determine whether pre or post fall. CT head reported as negative at the outside hospital; however, official report not available. She was transferred here for the explicit purpose of MRI/MRA to assess posterior circulation, given widened disk space at C4/C5 and question of cervical sprain. . At [**Hospital1 18**], patient's MS changes were initially thought to be post-concussive vs. secondary to uremia as mental status seemed to improve with hemodyalisis. However, after multiple dialysis sessions and correlated improving creatinine, patient's mental status remained stable. An MRI on [**2-2**] showed multiple new small emolizations and again a poorly visualized vertebral artery. Neurology continued to follow throughout hospitalization. - TEE [**2-4**] showed signs of hypertrophic cardiomyopathy with mod MR [**First Name (Titles) **] [**Last Name (Titles) **]. - TEE was performed to eval for atrial thrombus as possible source of emboli. - Carotid U/S showed < 40% stenosis of both carotids. - EEG showed diffuse slowing consistent with encephalopathy. - Serial cardiac enzymes to r/o MI as precipitant for fall were negative. . Neurology continued to follow the patient and believes her mental status changes are likely due to bihemispheric infarcts. Neurology will follow up with the patient in one month. . 2) S/P fall with widened disk space w/ cervical strain: Orthospine consult recommended keeping patient in a soft collar until seen in clinic as patient unable to tolerate MR of spine. . 3) Stage V CKD: Cr of 5.6, stable from end of [**Month (only) 1096**] BUN/Cr of 69/5.4. Patient was previously planning to undergo hemodialysis. - Nephrology service followed throughout hospitatization and recommended dialysis. The family consented and HD was started. A Right subclavian tunnelled catheter was placed by IR for HD use. A RUE vein mapping for possible AVM in the future was obtained. The patient was given multiple transfussions of FFP for HD. The patient is on a Monday, Wednesday, Friday schedule for dialysis. . 4) Hypertension: initially managed with nitroglycerin gtt while in the MICU but titrated off with stable blood pressure's after. Patient maintained on a regimen recommended by Nephrology of metoprolol which was titrated to effect as norvasc and hydralzine (initiated in the MICU) were discontinued. Patient's blood pressure continued to be stable. . 4) Atrial fibrillation: Remained rate controlled with beta-blocker, and intially anticoagulated with coumadin. Coumadin was discontinued secondary to supratherapeutic INR prior to HD line insertion. 3 bags of FFP given to reverse INR prior to temporary catheter placement. Heparin drip started [**2-2**] once new embolizations identified on MRA. Coumadin was restarted. Heparin was continued as the patient is not therapeutic on coumadin. The patient had a decrease in her platelets while on heparin to a nadir of 94 however her plat . 5) DM2: Pt was treated with sliding scale of insulin for hyperglycemia. . 6) FEN: Pt tolerating po. Nutrition was consulted as patient was not taking in enough calories. Her diet was adjusted and was given supplements with all her meals and snacks. Pt was encouraged to eat. Discussed with family the possibility of placing a PEG. Family felt patient's diet was sufficient at this time. . 7) Yeast infection: Pt thought to have yeast infection. Treated with one dose of diflucan. . 8) Code status: DNR/DNI, readdressed with daughter today. Medications on Admission: 1. Norvasc 2.5 mg qday 2. Diovan 40 mg daily 3. HCTZ 12.5 mg QOD 4. Lanoxin 6.25 mg daily 5. Lipitor 20 mg daily 6. Lasix 40 mg daily 7. Levoxyl 100 mcg daily 8. Warfarin 2 mg 5day/week, 1 mg Monday & Thursday 9. Toprol XL 125 mg daily 10. Detrol LA 2 mg daily 11. Betamol 0.5% - 1 drop [**Hospital1 **] OU 12. NPH insulin 10 units [**Hospital1 **] 13. Reglan 10 mg PRN nausea 14. Vitamin D 50,000 units per week 14. Phoslo 1334 mg TID 15. Slo-Mag 64 mg daily 16. MVI 17. Tylenol PRN knee/back pain Discharge Medications: 1. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution Sig: 1000 (1000) units Intravenous Continuous infusion: Please titrate per attached sliding scale. Can discontinue heparin once INR is [**2-6**] for 48 hours. 2. Detrol LA 2 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO at bedtime. 3. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a week. 4. Insulin NPH-Regular Human Rec Subcutaneous 5. Insulin Regular Human Subcutaneous 6. Slow-Mag 64 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. 7. Multi-Vitamin Tablet Sig: One (1) Tablet PO once a day. 8. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every six (6) hours as needed for pain. 9. Reglan 10 mg Tablet Sig: One (1) Tablet PO three times a day as needed for nausea. 10. Toprol XL 100 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. 11. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 12. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO once a day. 13. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO once a day: Please titrate to achieve INR of [**2-6**]. 14. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at [**Hospital6 1109**] - [**Location (un) 1110**] Discharge Diagnosis: s/p Fall Dementia [**2-5**] cerebral infarctions C4-C6 ligamentous injury Altered Mental Status Stage V Kidney Disease Atrial Fibrillation Yeast Infection Discharge Condition: Afebrile, Vital Signs Stable Discharge Instructions: Dialysis You were started on dialysis while in the hospital. Your last day of dialysis was [**2117-2-10**]. You should continue receiving dialysis on a Monday, Wednesday, Friday schedule. Atrial Fibrillation You coumadin was stopped and then restarted. You are being treated with heparin while the coumadin levels become therapeutic. Neck strain Please follow these instructions carefully: * Rest as much as possible. Increase your activity slowly when you start to feel better. * Apply cold packs or heat, whichever you find more comfortable, off and on through the day. * Be careful not to freeze or burn your skin. Do not put ice directly on your skin (place it in a plastic bag and wrap it in a towel). If you use a heating pad, keep it on low. * Take any prescribed medicines as directed. Do not drive, operate machinery or drink alcohol while taking pain medicines or muscle relaxants. Return to the Emergency Department or see your own doctor right away if any problems develop, including the following: * Your pain gets worse. * You develop pain, numbness, tingling or weakness in your arms or legs. * You lose control of your bowels or urine ("passing water"). * Trouble walking. * Your pain is not getting better after 2 days. * Anything else that worries you. Shortness of breath * Rest: You should restrict your activities until you are completely better. * Drink plenty of liquids (unless your doctor has told you not to.) Do not consume alcohol until you are completely better. * Many lung conditions are related to smoking. If you smoke, quitting now can help some problems, and prevent others from getting worse. * Be sure to take any prescribed medications as you were instructed. Continue your previously prescribed medications unless you were instructed to do otherwise. Yeast Infection. You were treated for a yeast infection. If you have worsening vaginal discharge, please notify your primary care provider for further treatment Followup Instructions: While on heparin, she will need platelets checked daily. Should platelet levels drop below 100, the heparin should be stopped and other medications may need to be started - please consult with [**Name8 (MD) **] MD [**First Name (Titles) 4120**] [**Last Name (Titles) 50993**]. Please check her INR every other day and adjust coumadin accordingly for a goal of [**2-6**]. Once INR is [**2-6**] for 48 hours, can discontinue heparin drip. Please check finger stick before meals and at bedtime, and use attached sliding scale for adjustments. She will need to keep the soft neck collar on until seen by orthopedics in clinic (see appointments below). Follow up with neurology on [**2117-3-9**] at 3:30pm with Dr [**Last Name (STitle) **]. Call [**Telephone/Fax (1) **]/8913 for more information and location of the appointment Follow up with orthopedics on [**2117-2-19**] at 1:30pm with Dr [**Last Name (STitle) 50994**] Please call [**Telephone/Fax (1) **] for more information. The appointment will be at the [**Location (un) 551**] of [**Hospital Ward Name 23**] Clinical Center

349,850,427,585,428,403,599,434,397,424,E880,250,290,437,244,V586,588,112

{'Toxic encephalopathy,Concussion with loss of consciousness of unspecified duration,Atrial fibrillation,Chronic kidney disease, Stage V,Chronic diastolic heart failure,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Urinary tract infection, site not specified,Cerebral embolism with cerebral infarction,Diseases of tricuspid valve,Mitral valve disorders,Accidental fall on or from other stairs or steps,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Vascular dementia, uncomplicated,Cerebral atherosclerosis,Unspecified acquired hypothyroidism,Long-term (current) use of anticoagulants,Secondary hyperparathyroidism (of renal origin),Candidiasis of vulva and vagina'}

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: s/p fall with altered mental status PRESENT ILLNESS: Ms. [**Known lastname 50992**] is a [**Age over 90 **] yo female with a h/o atrial fibrillation, CHF, hypertension, diastolic dysfunction, DM2, stage V chronic kidney disease and hypothyroidism who is transferred to [**Hospital1 18**] following two falls on [**11-28**]. Daughter states that she sat down earlier in the day on the staircase landing complaining of knee pain. At that time, she hit her head against the wall but was subsequently alert and oriented. Later in the day, around 4 p.m. she fell from the top of the staircase backwards down approximately 10 stairs. She was initially responsive and not complaining of any pain, but was unable to move. Her daughter called EMS. When EMS arrived, she was sitting on a bottom step, conversational. Her head subsequently dropped back and her mouth opened and she became unresponsive. . On initial exam at [**Hospital1 **] [**Location (un) 620**], patient was not responding to questions but opened her eyes to verbal stimuli. A CT of her c-spine was significant for C4/C5 space widening with ? anterior ligamentous sprain due to trauma. CT of her head was reported as negative. She was treated with a dose of ceftriaxone for reported UTI. . She was admitted to the ICU at [**Hospital1 **] [**Location (un) 620**] where she was reported to be fidgeting and moaning in bed, but otherwise nonverbal. BP was elevated to 228/122 and she was given 10 mg of IV labetalol without result. She was started on a nitroglycerin gtt at 0100 for BP control. She was noted to have a surgical right pupil. She was subsequently transferred to the MICU at [**Hospital1 18**] for MRI/MRA of her posterior circulation. MEDICAL HISTORY: 1) Atrial fibrillation 2) Diastolic CHF, EF 60% 3) Hypertension 4) Diabetes mellitus, Type II x 20 years 5) Stage V chronic kidney disease (Cr 4.1 in [**10-9**]), followed by Dr. [**Last Name (STitle) 4090**], were planning for tunneled catheter when the patient becomes sicker and requires dialysis 6) Hypothyroidism 7) Secondary hyperparathyroidism MEDICATION ON ADMISSION: 1. Norvasc 2.5 mg qday 2. Diovan 40 mg daily 3. HCTZ 12.5 mg QOD 4. Lanoxin 6.25 mg daily 5. Lipitor 20 mg daily 6. Lasix 40 mg daily 7. Levoxyl 100 mcg daily 8. Warfarin 2 mg 5day/week, 1 mg Monday & Thursday 9. Toprol XL 125 mg daily 10. Detrol LA 2 mg daily 11. Betamol 0.5% - 1 drop [**Hospital1 **] OU 12. NPH insulin 10 units [**Hospital1 **] 13. Reglan 10 mg PRN nausea 14. Vitamin D 50,000 units per week 14. Phoslo 1334 mg TID 15. Slo-Mag 64 mg daily 16. MVI 17. Tylenol PRN knee/back pain ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: VS: T 97.7, 176/79, HR 79, RR 15, SpO2 95% Gen: elderly WF, in c-collar, lying on right side in fetal position HEENT: normocephalic, atraumatic CV: regular rate, sinus rhythm on telemetry, nl S1 S2 Resp: CTA, normal respiratory effort Abdomen: soft, +BS, no grimace to deep palpation Extrem: no edema, 2+ pulses Skin: superficial abrasions on upper portion of posterior torso Neuro: unable to perform complete neuro exam due to lack of patient cooperation, eyes squeezed shut bilaterally, unable to assess pupil reactivity; cogwheeling of upper right extremity, hypertonic in upper extremities bilaterally; upgoing toes on right, downgoing on left; does not follow commands; some spontaneous movements in all extremities FAMILY HISTORY: non-contributory . SOCIAL HISTORY: Resides with daughter at home. Independent and performs all ADL's at baseline, except requires assistance with bathing. Ambulates with a cane. ### Response: {'Toxic encephalopathy,Concussion with loss of consciousness of unspecified duration,Atrial fibrillation,Chronic kidney disease, Stage V,Chronic diastolic heart failure,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Urinary tract infection, site not specified,Cerebral embolism with cerebral infarction,Diseases of tricuspid valve,Mitral valve disorders,Accidental fall on or from other stairs or steps,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Vascular dementia, uncomplicated,Cerebral atherosclerosis,Unspecified acquired hypothyroidism,Long-term (current) use of anticoagulants,Secondary hyperparathyroidism (of renal origin),Candidiasis of vulva and vagina'}

CHIEF COMPLAINT: 32 F found [**Last Name (un) **] parking lot, partially disrobed w/ bruise to right face and undulations of right leg. PRESENT ILLNESS: 39 F found unconsious, intoxicated, and brought by EMS to [**Hospital1 18**] ED s/p assault. On primary and secondary surveys she was found to have R lateral orbit step-off, R lateral laceration @ orbit, and R closed ankle fracture. MEDICAL HISTORY: denies MEDICATION ON ADMISSION: denies ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: 110 144/58 28 100 NRB GCS=15 Pupils equal and reactive 3mm Face 1 cm R temporal laceration CTA bilaterally RRR no MRG soft NT ND C/T/L spine no step offs, no tenderness rectal - normal tone, negative guiac R LE deformity FAMILY HISTORY: non-contributory SOCIAL HISTORY: +tob/ETOH

Trimalleolar fracture, closed,Closed fracture of other facial bones,Closed fracture of base of skull without mention of intra cranial injury, with loss of consciousness of unspecified duration,Other specified open wounds of ocular adnexa,Assault by unspecified means

Fx trimalleolar-closed,Fx facial bone NEC-close,Cl skul base fx-coma NOS,Opn wnd ocular adnex NEC,Assault NOS

Admission Date: [**2118-11-1**] Discharge Date: [**2118-11-7**] Date of Birth: [**2079-4-27**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1556**] Chief Complaint: 32 F found [**Last Name (un) **] parking lot, partially disrobed w/ bruise to right face and undulations of right leg. Major Surgical or Invasive Procedure: Ex-fix R leg Open reduction/internal fixation lateral and medial malleolus. Suture repair of R palpebral laceration History of Present Illness: 39 F found unconsious, intoxicated, and brought by EMS to [**Hospital1 18**] ED s/p assault. On primary and secondary surveys she was found to have R lateral orbit step-off, R lateral laceration @ orbit, and R closed ankle fracture. Past Medical History: denies Social History: +tob/ETOH Family History: non-contributory Physical Exam: 110 144/58 28 100 NRB GCS=15 Pupils equal and reactive 3mm Face 1 cm R temporal laceration CTA bilaterally RRR no MRG soft NT ND C/T/L spine no step offs, no tenderness rectal - normal tone, negative guiac R LE deformity Pertinent Results: [**2118-11-1**] 02:25AM BLOOD WBC-12.6* RBC-4.33 Hgb-14.0 Hct-40.3 MCV-93 MCH-32.3* MCHC-34.7 RDW-12.1 Plt Ct-364 [**2118-11-1**] 06:48AM BLOOD WBC-16.3* RBC-3.55* Hgb-11.4* Hct-33.2* MCV-93 MCH-32.0 MCHC-34.2 RDW-12.2 Plt Ct-280 [**2118-11-2**] 03:13AM BLOOD WBC-12.9* RBC-3.40* Hgb-10.9* Hct-31.4* MCV-92 MCH-32.0 MCHC-34.6 RDW-12.0 Plt Ct-227 [**2118-11-3**] 06:50AM BLOOD WBC-11.6* RBC-3.16* Hgb-10.2* Hct-29.9* MCV-95 MCH-32.1* MCHC-34.0 RDW-11.9 Plt Ct-225 [**2118-11-4**] 06:44AM BLOOD WBC-13.2* RBC-2.91* Hgb-9.4* Hct-27.4* MCV-94 MCH-32.2* MCHC-34.2 RDW-12.1 Plt Ct-271 Brief Hospital Course: 32 F found [**Last Name (un) **] parking lot, partially disrobed w/ bruise to right face and c/o right leg pain. In ED patient with transient episode of hypotension to the 80's w/ tachycardia. Received volume resuscitation. Work-up significant for R tib/fib s/p splint in ED, R facial laceration. and R lateral orbit wall fracture. Admitted to TSICU for observation. Head CT-> R sphenoid fracture/ lateral orbit fracture. Social services were contact[**Name (NI) **] and a rape kit was utilized. C-spine was cleared on [**2118-11-2**]. Taken to OR for ORIF R trimalleolar fracture on [**2118-11-2**]. She was kept NWB on her RLE and heparin SC. She progressed well with the physical therapist. A short leg bivalve cast was applied on [**2118-11-7**]. Medications on Admission: denies Discharge Medications: 1. Lopinavir-Ritonavir 400-100 mg/5 mL Solution Sig: Five (5) ML PO BID (2 times a day). Disp:*30 30* Refills:*0* 2. Lamivudine-Zidovudine 150-300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*30 tablets* Refills:*0* 3. Percocet 1-2 tabs PO q4-6 hours Disp:*30 Tablet(s)* Refills:*0* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*30 Capsule(s)* Refills:*0* 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 6. Lovenox 40 mg/0.4mL Syringe Sig: One (1) Subcutaneous once a day for 2 weeks. Disp:*14 injection* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Right orbit lateral wall fracture Right zygoma fracture R maxillary sinus L wall fx w/ hematoma R palpebral laceration Right trimalleolar ankle fracture, closed. Discharge Condition: Stable Discharge Instructions: [**Name8 (MD) **] M.D. for drainage from ears or nose, fever, increase in severity of symptoms, change in neurologcal status, blurry vision, double vision, numbness, tingling, questions or concerns. Followup Instructions: Follow-up with Plastic Surgery clinic for elective repair of facial fractures. Please call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] to schedule [**Telephone/Fax (1) 28541**]. Follow-up with Dr. [**Last Name (STitle) 1005**] Orthopaedic Surgery in 2 weeks. Please call clinic to schedule [**Telephone/Fax (1) 1228**]. Follow-up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in clinic on Tuesday. Completed by:[**2118-11-10**]

824,802,801,870,E968

{'Trimalleolar fracture, closed,Closed fracture of other facial bones,Closed fracture of base of skull without mention of intra cranial injury, with loss of consciousness of unspecified duration,Other specified open wounds of ocular adnexa,Assault by unspecified means'}

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: 32 F found [**Last Name (un) **] parking lot, partially disrobed w/ bruise to right face and undulations of right leg. PRESENT ILLNESS: 39 F found unconsious, intoxicated, and brought by EMS to [**Hospital1 18**] ED s/p assault. On primary and secondary surveys she was found to have R lateral orbit step-off, R lateral laceration @ orbit, and R closed ankle fracture. MEDICAL HISTORY: denies MEDICATION ON ADMISSION: denies ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: 110 144/58 28 100 NRB GCS=15 Pupils equal and reactive 3mm Face 1 cm R temporal laceration CTA bilaterally RRR no MRG soft NT ND C/T/L spine no step offs, no tenderness rectal - normal tone, negative guiac R LE deformity FAMILY HISTORY: non-contributory SOCIAL HISTORY: +tob/ETOH ### Response: {'Trimalleolar fracture, closed,Closed fracture of other facial bones,Closed fracture of base of skull without mention of intra cranial injury, with loss of consciousness of unspecified duration,Other specified open wounds of ocular adnexa,Assault by unspecified means'}

CHIEF COMPLAINT: PRESENT ILLNESS: Mrs. [**Known lastname 44908**] is a 82 year-old woman who has a history of noninsulin dependent diabetes mellitus, hypertension, hypercholesterolemia who originally presented to an outside hospital the night prior to admission with symptoms of chest pain. The patient does have a history of prior hospital admissions for chest pain and she has ruled out for a myocardial infarction in the past. Recently, however, the patient has been having more frequent episodes of midsternal chest pain, which often radiated to her throat and jaw. Her symptoms were occurring mostly around meal times and were not associated with nausea, vomiting, diaphoresis or shortness of breath. The patient presented to an outside hospital after she woke up with more intense chest pain. She was then treated with aspirin and sublingual nitroglycerin and her pain was relived. Her troponin level at the time was 1.92, creatinine kinase was 136 with the MB fraction of 10.7. A MIBI done a week prior to admission was positive for a inferior reversible defect and a fixed apical defect as well as apical dyskinesia and an ejection fraction approximately 33%. The patient was consequently transferred to [**Hospital1 69**] for cardiac catheterization and future management of her symptoms. MEDICAL HISTORY: 1. Hypertension. 2. Chronic renal insufficiency. 3. Asthma. 4. Diabetes mellitus controlled with oral antiglycemics. 5. Hypercholesterolemia. MEDICATION ON ADMISSION: Glyburide 10 mg po b.i.d., Glucophage 1 gram po b.i.d., Lopid 600 mg po b.i.d., Lipitor 10 mg po b.i.d., aspirin enteric coated 325 mg po q day, Protonix 40 mg po q day, Albuterol inhalers prn, Lopressor 25 mg po b.i.d. ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: The patient lives with her husband.

Asthma, unspecified type, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Pure hypercholesterolemia,Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery,Intermediate coronary syndrome,Atrial fibrillation,Mitral valve disorders

Asthma NOS,DMII wo cmp nt st uncntr,Pure hypercholesterolem,Hypertension NOS,Crnry athrscl natve vssl,Intermed coronary synd,Atrial fibrillation,Mitral valve disorder

Admission Date: [**2166-10-20**] Discharge Date: [**2166-10-30**] Service: CARDIAC SURGERY HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 44908**] is a 82 year-old woman who has a history of noninsulin dependent diabetes mellitus, hypertension, hypercholesterolemia who originally presented to an outside hospital the night prior to admission with symptoms of chest pain. The patient does have a history of prior hospital admissions for chest pain and she has ruled out for a myocardial infarction in the past. Recently, however, the patient has been having more frequent episodes of midsternal chest pain, which often radiated to her throat and jaw. Her symptoms were occurring mostly around meal times and were not associated with nausea, vomiting, diaphoresis or shortness of breath. The patient presented to an outside hospital after she woke up with more intense chest pain. She was then treated with aspirin and sublingual nitroglycerin and her pain was relived. Her troponin level at the time was 1.92, creatinine kinase was 136 with the MB fraction of 10.7. A MIBI done a week prior to admission was positive for a inferior reversible defect and a fixed apical defect as well as apical dyskinesia and an ejection fraction approximately 33%. The patient was consequently transferred to [**Hospital1 69**] for cardiac catheterization and future management of her symptoms. PAST MEDICAL HISTORY: 1. Hypertension. 2. Chronic renal insufficiency. 3. Asthma. 4. Diabetes mellitus controlled with oral antiglycemics. 5. Hypercholesterolemia. PAST SURGICAL HISTORY: 1. Status post cholecystectomy. 2. Status post appendectomy. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Glyburide 10 mg po b.i.d., Glucophage 1 gram po b.i.d., Lopid 600 mg po b.i.d., Lipitor 10 mg po b.i.d., aspirin enteric coated 325 mg po q day, Protonix 40 mg po q day, Albuterol inhalers prn, Lopressor 25 mg po b.i.d. SOCIAL HISTORY: The patient lives with her husband. LABORATORIES ON ADMISSION: Hematocrit 33.8, platelets 224, white blood cell count 7.6, BUN 38, creatinine 1.5, potassium 4.8, INR 1.2, troponin 1.92, creatine kinase 136 with the MB fraction of 10.7. IMAGING STUDIES: A preoperative chest x-ray obtained on [**2166-10-21**] showed approximately 1 cm right mid lung zone pulmonary nodule. The heart was in the upper limits of normal. HOSPITAL COURSE: The patient was admitted to the hospital and underwent cardiac catheterization on [**2166-10-20**]. Cardiac catheterization showed moderate mitral regurgitation, inferior apical akinesis, global hypokinesis with a left ventricular ejection fraction of approximately 35%. Coronary angiography showed nonosbtructed left MCA, totally occluded left anterior descending coronary artery, with an ostial lesion of 60%, left circumflex with moderate diffuse disease with an ostial 80% lesion, right coronary artery was totally occluded. Given the history of unstable angina and findings on the cardiac catheterization the patient underwent coronary artery bypass grafting times five on [**2166-10-22**]. Bypasses were as follows, from the ascending thoracic aorta to the obtuse marginal and posterior lateral branch of the circumflex with reverse otogenous saphenous vein and bypass to the posterior descending branch on the right with a second segment of vein into the ramus intermedius with a third segment of vein and to the left anterior descending coronary artery to the left internal mammary artery utilizing cardiopulmonary bypass. The patient tolerated the procedure well. During the procedure the patient was difficult to wean from bypass due to progressive left ventricular failure and reoccurrence of mitral regurgitation. The patient was then placed back on bypass and consequently arrested for approximately five minutes and then weaned fairly easily with good hemodynamics and essentially no mitral regurgitation. After being off bypass for approximately fifteen minutes she once again developed progressive deterioration of ventricular function, which required institution of a balloon pump. Once the balloon pump was placed, however, she maintained reasonably good biventricular function and good hemodynamics. The patient was transferred to the Intensive Care Unit in fair condition. She remained intubated. The patient was extubated on postoperative day one. The extubation was delayed due to hemodynamic instability. The patient was maintained on supplemental oxygen post extubation with good saturation levels. The patient remained in sinus rhythm with no ectopy. Her intraaortic balloon pump was weaned gradually. The patient was transfused with 2 units of packed red blood cells. The patient was vigorously diuresed. Her intraaortic balloon pump was discontinued on postoperative day one without any complications. The patient was noted to be confused and agitated postoperative day two and three while still in the Intensive Care Unit. She was maintained on minimal sedation. On postoperative day three the patient went into atrial fibrillation with heart rate in the 140s. The patient was treated with intravenous Lopressor. Physical therapy was consulted, which followed the patient throughout hospitalization course. Postoperative day three and four while still in the Intensive Care Unit the patient was noted to be hypertensive with systolic blood pressures in the 140s and 150s. She responded well to intravenous hydralazine. She remained in sinus rhythm with occasional premature atrial contractions. The patient remained afebrile. On examination her sternum remained stable. Her incision remained clean, dry and intact. There was no extremity edema. The Swan-Ganz catheter was removed on postoperative day four. The patient's confusion improved on postoperative day five. Her Foley catheter was removed. Her blood pressures were stable. Her rhythm was sinus. The patient was transferred to the regular floor on postoperative day four in stable condition. Electrophysiology Service was consulted given the history of postoperative atrial fibrillation. The patient was mostly in sinus rhythm, but continued to have occasional paroxysmal atrial fibrillation during which time she would break into 40s heart rate and then quickly increase her heart rate again. She remained asymptomatic with possible left shoulder discomfort. Based on the recommendations provided by the Electrophysiology Service the patient was started on Amiodarone and was also anticoagulated with Coumadin to a target INR of 2 to 2.5. On postoperative day seven the patient was noted to be more confused then usual, in addition she was agitated slightly. This required a sitter overnight. However, since that time the patient no longer exhibited signs of agitation or confusion. Her chest tubes were removed. Her pacing wires were removed. In addition, the patient was noted to be hypertensive with systolic blood pressures in the 150s and 160s. Consequently she was started on a small standing dose of Captopril with good response. The patient remained in sinus rhythm. She was ambulating with assistance. She was eating well. The patient was discharged to the rehabilitation facility on [**2166-10-31**]. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Rehabilitation facility. DISCHARGE DIAGNOSIS: 1. Coronary artery disease status post coronary artery bypass grafting times five. 2. Mitral regurgitation. 3. Aortic insufficiency. 4. Hypertension. 5. Hypercholesterolemia. 6. Noninsulin dependent diabetes mellitus. 7. Chronic renal insufficiency. 8. Asthma. DISCHARGE MEDICATIONS: 1. Coumadin the dose to be adjusted until a stable level of INR 2 to 2.5 is obtained. 2. Amiodarone 400 mg po b.i.d. times seven days followed by 400 mg po q day times seven days followed by 200 mg po q day. 3. Glyburide 10 mg po b.i.d. 4. Metformin 1 gram po b.i.d. 5. Milk of Magnesia 30 milliliters po h.s. prn constipation. 6. Percocet one to two tablets po q 4 to 6 hours prn pain. 7. Aspirin 81 mg po q day. 8. Colace 100 mg po b.i.d. 9. Lasix 20 mg po b.i.d. times seven days. 10. Potassium chloride 20 milliequivalents po b.i.d. times seven days. 11. Lopresor 12.5 mg po b.i.d. 12. Captopril 6.25 mg po t.i.d. (adjust as tolerated). 13. Lopid 600 mg po b.i.d. 14. Lipitor 10 mg po q day. 15. Protonix 40 mg po q day. DISCHARGE INSTRUCTIONS: 1. The patient is to follow up with her surgeon Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**] in approximately six weeks. 2. The patient is to present to the clinic for sternal wound check as directed. 3. The patient is to follow up with her cardiologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in approximately three to four weeks. 4. The patient is to obtain [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor prior to discharge from the hospital and to be followed by Dr. [**Last Name (STitle) 284**] of the Electrophysiology Service. 5. The patient is to follow up with her primary care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3314**] in approximately one to two weeks to review her medications. 6. The patient is to continue Coumadin indefinitely until seen by a cardiologist. Her INR goal is 2 to 2.5. Her anticoagulation laboratories are to be checked frequently to obtain the correct Coumadin dose. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Last Name (NamePattern1) 1741**] MEDQUIST36 D: [**2166-10-30**] 09:26 T: [**2166-10-30**] 10:03 JOB#: [**Job Number 20404**]

493,250,272,401,414,411,427,424

{'Asthma, unspecified type, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Pure hypercholesterolemia,Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery,Intermediate coronary syndrome,Atrial fibrillation,Mitral valve disorders'}

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: Mrs. [**Known lastname 44908**] is a 82 year-old woman who has a history of noninsulin dependent diabetes mellitus, hypertension, hypercholesterolemia who originally presented to an outside hospital the night prior to admission with symptoms of chest pain. The patient does have a history of prior hospital admissions for chest pain and she has ruled out for a myocardial infarction in the past. Recently, however, the patient has been having more frequent episodes of midsternal chest pain, which often radiated to her throat and jaw. Her symptoms were occurring mostly around meal times and were not associated with nausea, vomiting, diaphoresis or shortness of breath. The patient presented to an outside hospital after she woke up with more intense chest pain. She was then treated with aspirin and sublingual nitroglycerin and her pain was relived. Her troponin level at the time was 1.92, creatinine kinase was 136 with the MB fraction of 10.7. A MIBI done a week prior to admission was positive for a inferior reversible defect and a fixed apical defect as well as apical dyskinesia and an ejection fraction approximately 33%. The patient was consequently transferred to [**Hospital1 69**] for cardiac catheterization and future management of her symptoms. MEDICAL HISTORY: 1. Hypertension. 2. Chronic renal insufficiency. 3. Asthma. 4. Diabetes mellitus controlled with oral antiglycemics. 5. Hypercholesterolemia. MEDICATION ON ADMISSION: Glyburide 10 mg po b.i.d., Glucophage 1 gram po b.i.d., Lopid 600 mg po b.i.d., Lipitor 10 mg po b.i.d., aspirin enteric coated 325 mg po q day, Protonix 40 mg po q day, Albuterol inhalers prn, Lopressor 25 mg po b.i.d. ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: The patient lives with her husband. ### Response: {'Asthma, unspecified type, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Pure hypercholesterolemia,Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery,Intermediate coronary syndrome,Atrial fibrillation,Mitral valve disorders'}

CHIEF COMPLAINT: elective admission for cardioversion PRESENT ILLNESS: 80 YO F with h/o atrial fibrillation (on coumadin and metoprolol), CVA [**7-7**], hypertension, hypercholesterolemia, CHF, ischemic cardiomyopathy (EF 40-45%) and PVD, who underwent cardioversion for Afib on the morning of his admission that resulted in asystolic arrest, s/p CPR, intubation, temporary pacer placement. . Of note, she was recently hospitalized for pneumonia, exacerbation of CHF and COPD in 3/[**2119**]. She treated with antibiotics(vanc/cefepime/cipro then vanc/[**Year (4 digits) **]/flagyl with h/o MRSA and aspiration), received steroid treatment and also diuresed. Subsequently, she was admitted again in [**3-/2120**] for hypoxemia, b/l pleural effuisons, s/p diuresis and her steroid dose was increased at that time. During her hospitalization, she was noted to have repeated episodes of AFib/Aflutter with RVR to the 150's. Her metoprolol dose was increased and she wsa started on amiodarone. Initially, she was recommended to undergo D/C cardioversion, however, her INR was subtherapeutic requiring a TEE. Ultimately, this was postponed due to difficulty of monitoring her oxygentation during the procedure. She was discharged back to [**Hospital3 **], had 4 consecutive wks of therapeutic INR now referred for cardioversion. . On the day of admission, she was in her normal state of health piror to cardioversion. The patient was sedated by a member of the anesthesia staff with 30mg IV propofol and when appropriate was shocked with 200J external biphasic energy with subsequent asystolic arrest. After failure to capture with transcutaneous pacing and lack of pulses, CPR was initiated. She underwent [**12-31**] cycles of CPR, and received 1mg atropine and 1mg epinephrine with return of spontaneous circulation. Dopamine gtt was started at 10. She was also intubated at this time. Her rhythm was altered between junctional escape, atrial tachcyardia, and escape capture bigeminy. She was then transferred to the EP lab for placement of a temporary pacemaker and arterial line for BP monitoring. Patient also received 100 mg hydrocortisone. She was admitted to the CCU for further management and monitoring. MEDICAL HISTORY: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, + Hypertension MEDICATION ON ADMISSION: 1. aspirin 81 mg Tablet PO DAILY (Daily). 2. omeprazole 20 mg Capsule PO DAILY (Daily). 3. levothyroxine 37.5 mcg PO DAILY (Daily). 4. metoprolol tartrate 37.5 mg PO QID (4 times a day). 5. amiodarone 200 mg PO DAILY (Daily). 6. docusate sodium 100 mg PO once a day. 7. Calcium+D 500 mg(1,250mg) Two (2) tabs PO once a day. 8. Fish Oil 1,200-144-216 mg caps Two (2) Capsule PO daily. 9. Vitamin C With Rose Hips 1,000 mg PO twice a day. 10. vitamin E 200 unit Capsule PO once a day. 11. multivitamin Tablet PO once a day. 12. garlic 1,500 mg Capsule PO once a day. 13. magnesium 250 mg Tablet PO once a day. 14. protein supplement Liquid Sig: Thirty (30) cc PO twice a day: diluted in [**12-31**] cup water. 15. florastar Two [**Age over 90 1230**]y (250) mg once a day. 16. prednisone 5 mg Tablet Sig: ASDIR Tablet PO once a day: Prednisone taper as follows: [**Date range (3) 103779**] 40mg; [**Date range (3) 103780**] 35mg; [**Date range (3) 103781**] 30mg; [**Date range (3) 103782**] 25mg; [**Date range (1) 103783**] 20mg; [**Date range (1) 103784**] 15mg; [**Date range (1) 103785**] 10mg; [**Date range (1) 103786**] 5mg. 17. ipratropium Inhaler Two (2) Puff Inhalation QID (4 times a day). 18. torsemide 20 mg Tablet Sig: One (1) Tablet PO once a day. 19. warfarin 1 mg Tablet Sig: 3-4 Tablets PO once a day: Please hold medication until INR < 3.0. . From [**Hospital1 **]: Aspirin 81 mg qd atrovent 2puff inh qid benebprotein 1 scoop po bid caltrate600/vit D 2tab qd colace 100mg qd cordarone 200mg qd demadex 20mg QD diamox 250mg qd fish oil 1g qd florastor 250 qd k-dur 40 emq qd lopressor 50mg q6h mag ox 400 mg qd miralax 17 qd prednisone 25mg qd prilosec 20mg qd senokot 2 qsh synthroid 37.5 mcg qd mvi vitamin c 500 qd vitamin E 200u qd xenaderm TP [**Hospital1 **] albuterol neb q4h prn atrovent neb q4h prn desyrel 25mg qhs prn lactulose 20gm qd prn tylenol 650 mg q4h prn coumadin 2mg qd dulcolax 10mg suppository PR ALLERGIES: Fosamax / Zyvox / Heparin Agents / Statins-Hmg-Coa Reductase Inhibitors PHYSICAL EXAM: On CCU admission: FAMILY HISTORY: Significant for hypertension and history of arrhythmias in her mother. Stroke in both mother and father. Father had asthma. SOCIAL HISTORY: She is a retired psychiatrist. She lives alone, HHA twice weekly. Uses a wheelchair, former smoker - 150 pk-yrs, quit in [**2107**].

Atrial fibrillation,Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Cardiac complications, not elsewhere classified,Acidosis,Candidiasis of other urogenital sites,Chronic airway obstruction, not elsewhere classified,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Congestive heart failure, unspecified,Other specified forms of chronic ischemic heart disease,Personal history of malignant neoplasm of breast,Personal history of peptic ulcer disease

Atrial fibrillation,Acute respiratry failure,Food/vomit pneumonitis,Surg compl-heart,Acidosis,Candidias urogenital NEC,Chr airway obstruct NEC,Abn react-procedure NEC,CHF NOS,Chr ischemic hrt dis NEC,Hx of breast malignancy,Prsnl hst peptic ulcr ds

Admission Date: [**2120-4-29**] Discharge Date: [**2120-5-2**] Date of Birth: [**2039-7-28**] Sex: F Service: MEDICINE Allergies: Fosamax / Zyvox / Heparin Agents / Statins-Hmg-Coa Reductase Inhibitors Attending:[**First Name3 (LF) 2736**] Chief Complaint: elective admission for cardioversion Major Surgical or Invasive Procedure: electric cardioversion Cardio-Pulmonary Resucitation intubation and mechanical ventilation temporary intravenous pacemaker insertion History of Present Illness: 80 YO F with h/o atrial fibrillation (on coumadin and metoprolol), CVA [**7-7**], hypertension, hypercholesterolemia, CHF, ischemic cardiomyopathy (EF 40-45%) and PVD, who underwent cardioversion for Afib on the morning of his admission that resulted in asystolic arrest, s/p CPR, intubation, temporary pacer placement. . Of note, she was recently hospitalized for pneumonia, exacerbation of CHF and COPD in 3/[**2119**]. She treated with antibiotics(vanc/cefepime/cipro then vanc/[**Year (4 digits) **]/flagyl with h/o MRSA and aspiration), received steroid treatment and also diuresed. Subsequently, she was admitted again in [**3-/2120**] for hypoxemia, b/l pleural effuisons, s/p diuresis and her steroid dose was increased at that time. During her hospitalization, she was noted to have repeated episodes of AFib/Aflutter with RVR to the 150's. Her metoprolol dose was increased and she wsa started on amiodarone. Initially, she was recommended to undergo D/C cardioversion, however, her INR was subtherapeutic requiring a TEE. Ultimately, this was postponed due to difficulty of monitoring her oxygentation during the procedure. She was discharged back to [**Hospital3 **], had 4 consecutive wks of therapeutic INR now referred for cardioversion. . On the day of admission, she was in her normal state of health piror to cardioversion. The patient was sedated by a member of the anesthesia staff with 30mg IV propofol and when appropriate was shocked with 200J external biphasic energy with subsequent asystolic arrest. After failure to capture with transcutaneous pacing and lack of pulses, CPR was initiated. She underwent [**12-31**] cycles of CPR, and received 1mg atropine and 1mg epinephrine with return of spontaneous circulation. Dopamine gtt was started at 10. She was also intubated at this time. Her rhythm was altered between junctional escape, atrial tachcyardia, and escape capture bigeminy. She was then transferred to the EP lab for placement of a temporary pacemaker and arterial line for BP monitoring. Patient also received 100 mg hydrocortisone. She was admitted to the CCU for further management and monitoring. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: [**2113**] (1 vessel disease) -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: - CAD with h/o anterior MI s/p POBA in [**2113**] on aspirin with low - PAD s/p recent vein graft angioplasty on [**2120-1-31**] - CHF (LVEF [**2118**] 40-45%) - HTN - Atrial fibrillation - H/o CVA w/o residual deficits - COPD - Spinal stenosis with both leg weakness wheelchair bound - Breast cancer - left side s/p partial mastectomy - Leg weakness - Peripheral artery disease - Osteoarthritis - PUD - Left MCA stroke in [**2118**] s/p successful TPA - [**2113-12-20**] - Right common femoral to above-knee popliteal artery bypass with non-reversed right saphenous vein and angioscopy. - [**2113**] multiple left common femoral artery intervention with evaluation of hematoma. . ALLERGIES: Fosamax / Zyvox / Heparin Agents / Statins-Hmg-Coa Reductase Inhibitors Social History: She is a retired psychiatrist. She lives alone, HHA twice weekly. Uses a wheelchair, former smoker - 150 pk-yrs, quit in [**2107**]. Family History: Significant for hypertension and history of arrhythmias in her mother. Stroke in both mother and father. Father had asthma. Physical Exam: On CCU admission: . General Appearance: Thin Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube Lymphatic: Cervical WNL Cardiovascular: (S1: Normal), (S2: Normal) Peripheral [**Year (4 digits) **]: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), Coarse Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended Extremities: Right lower extremity edema: Absent, Left lower extremity edema: Absent, No(t) Clubbing Pertinent Results: [**2120-4-29**] 06:09PM TYPE-ART PO2-89 PCO2-76* PH-7.36 TOTAL CO2-45* BASE XS-12 [**2120-4-29**] 06:09PM GLUCOSE-142* [**2120-4-29**] 02:26PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.015 [**2120-4-29**] 02:26PM URINE BLOOD-SM NITRITE-NEG PROTEIN-600 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 LEUK-LG [**2120-4-29**] 02:26PM URINE RBC-11* WBC-23* BACTERIA-FEW YEAST-RARE EPI-<1 TRANS EPI-<1 [**2120-4-29**] 02:03PM TYPE-ART PO2-87 PCO2-74* PH-7.37 TOTAL CO2-44* BASE XS-13 [**2120-4-29**] 02:03PM GLUCOSE-136* [**2120-4-29**] 02:03PM GLUCOSE-136* [**2120-4-29**] 10:54AM TYPE-ART PO2-328* PCO2-46* PH-7.55* TOTAL CO2-42* BASE XS-16 [**2120-4-29**] 10:54AM LACTATE-1.6 [**2120-4-29**] 10:54AM freeCa-1.15 [**2120-4-29**] 10:39AM GLUCOSE-113* UREA N-50* CREAT-0.8 SODIUM-145 POTASSIUM-3.7 CHLORIDE-99 TOTAL CO2-40* ANION GAP-10 [**2120-4-29**] 10:39AM estGFR-Using this [**2120-4-29**] 10:39AM ALT(SGPT)-30 AST(SGOT)-26 CK(CPK)-33 ALK PHOS-49 TOT BILI-0.7 [**2120-4-29**] 10:39AM CK-MB-5 cTropnT-0.05* [**2120-4-29**] 10:39AM CALCIUM-8.5 PHOSPHATE-2.8 MAGNESIUM-2.1 [**2120-4-29**] 10:39AM WBC-10.3 RBC-4.54 HGB-12.4 HCT-38.1 MCV-84 MCH-27.4 MCHC-32.7 RDW-16.2* [**2120-4-29**] 10:39AM NEUTS-89.7* LYMPHS-7.5* MONOS-1.8* EOS-0.9 BASOS-0.1 [**2120-4-29**] 10:39AM PLT COUNT-150 [**2120-4-29**] 10:39AM PT-22.6* PTT-28.4 INR(PT)-2.1* [**2120-4-29**] 09:33AM TYPE-ART PO2-150* PCO2-64* PH-7.44 TOTAL CO2-45* BASE XS-16 INTUBATED-INTUBATED [**2120-4-29**] 09:33AM HGB-13.0 calcHCT-39 O2 SAT-98 CARBOXYHB-2 [**2120-4-29**] 09:33AM HGB-13.0 calcHCT-39 O2 SAT-98 CARBOXYHB-2 [**2120-4-29**] 09:33AM freeCa-1.19 [**2120-4-29**] 08:05AM PT-23.6* INR(PT)-2.2* . [**4-29**]: The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild to moderate regional left ventricular systolic dysfunction with severe hypokinesis of the distal half of the septum and anterior walls, and apex. The remaining segments are low normal in contraction (LVEF 35%). Right ventricular chamber size is normal. with borderline normal free wall function. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [**2120-4-11**], the regional dysfunction is similar, though the remaining segments are now mildly hypokinetic leading to more depressed global LVEF. The severity of mitral regurgitation is now increased. LABS/STUDIES EKG [**2120-4-10**]: Atrial fibrillation. Right bundle-branch block. Left anterior fascicular block. Anterior myocardial infarction of undetermined age. Cannot exclude ischemia. Clinical correlation is suggested. Since the previous tracing of [**2120-4-2**] precordial lead ST-T wave changes appear slightly more prominent but may be no significant change. . Brief Hospital Course: 80 YO F with h/o atrial fibrillation (on coumadin and metoprolol), s/p CVA, hypertension, hypercholesterolemia, CHF, ischemic cardiomyopathy (EF 40-45%),PVD and recent hospitalizations for pneumonia, pleural effusions, COPD exacerbations and CHF exacerbation who underwent elective electric cardioversion for Afib on the morning of her admission which resulted in aystolic arrest. After sucessful resucitation including CPR intubation, MV and temporary pacer lead placement she was transfered to the ICU where her course was marked by atrial fibrilation with difficult to control RVR and repeated episodes of PEA and asystole arrest from which she finally expired. . # Atrial fibrilation, Asystolic arrest post cardioversion, subsequent arrythmias: Asystole initially occurred in the setting of cardioversion and was followed by junctional escape rhythm, atrial tachcyardia, and escape capture bigeminy which were treated per ACLS protocol, temporary pacemaker was placed by EP but pt did not requiring pacing subsequently. After transfer to CCU she continued to have AFib with difficult to control RVR. She was treated with digoxin for rate control d/t tenous blood pressures. On day 3 of her admission she had brief episode of PEA which was treated per ACLS protocol. She subsequently improved and AF/RVR were reasonably controlled with amiodarone + digoxin. On day 3 post admission she was able to wean off pressors and was later extubated. Unfortunately subsequently developed respiratory failure requiring intubation, hypotension requiring maximal doses of three pressors, worsening lactic acidosis and recurrent episodes of PEA and asystole which were treated per ACLS protocol. ECG did not show any signs of ischemia and bed-side echocardiography ruled out tamponade and was essentially unchanged from prior. She repeatedly arrested until she finally expired on the morning of day 4 after her admission. . # Respiratory failure: Patient had underlying COPD and CHF with recent prior admissions for pneumonia, pleural effusions, COPD exacerbations and CHF exacerbation. On this admission repiratory failure initially occurred in setting of cardiac arrest on [**4-29**]. She was subsequently treated with pulmonary toilet and stress dose steroids, she passed SBT and was extubated in the AM of [**5-1**]. In the PM of the same day she developed respiratory distress with hypercarbea which was followed by PEA arrest and reintubation. The reason for her second respiratory failure was most likely CO2 retention post extubation in this difficult to wean patient with significant underlying COPD. PE was thought less likely in the absence of significant hypoxia and in the presence of a supratheraputic INR (upto 6.6 that AM). After reintubation CO2 levels and respiratory status stabalized but patient continued to detriorate with recurrent PEA and asystole arrests from which she finally expired. . # Hypotension: Initially secondary to arrest, but persisted and required pressors. Possible etiologies were thought to include reduced CO d/t myocardial stunning after cardiversion + AF with RVR; possible adrenal insufficiency in this patient who had a recent steroid taper; infectious process. Patient was treated with pressors and recieved stress dose steroids. Work up for infection revealed positive UA with growth of GNR + yeast in urine culture. Patient was however not febrile and leukocytosis to max of 14 developed only after initiation of stress dose steroids. Sepsis was thus thought less likely as the process driving her hypotention. She was treated with Vanco + zocyn for hospital acquired GNR UTI, fluconazole was started on day 3 d/t repeated growth of yeast on urine cultures in the setting of chronic prednisone treatment and possible immunosupression. Her cardiac arrythmias were managed as above. Patient was temporarily able to wean off pressors on day 3 of admission but unfortunately subsequently deteriorated and expired as outlined above. Medications on Admission: 1. aspirin 81 mg Tablet PO DAILY (Daily). 2. omeprazole 20 mg Capsule PO DAILY (Daily). 3. levothyroxine 37.5 mcg PO DAILY (Daily). 4. metoprolol tartrate 37.5 mg PO QID (4 times a day). 5. amiodarone 200 mg PO DAILY (Daily). 6. docusate sodium 100 mg PO once a day. 7. Calcium+D 500 mg(1,250mg) Two (2) tabs PO once a day. 8. Fish Oil 1,200-144-216 mg caps Two (2) Capsule PO daily. 9. Vitamin C With Rose Hips 1,000 mg PO twice a day. 10. vitamin E 200 unit Capsule PO once a day. 11. multivitamin Tablet PO once a day. 12. garlic 1,500 mg Capsule PO once a day. 13. magnesium 250 mg Tablet PO once a day. 14. protein supplement Liquid Sig: Thirty (30) cc PO twice a day: diluted in [**12-31**] cup water. 15. florastar Two [**Age over 90 1230**]y (250) mg once a day. 16. prednisone 5 mg Tablet Sig: ASDIR Tablet PO once a day: Prednisone taper as follows: [**Date range (3) 103779**] 40mg; [**Date range (3) 103780**] 35mg; [**Date range (3) 103781**] 30mg; [**Date range (3) 103782**] 25mg; [**Date range (1) 103783**] 20mg; [**Date range (1) 103784**] 15mg; [**Date range (1) 103785**] 10mg; [**Date range (1) 103786**] 5mg. 17. ipratropium Inhaler Two (2) Puff Inhalation QID (4 times a day). 18. torsemide 20 mg Tablet Sig: One (1) Tablet PO once a day. 19. warfarin 1 mg Tablet Sig: 3-4 Tablets PO once a day: Please hold medication until INR < 3.0. . From [**Hospital1 **]: Aspirin 81 mg qd atrovent 2puff inh qid benebprotein 1 scoop po bid caltrate600/vit D 2tab qd colace 100mg qd cordarone 200mg qd demadex 20mg QD diamox 250mg qd fish oil 1g qd florastor 250 qd k-dur 40 emq qd lopressor 50mg q6h mag ox 400 mg qd miralax 17 qd prednisone 25mg qd prilosec 20mg qd senokot 2 qsh synthroid 37.5 mcg qd mvi vitamin c 500 qd vitamin E 200u qd xenaderm TP [**Hospital1 **] albuterol neb q4h prn atrovent neb q4h prn desyrel 25mg qhs prn lactulose 20gm qd prn tylenol 650 mg q4h prn coumadin 2mg qd dulcolax 10mg suppository PR Discharge Medications: NA Discharge Disposition: Expired Discharge Diagnosis: NA Discharge Condition: NA Discharge Instructions: NA Followup Instructions: NA Completed by:[**2120-5-3**]

427,518,507,997,276,112,496,E879,428,414,V103,V127

{'Atrial fibrillation,Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Cardiac complications, not elsewhere classified,Acidosis,Candidiasis of other urogenital sites,Chronic airway obstruction, not elsewhere classified,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Congestive heart failure, unspecified,Other specified forms of chronic ischemic heart disease,Personal history of malignant neoplasm of breast,Personal history of peptic ulcer disease'}

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: elective admission for cardioversion PRESENT ILLNESS: 80 YO F with h/o atrial fibrillation (on coumadin and metoprolol), CVA [**7-7**], hypertension, hypercholesterolemia, CHF, ischemic cardiomyopathy (EF 40-45%) and PVD, who underwent cardioversion for Afib on the morning of his admission that resulted in asystolic arrest, s/p CPR, intubation, temporary pacer placement. . Of note, she was recently hospitalized for pneumonia, exacerbation of CHF and COPD in 3/[**2119**]. She treated with antibiotics(vanc/cefepime/cipro then vanc/[**Year (4 digits) **]/flagyl with h/o MRSA and aspiration), received steroid treatment and also diuresed. Subsequently, she was admitted again in [**3-/2120**] for hypoxemia, b/l pleural effuisons, s/p diuresis and her steroid dose was increased at that time. During her hospitalization, she was noted to have repeated episodes of AFib/Aflutter with RVR to the 150's. Her metoprolol dose was increased and she wsa started on amiodarone. Initially, she was recommended to undergo D/C cardioversion, however, her INR was subtherapeutic requiring a TEE. Ultimately, this was postponed due to difficulty of monitoring her oxygentation during the procedure. She was discharged back to [**Hospital3 **], had 4 consecutive wks of therapeutic INR now referred for cardioversion. . On the day of admission, she was in her normal state of health piror to cardioversion. The patient was sedated by a member of the anesthesia staff with 30mg IV propofol and when appropriate was shocked with 200J external biphasic energy with subsequent asystolic arrest. After failure to capture with transcutaneous pacing and lack of pulses, CPR was initiated. She underwent [**12-31**] cycles of CPR, and received 1mg atropine and 1mg epinephrine with return of spontaneous circulation. Dopamine gtt was started at 10. She was also intubated at this time. Her rhythm was altered between junctional escape, atrial tachcyardia, and escape capture bigeminy. She was then transferred to the EP lab for placement of a temporary pacemaker and arterial line for BP monitoring. Patient also received 100 mg hydrocortisone. She was admitted to the CCU for further management and monitoring. MEDICAL HISTORY: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, + Hypertension MEDICATION ON ADMISSION: 1. aspirin 81 mg Tablet PO DAILY (Daily). 2. omeprazole 20 mg Capsule PO DAILY (Daily). 3. levothyroxine 37.5 mcg PO DAILY (Daily). 4. metoprolol tartrate 37.5 mg PO QID (4 times a day). 5. amiodarone 200 mg PO DAILY (Daily). 6. docusate sodium 100 mg PO once a day. 7. Calcium+D 500 mg(1,250mg) Two (2) tabs PO once a day. 8. Fish Oil 1,200-144-216 mg caps Two (2) Capsule PO daily. 9. Vitamin C With Rose Hips 1,000 mg PO twice a day. 10. vitamin E 200 unit Capsule PO once a day. 11. multivitamin Tablet PO once a day. 12. garlic 1,500 mg Capsule PO once a day. 13. magnesium 250 mg Tablet PO once a day. 14. protein supplement Liquid Sig: Thirty (30) cc PO twice a day: diluted in [**12-31**] cup water. 15. florastar Two [**Age over 90 1230**]y (250) mg once a day. 16. prednisone 5 mg Tablet Sig: ASDIR Tablet PO once a day: Prednisone taper as follows: [**Date range (3) 103779**] 40mg; [**Date range (3) 103780**] 35mg; [**Date range (3) 103781**] 30mg; [**Date range (3) 103782**] 25mg; [**Date range (1) 103783**] 20mg; [**Date range (1) 103784**] 15mg; [**Date range (1) 103785**] 10mg; [**Date range (1) 103786**] 5mg. 17. ipratropium Inhaler Two (2) Puff Inhalation QID (4 times a day). 18. torsemide 20 mg Tablet Sig: One (1) Tablet PO once a day. 19. warfarin 1 mg Tablet Sig: 3-4 Tablets PO once a day: Please hold medication until INR < 3.0. . From [**Hospital1 **]: Aspirin 81 mg qd atrovent 2puff inh qid benebprotein 1 scoop po bid caltrate600/vit D 2tab qd colace 100mg qd cordarone 200mg qd demadex 20mg QD diamox 250mg qd fish oil 1g qd florastor 250 qd k-dur 40 emq qd lopressor 50mg q6h mag ox 400 mg qd miralax 17 qd prednisone 25mg qd prilosec 20mg qd senokot 2 qsh synthroid 37.5 mcg qd mvi vitamin c 500 qd vitamin E 200u qd xenaderm TP [**Hospital1 **] albuterol neb q4h prn atrovent neb q4h prn desyrel 25mg qhs prn lactulose 20gm qd prn tylenol 650 mg q4h prn coumadin 2mg qd dulcolax 10mg suppository PR ALLERGIES: Fosamax / Zyvox / Heparin Agents / Statins-Hmg-Coa Reductase Inhibitors PHYSICAL EXAM: On CCU admission: FAMILY HISTORY: Significant for hypertension and history of arrhythmias in her mother. Stroke in both mother and father. Father had asthma. SOCIAL HISTORY: She is a retired psychiatrist. She lives alone, HHA twice weekly. Uses a wheelchair, former smoker - 150 pk-yrs, quit in [**2107**]. ### Response: {'Atrial fibrillation,Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Cardiac complications, not elsewhere classified,Acidosis,Candidiasis of other urogenital sites,Chronic airway obstruction, not elsewhere classified,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Congestive heart failure, unspecified,Other specified forms of chronic ischemic heart disease,Personal history of malignant neoplasm of breast,Personal history of peptic ulcer disease'}

CHIEF COMPLAINT: S/P jump from moving train intubated PRESENT ILLNESS: 33 year old male who jumped or fell from a train, moving at approximately 40 mph. He was found reportedly with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2611**] Coma Scale of 3 on the scene, taken to an outside hospital where he was intubated and sent to [**Hospital1 18**] by helicopter. MEDICAL HISTORY: none MEDICATION ON ADMISSION: none ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: T: 97 BP: 126/98 HR: 110 R 23 O2Sats 98% ETT Gen: Intubated, extensor posturing x4 HEENT: Head laceration Neck: Cspine hard collar Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft Neuro post fentanyl: Post-fentanyl: NO EO, Pupils 2 and nonreactive, extensor posturing to all 4 extremities. No corneals. Biting down on ETT. FAMILY HISTORY: nc SOCIAL HISTORY: Works as a chef for a local church. Currently in college. Married with a child, wife currently pregnant with second child. Nonsmoker, occasional ETOH, no recreational drug use. Wife, brothers and [**Name2 (NI) **] at bedside.

Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with prolonged [more than 24 hours] loss of consciousness without return to pre-existing conscious level,Cerebral edema,Pneumonitis due to inhalation of food or vomitus,Contusion of lung without mention of open wound into thorax,Hyperosmolality and/or hypernatremia,Closed fracture of lower end of radius with ulna,Closed fracture of dorsal [thoracic] vertebra without mention of spinal cord injury,Fall in, on, or from railway train injuring passenger on railway,Physical restraints status,Open wound of scalp, without mention of complication,Fever presenting with conditions classified elsewhere

Brain lac NEC-deep coma,Cerebral edema,Food/vomit pneumonitis,Lung contusion-closed,Hyperosmolality,Fx low radius w ulna-cl,Fx dorsal vertebra-close,Fall from train-passengr,Physical restrain status,Open wound of scalp,Fever in other diseases

Admission Date: [**2157-11-28**] Discharge Date: [**2157-12-20**] Date of Birth: [**2127-12-1**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4691**] Chief Complaint: S/P jump from moving train intubated Major Surgical or Invasive Procedure: [**2157-11-27**] Placement of right frontal intracranial pressure monitor. [**2157-12-1**] 1. Percutaneous tracheostomy. 2. Percutaneous endoscopic gastrostomy. 3. Inferior vena cava filter via the right femoral route. [**2157-12-1**] Pressure monitor removed History of Present Illness: 33 year old male who jumped or fell from a train, moving at approximately 40 mph. He was found reportedly with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2611**] Coma Scale of 3 on the scene, taken to an outside hospital where he was intubated and sent to [**Hospital1 18**] by helicopter. Past Medical History: none Social History: Works as a chef for a local church. Currently in college. Married with a child, wife currently pregnant with second child. Nonsmoker, occasional ETOH, no recreational drug use. Wife, brothers and [**Name2 (NI) **] at bedside. Family History: nc Physical Exam: T: 97 BP: 126/98 HR: 110 R 23 O2Sats 98% ETT Gen: Intubated, extensor posturing x4 HEENT: Head laceration Neck: Cspine hard collar Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft Neuro post fentanyl: Post-fentanyl: NO EO, Pupils 2 and nonreactive, extensor posturing to all 4 extremities. No corneals. Biting down on ETT. Later exam: R pupil reactive 5 to 2, left remains nonreactive. Post-mannitol: Pupils 2.5-2 bilaterally Pertinent Results: MICRO: [**11-28**] MRSA: neg [**11-28**] BCx x 2: NG [**11-28**]: UCx: NEG [**11-29**]: BCx: NG [**11-29**]: Urine Cx: NEG [**11-29**]: Sputum Cx: Bad Sample [**11-29**]: Hep C: VL not detected [**11-30**]: UCx: NG [**11-30**]: BCx: NG [**11-30**]: Sputum: Bad Sample Multiple cultures of blood, urine and sputum taken thru [**2157-12-15**] are all negative including c&s of spinal fluid IMAGING: [**11-27**] CT Head: 1. Small focal hyperdensities in the bifrontal region (near the vertex), and left basal ganglia, compatible with small hemorrhagic contusion. No intraventricular hemorrhagic extension. 2. Tiny SAH near the vertex contusion site. Cannot exclude a small SDH. 3. Large subgaleal hematoma at/near the vertex. 4. No evidence of bony fracture. [**11-27**] CT C-spine: No acute cervical fx or malalignment. Patchy opacity in the R lung apex, could represent contusion vs aspiration. [**11-27**] CT Thorax/Pelvis: 1. Bilateral patchy opacities in the lungs, compatible with aspiration, contusion or atelectasis. No PTX. 2. No intra-abdominal solid organ injury. 3. No spinal fx or malalignment. Bony pelvis intact. 12/5 L Wrist Xrays: minimally displaced distal radius fracure, ulnar styloid fx [**11-28**] CT Head: Tiny intraventricular hemorrhagic extension into the left occipital [**Doctor Last Name 534**]. Small amount of subarachnoid hemorrhage in the vertex, unchanged. No developing hydrocephalus. [**11-29**]: EEG: P [**11-29**]: Head CTA: 1. Unchanged hemorrhagic contusions, diffuse axonal injury, subarachnoid and subdural hemorrhage. 2. Unchanged diffuse cerebral swelling. 3. Unremarkable head CTA. [**11-29**]: CTA Chest: 1. No evidence of pulmonary embolism. 2. Marked worsening of lower lobe consolidation, concerning for infection, and possibly aspiration. 3. Mildly displaced T3 vertebral body fracture. 4. Endotracheal tube tip at the thoracic inlet, and should be advanced. [**12-1**] CT Head: Subdural and intraparenchymal hemorrhage again identified with no evidence of new bleeding. No evidence of infarction or mass effect [**2157-12-14**] EEG :This telemetry over four hours showed an encephalopathic background with prominent generalized slowing suggestive of deeper structure dysfunction. There were no prominently lateralized features. There were no epileptiform abnormalities, including at the time of the pushbutton activation. [**2157-12-14**] MRI T spine : 1. Likely Chance-type fracture of the T12 vertebral body, which may be an unstable fracture (if two or more "columns" are involved). If confirmation is necessary, a focused MDCT, targeting the thoracolumbar junction can be obtained. There is no retropulsion or spinal canal compromise. 2. T3 vertebral body anteroinferior compression fracture. 3. Normal signal intensity of the thoracic spinal cord on all pulse sequences including STIR). [**2157-12-15**] EEG : This monitoring on the morning of [**12-15**] showed the same continued encephalopathic background. There were eye movement artifacts, as well. There were no epileptiform features. The pushbutton activations showed no change in the background. [**2157-12-15**] CT T-L spine : 1. No evidence for T12 bony injury to correlate with the MR findings. 2. Posterior inferior vertebral body fracture of T3 without bony retropulsion and without involvement of the posterior elements. Brief Hospital Course: Mr. [**Known lastname 19704**] was evaluated by the Trauma team in the Emergency Room and his scans were reviewed. He was admitted to the trauma ICU on the neurosurgery service for his head bleed. A bolt was placed and ICP's were monitored. Mannitol and normal saline were started. The patient was transferred to the trauma surgery service for concern of pulm contusions. Tube feeds were started on [**11-28**]. On [**11-29**] a neo gtt was utilized to maintain the CPP. On [**11-29**] a CTA chest was performed as pt was hypoxic and this revealed no pulmonary embolism. On [**11-30**] and [**12-1**] he had fevers a CXR revealed worsening PNA (aspiration likely). On [**12-1**] the bolt was removed after a CT head revealed no change or worsening. He also underwent trach/PEG/IVC filter on [**12-1**]. From a neurologic standpoint his mental status remained the same for weeks...not responsive and not tracking. There was no change in his head CT. He moved his extremities randomly, arms >> legs. His cervical collar remained on as we were unable to clear his neck due to his depressed mental status. The Neurosurgery service followed him closely and want to re image in a few more weeks. Following transfer to the Trauma floor it became more apparent that he had minimal movement of his lower extremities and he also had nystagmus. The Neurology service was consulted and multiple EEG's were done and ruled out seizure activity. He also had an LP done due to persistent fevers and that was negative including the culture. His nystagmus was simply from encephalopathy. An MRI of his T spine was also recommended due to his decreased movement of his lower extremities. A T 12 Chance fracture was noted with ligamentous injury along with a T 3 vertebral body compression fracture. There was no evidence of cord compression. The Ortho Spine surgeons reviewed the films and recommended treatment with a TLSO brace and re imaging in [**1-26**] weeks to check alignment. He became much more alert on [**2157-12-19**] and was able to recognize his family and speak. Currently he responds to questions with short answers, tracks appropriately but is not always consistent. The Neurosurgery service is still unable to clear his C spine as he does not consistently answer questions clearly. During his ICU stay he required mechanical ventilation and early tracheostomy due to his mental status and the necessity of protecting his airway. He also had Chest CT findings of bilateral lower lobe opacities, possibly due to aspiration associated with hypoxia. He was cultured on multiple occasions as he was febrile on a daily basis. He was treated for ventilator acquired pneumonia but other than for admission had a minimally elevated WBC. Sputum cultures were all negative and eventually he was slowly able to be weaned from the respirator and maintained adequate oxygenation on a Trach collar. His recurrent fevers prompted more than pan culturing. He had a duplex scan of his lower extremities which ruled out DVT and a liver ultrasound which ruled out cholecystitis. He was empirically treated with Zosyn and Vancomycin and both of these drugs were stopped on [**2157-12-13**]. Since that time he has had low grade fevers intermittently and a normal WBC. The Neurology service thinks that the fevers are coming from his brain injury. In order to keep him nutritionally fit a PEG tube was placed for tube feedings. Recently he has been switched from continuous feedings to bolus feedings and he is tolerating them well. He has not been consistently alert enough to undergo a swallowing study but if he continues to improve as he is doing now, he should be able to participate in a week or so. He has become hypernatremic to 155 since changing feeding methods and his free water flushes have just been increased along with IV D5W until his sodium returns to normal. Today his sodium is 149 and his IV D5W has stopped. He will continue to get an extra 600cc water daily with tube feedings. The Orthopedic service evaluated him on admission and felt that his left arm may require surgical repair but during this acute phase the radial and ulnar fractures were stabilized with a short arm cast. He will be re imaged in a few weeks and further recommendations will come at that time. For now, he is non weight bearing with his left arm. Due to the mechanism of his injury and the thought that it was a suicide attempt, he was evaluated by the Psychiatry service. Most of their assessment was done with the help of his family as he was unable to participate in answering questions. He evidently had no history of depression or suicide attempts in the past and what actually happened may never come to light however, once stable and communicative, he should be reevaluated. The Physical Therapy and Occupational Therapy service have been involved with [**Doctor First Name **] during his ICU stay and while on the floor. He is able to transfer out of bed with his TLSO brace on and will hopefully increase the amount of time out of bed and eventually begin balance and gait training. His brain injury will require intense rehab including both the patient and his family. Hopefully in time he will be able to return home with his wife and children. Medications on Admission: none Discharge Medications: 1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 2. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane [**Hospital1 **] (2 times a day). 3. Senna Lax 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 4. ibuprofen 100 mg/5 mL Suspension Sig: Twenty (20) mL PO Q8H (every 8 hours) as needed for fever. 5. bacitracin zinc 500 unit/g Ointment Sig: One (1) Appl Topical QID (4 times a day). 6. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). 7. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: S/P fall from train 1. L occipital laceration 2. Bifrontal contusions 3. Left basal ganglia contusion 4. IPH 5. SAH at vertex 6. Diffuse cerebral edema 7. Subgaleal hematoma at vertex 8. Bilateralpatchy lung opacities 9. Left distal radius fx 10.Left ulnar styloid fx 11.Moderately displaced T3 vert body fx 12.T 12 chance fx 13.TBI 14.Aspiration pneumonia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair with TLSO brace on. Discharge Instructions: You were admitted to the hospital after falling from a train, sustaining severe injuries. You ultimately required a breathing tube in your neck and a feeding tube in your stomach to maintain your nutrition. You have made remarkable improvements over the last week and hopefully will continue to do so at rehab. As you make progress you will eventually be able to have your trach tube and feeding tube removed. You also had multiple broken bones including a left arm fracture which will remain in a cast for at least 6 weeks. Do NOT bear any weight on that arm. A decision will be made at your follow up appointment regarding the need for surgical repair. You have a thoracic spine fracture and will need to wear the TLSO brace for 3 months. Put the brace on before you get out of bed. You will have to work hard with Occupational Therapy and Physical Therapy. Many things that came easy to you before the accident will need to be relearned now. This takes alot of time and patience on your part. You will have doctors that take [**Name5 (PTitle) **] of you at rehab but you will still need to return to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1675**] for follow up with some of your specialists here. Followup Instructions: Call the Ortho Spine Clinic at [**Telephone/Fax (1) 3573**] for a follow up appointment in [**1-26**] weeks with Dr. [**Last Name (STitle) 363**]. You will need Xrays done at that time to check the alignment of your spine. You will also have your left arm checked at the same time. Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up appointment in 4 weeks. Call the [**Hospital 4695**] Clinic at [**Telephone/Fax (1) 1669**] for a follow up appointment with Dr. [**First Name (STitle) **] in 3 weeks. You will need a non contrast head CT prior to that appointment. The secretary will arrange that for you. Completed by:[**2157-12-20**]

851,348,507,861,276,813,805,E804,V498,873,780

{'Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with prolonged [more than 24 hours] loss of consciousness without return to pre-existing conscious level,Cerebral edema,Pneumonitis due to inhalation of food or vomitus,Contusion of lung without mention of open wound into thorax,Hyperosmolality and/or hypernatremia,Closed fracture of lower end of radius with ulna,Closed fracture of dorsal [thoracic] vertebra without mention of spinal cord injury,Fall in, on, or from railway train injuring passenger on railway,Physical restraints status,Open wound of scalp, without mention of complication,Fever presenting with conditions classified elsewhere'}

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: S/P jump from moving train intubated PRESENT ILLNESS: 33 year old male who jumped or fell from a train, moving at approximately 40 mph. He was found reportedly with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2611**] Coma Scale of 3 on the scene, taken to an outside hospital where he was intubated and sent to [**Hospital1 18**] by helicopter. MEDICAL HISTORY: none MEDICATION ON ADMISSION: none ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: T: 97 BP: 126/98 HR: 110 R 23 O2Sats 98% ETT Gen: Intubated, extensor posturing x4 HEENT: Head laceration Neck: Cspine hard collar Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft Neuro post fentanyl: Post-fentanyl: NO EO, Pupils 2 and nonreactive, extensor posturing to all 4 extremities. No corneals. Biting down on ETT. FAMILY HISTORY: nc SOCIAL HISTORY: Works as a chef for a local church. Currently in college. Married with a child, wife currently pregnant with second child. Nonsmoker, occasional ETOH, no recreational drug use. Wife, brothers and [**Name2 (NI) **] at bedside. ### Response: {'Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with prolonged [more than 24 hours] loss of consciousness without return to pre-existing conscious level,Cerebral edema,Pneumonitis due to inhalation of food or vomitus,Contusion of lung without mention of open wound into thorax,Hyperosmolality and/or hypernatremia,Closed fracture of lower end of radius with ulna,Closed fracture of dorsal [thoracic] vertebra without mention of spinal cord injury,Fall in, on, or from railway train injuring passenger on railway,Physical restraints status,Open wound of scalp, without mention of complication,Fever presenting with conditions classified elsewhere'}

CHIEF COMPLAINT: s/p pulling out PEG tube and inability to pass foley PRESENT ILLNESS: Pt is a 76 yo [**Location 7972**] Creole speaking male with HTN, essential thrombocytopenia, s/p right craniotomy for subdural hematoma, additional admission in [**Month (only) 547**] for management of SDH, PCA stroke, and c. diff colitis, who presents because he pulled out his PEG tube and inability to pass foley. Pt was started on ritalin last week for being sluggish. He was noted to be delirium over the weekend and ritalin was d/cd on saturday. Day of admission, pt was delirius, and pulled out his PEG tube. Reportedly, pt also with low back pain over the past week and adominal pain which is chronic. MEDICAL HISTORY: Subdural hematoma Hypertension Hypercholesterolemia Essential thrombocytopenia s/p placement of GJ tube infected GJ tube insertion site h/o C diff infection (diagnosed in [**Month (only) **] admit) MEDICATION ON ADMISSION: 1. Modafinil 50 mg qday 2. Celecoxib 100 [**Hospital1 **] 3. Metoprolol 25 tid 4. Lansoprazole 30 qhs 5. Cholestyramine 4 g [**Hospital1 **] 6. Paroxetine 30 mg qday 7. Clonidine 0.1 mg q8 hours 8. Paroxetine 30 mg qday 9. Cholestyramine 4 g [**Hospital1 **] 10. Dalteparin 2500 units qday ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: VS: T: 96.1; BP: 197/70; HR: 50; RR: 16; O2: 98 RA Gen: Confused laying in bed in NAD HEENT: PERRLA; Sclera anicteric CV: RRR S1S2. No M/R/G Lungs: CTA b/l anteriorly. Abd: +BS. Diffuse tenderness without rebound or guarding >er LLQ and suprapubic areas. G-tube removed. Site is not erythematous. Ext: No edema. DP 2+ Neuro: Did not know where he was, or day, or month. MS: [**4-23**] upper extremities b/l. LE: left flexion [**3-24**], all else [**4-23**]. FAMILY HISTORY: Non-contributory SOCIAL HISTORY: Pt is haitian Creole speaking. He is married with a son and a daughter.

Mechanical complication of gastrostomy,Urinary tract infection, site not specified,Blood in stool,Retention of urine, unspecified,Intestinal infection due to Clostridium difficile,Atrial fibrillation,Encephalopathy, unspecified,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Chronic ulcer of other specified sites,Unspecified essential hypertension

Gastrostomy comp - mech,Urin tract infection NOS,Blood in stool,Retention urine NOS,Int inf clstrdium dfcile,Atrial fibrillation,Encephalopathy NOS,Pseudomonas infect NOS,Chronic skin ulcer NEC,Hypertension NOS

Admission Date: [**2111-5-26**] Discharge Date: [**2111-6-12**] Date of Birth: [**2035-5-25**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2641**] Chief Complaint: s/p pulling out PEG tube and inability to pass foley Major Surgical or Invasive Procedure: PICC line placement PEG tube insertion EGD with cauterization PICC line insertion History of Present Illness: Pt is a 76 yo [**Location 7972**] Creole speaking male with HTN, essential thrombocytopenia, s/p right craniotomy for subdural hematoma, additional admission in [**Month (only) 547**] for management of SDH, PCA stroke, and c. diff colitis, who presents because he pulled out his PEG tube and inability to pass foley. Pt was started on ritalin last week for being sluggish. He was noted to be delirium over the weekend and ritalin was d/cd on saturday. Day of admission, pt was delirius, and pulled out his PEG tube. Reportedly, pt also with low back pain over the past week and adominal pain which is chronic. Past Medical History: Subdural hematoma Hypertension Hypercholesterolemia Essential thrombocytopenia s/p placement of GJ tube infected GJ tube insertion site h/o C diff infection (diagnosed in [**Month (only) **] admit) Social History: Pt is haitian Creole speaking. He is married with a son and a daughter. Family History: Non-contributory Physical Exam: VS: T: 96.1; BP: 197/70; HR: 50; RR: 16; O2: 98 RA Gen: Confused laying in bed in NAD HEENT: PERRLA; Sclera anicteric CV: RRR S1S2. No M/R/G Lungs: CTA b/l anteriorly. Abd: +BS. Diffuse tenderness without rebound or guarding >er LLQ and suprapubic areas. G-tube removed. Site is not erythematous. Ext: No edema. DP 2+ Neuro: Did not know where he was, or day, or month. MS: [**4-23**] upper extremities b/l. LE: left flexion [**3-24**], all else [**4-23**]. Pertinent Results: Labs on admission: [**2111-5-26**] 05:15PM BLOOD WBC-12.2*# RBC-3.74* Hgb-11.5* Hct-34.6* MCV-93 MCH-30.9 MCHC-33.3 RDW-15.3 Plt Ct-746* [**2111-5-26**] 05:15PM BLOOD Neuts-69.9 Lymphs-21.1 Monos-8.4 Eos-0.3 Baso-0.2 [**2111-5-26**] 05:15PM BLOOD Glucose-100 UreaN-15 Creat-1.0 Na-140 K-5.0 Cl-104 HCO3-27 AnGap-14 [**2111-5-26**] 05:15PM BLOOD ALT-21 AST-26 AlkPhos-140* Amylase-69 [**2111-5-26**] 05:15PM BLOOD Calcium-9.9 Phos-3.6 Mg-1.7 __________________________ Other: [**2111-5-26**] 05:15PM BLOOD ALT-21 AST-26 AlkPhos-140* Amylase-69 [**2111-5-27**] 09:05AM BLOOD VitB12-690 Folate-19.4 [**2111-5-27**] 09:05AM BLOOD TSH-2.8 [**2111-6-3**] 06:13PM BLOOD Lactate-1.1 [**2111-6-8**] 08:37AM BLOOD Lactate-1.0 __________________________ Labs on discharge: [**2111-6-11**] Hct: 33.0* [**2111-6-10**] Hct: 33.1* [**2111-6-9**] Hct: 32.2* [**2111-6-8**] Hct: 32.5* ___________________________ Micro: [**2111-5-26**]- UCx- no growth [**2111-5-27**] 12:18 pm URINE **FINAL REPORT [**2111-5-29**]** URINE CULTURE (Final [**2111-5-29**]): PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CIPROFLOXACIN--------- 2 I GENTAMICIN------------ <=1 S IMIPENEM-------------- 4 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S [**2111-5-27**] RPR -negative [**2111-5-21**], [**2111-5-31**], [**2111-6-9**]- C. diff no growth [**2111-6-2**]- UCx- no growth _____________________________________ Radiology: [**2111-5-26**] CT ab/pelvis with and without contrast-1. Improved appearance of previously described colitis. 2. No acute abnormality. [**2111-5-27**]- CT head without contrast-CT OF THE BRAIN WITHOUT INTRAVENOUS CONTRAST: There is again seen an area of linear density adjacent to the inner table at the location of the right-sided craniotomy, which is unchanged in appearance since [**2111-5-19**], likely post- surgical in origin. No acute intracranial hemorrhage is identified. There is no new mass effect or shift of normally midline structures. The lateral ventricles are symmetric and unchanged in size. The basilar cisterns are patent. Stable appearance of old infarct in the right posterior cerebral artery distribution is noted. Stable periventricular white matter hypodensity consistent with small vessel ischemic change is seen. Elsewhere within the brain, the [**Doctor Last Name 352**]-white differentiation is preserved. [**2111-5-28**]-EEG-: Abnormal EEG due to the slow and disorganized background rhythm. This indicates a widespread encephalopathy. Medications, metabolic disturbances, and infection are among the most common causes. There were no epileptiform features. [**2111-6-4**]-EEG-This is an abnormal routine EEG due to the presence of a slow and disorganized background rhythm in the theta frequency range with occasional intermixed, generalized delta frequency slowing. These findings suggest deep, midline subcortical dysfunction and are consistent with an encephalopathy. Common causes include infections, medication effects, and metabolic disturbances. No lateralizing or epileptiform abnormalities were identified. If clinical concern for seizures persists, a repeat study after the patient's mental status improves, may be of benefit to better discriminate focal abnormality that can be obscured by an encephalopathic pattern. Sinus bradycardia was noted. [**2111-6-8**] MRA/MRI head-1. New focus of increased susceptibility in the peripheral right cerebellar hemisphere, which may be artifactual, but could represent a small area of hemorrhage. Please note that this finding was not seen on the previous examination, but the difference may be due to the present study obtained at 3T, as opposed to the 1.5T study earlier. The higher field strength of the present study could increase the visibility of magnetic susceptibility. 2. No evidence of acute ischemia. 3. Stable MRA of the circle of [**Location (un) 431**] compared to [**2107-10-20**]. [**2111-6-10**] MRI gadolidium-1. Enhancement of the pachymeninges along the entire right convexity, likely related to previous subdural hemorrhage. 2. Developmental venous anomaly in the right frontal lobe, a benign finding. 3. No evidence of acute ischemia. 4. No cerebral masses. Brief Hospital Course: On [**2111-5-28**], pt was noted to be tachycardic, then had decreased in BP from 120's from 150-180's. That same day patient had 2 large melenic stools. ~ 10 point Hct drop from 32 on [**5-27**] am to 23 on [**5-28**]. He was given 2 units of pRBC and then was transferred to the MICU. MICU course: Patient had an episode on bloody emesis ~300 cc but Hct remained stable. EGD was initially attempted but could unsuccessful to visualize bleeding b/o old clot. EGD repeated on [**2111-5-29**] and showed small ulcer w/ signs of recent bleeding at gastrostomy site. This was injected wtih epinephrine and cauterized. Additionally, pt was found to have a pseudomonal UTI and mental status improved. Then pt had two unresponsive episodes on the floor. The following is by problem of the above: 1. Altered mental status/unresponsive- Pt was initially pulling at his foley and IVs pulling them out when he was initially hospitalized. He eventually was found to have a pseudomonal UTI and was fully treated with Zosyn (see below). His mental status cleared to baseline per family where at times he was oriented x 3. Thus, his altered mental status when he was in the hospital was attributable to his UTI and has now resolved to his previous mental status. Pt also had with two episodes of unresponsiveness on [**2111-6-3**] and [**2111-6-7**]. MRI/MRA showed ? small amount of hemorhage in right cerebellar hemishphere which could be artifact. MRA was fine. Repeat MRI with gadolidium showed no acute stroke. EEG was repeated and was only consistent with encephalopathy. Neurology was consulted on pt who thought that pt may have seizures but it was unclear. [**Name2 (NI) **] was stable for the rest of his hospitalization. B12 was checked (pt with history of b12 deficiency) and it was normal. Pt would pull at his tubes/lines frequently but this decreased towards the end of his hospital stay. HE was on 1:1 sitters and restraints during hospitalization having the restraints taken off within a few days. The 1:1 sitter was taken off a few days before discharge and pt did well, with no agitation. We held pt's provigil and paxil during altered mental status and avoided sedating medications. 2. GI Bleed-Pt had a GIB secondary to ulceration at PEG tube from pulling it out. He had an EGD which showed this and the ulceration was cauterized. He required blood transfusion x 2 initially and then 2 units of pRBC when he came back on the floor to bump him up. We initially were checking Hct q12 when pt arrived back on the floor and then when Hct was stable for a few days qday. We started with protonix [**Hospital1 **] and switched to prevacid [**Hospital1 **] once G tube was placed. He will get this for one month in total and then to qday. 3. [**Name (NI) 12007**] Pt grew pseudomonas in his urine which was sensitive to Zosyn. He completed a 14 day course of Zosyn while in-house. He had negative U/A, UCx after that. His initial delirium was likely due to this, and has now resolved to baseline. FOley placement was difficult therefore no voiding trials were done. 4. G-tube displacement- As above. Replaced [**2111-5-28**]. Receiving tube feeds through it. Needs speech and swallow evaluation for safety of po intake in setting of baseline delerium. 5. Foley placement/[**Name (NI) 12008**] Pt had inability to place foley initially and then had a 22 caude placed in the ED. GU saw pt when he was out of the MICU and replaced a 22 caude catheter. Flomax was started for urinary retention. However, we d/cd it as that was the only change in medications prior to initial unresponsiveness. Inability to pass foley is likely [**1-21**] foley trauma/acute edema. He will need a voiding trial in rehab and outpt follow up with urology. 6. Essential [**Name (NI) 12009**] Pt was not on his hydroxyurea upon coming in, stopping in in his surgery admission. We restarted hydroxyurea after discussing this with his hematologist, Dr. [**Last Name (STitle) **]. Plavix on hold [**1-21**] bleed. Pt will need follow up with Dr. [**Last Name (STitle) **] as an outpatient. Please continue to hold plavix (for at least 6 weeks) ; follow outpt hematolgy recommendations. 7. Depression- we d/cd paxil in setting of altered mental status. This should be restarted when pt follows up with his PCP. 8. HTN- BP meds were initially being held in the setting of acute bleed. We restarted his clonidine and metoprolol at outpt doses. 9. Hyperlipidemia- Cholestyramine was on hold. We restarted it prior to discharge. 10. C. diff- Pt with c. diff positive on prior hospitalizations with persistant diarrhea. We treated him with vancomycin while on zosyn, and have now d/c'd vancomycin. 11. PPx- Subcutaneous heparin restarted after GIB stable. Prevacid. 12. [**Name (NI) 12010**] Pt had a Right fem line in the MICU which was d/cd. He had a right arm PICC placed by IR which was d/cd when the antibiotic course was finished. He had peripheral IVs otherwise. 13. F/E/[**Name (NI) **] Pt was on tube feeds. Nutrition consulted for help. Electrolytes were checked and repleted prn. Speech and Swallow evaluation needed for safety of po intake. 14. Code Status-Pt was Full Code. Medications on Admission: 1. Modafinil 50 mg qday 2. Celecoxib 100 [**Hospital1 **] 3. Metoprolol 25 tid 4. Lansoprazole 30 qhs 5. Cholestyramine 4 g [**Hospital1 **] 6. Paroxetine 30 mg qday 7. Clonidine 0.1 mg q8 hours 8. Paroxetine 30 mg qday 9. Cholestyramine 4 g [**Hospital1 **] 10. Dalteparin 2500 units qday Discharge Medications: 1. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO twice a day. 2. Hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) SC Injection TID (3 times a day). 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 5. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed. 6. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO BID (2 times a day) for 2 weeks: After 2 weeks stop [**Hospital1 **] dosing and switch to daily dosing. 9. Cholestyramine-Sucrose 4 g Powder Sig: One (1) PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital3 1186**] - [**Location (un) 538**] Discharge Diagnosis: Primary diagnosis: Delirium Gastrointestinal bleed Urinary Tract Infection Inability to pass foley Clostridium difficile Secondary diagnosis: Hypertension Essential thrombocytosis Hyperlipidemia Discharge Condition: Pt is doing significantly better. His Hct is stable and his mental status has returned to baseline per family. They note that he has had intermittant delerium since SDH in spring, now baseline, does not require inpatient care. Discharge Instructions: Call your doctor or go to the ED if you have change in your mental status, bright red blood per rectum, black stools, have fever >101, chills, nausea, vomiting, chest pain, problems breathing, shortness of breath, or any other health concern. Take your medications as prescribed. Go to your appointments below. 1.Call your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 7976**] within the next 7-10 days for follow up. 2. Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 742**] NEUROSURGERY WEST Where: LM [**Hospital Unit Name 12011**] Phone:[**Telephone/Fax (1) 3666**] Date/Time:[**2111-6-18**] 2:15 -HEMATOLOGY: DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]- call for appointment [**Telephone/Fax (1) 9645**] -UROLOGY: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9125**] call for appointment: [**Telephone/Fax (1) 6445**] Take your medications as prescribed. Followup Instructions: 1.Call your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 7976**] within the next 7-10 days for follow up. 2. Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 742**] NEUROSURGERY WEST Where: LM [**Hospital Unit Name 12011**] Phone:[**Telephone/Fax (1) 3666**] Date/Time:[**2111-6-18**] 2:15 -DR. [**Last Name (STitle) **]- [**Telephone/Fax (1) 9645**] -UROLOGY: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9125**] call for appointment: [**Telephone/Fax (1) 6445**] Completed by:[**2111-6-12**]

536,599,578,788,008,427,348,041,707,401

{'Mechanical complication of gastrostomy,Urinary tract infection, site not specified,Blood in stool,Retention of urine, unspecified,Intestinal infection due to Clostridium difficile,Atrial fibrillation,Encephalopathy, unspecified,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Chronic ulcer of other specified sites,Unspecified essential hypertension'}

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: s/p pulling out PEG tube and inability to pass foley PRESENT ILLNESS: Pt is a 76 yo [**Location 7972**] Creole speaking male with HTN, essential thrombocytopenia, s/p right craniotomy for subdural hematoma, additional admission in [**Month (only) 547**] for management of SDH, PCA stroke, and c. diff colitis, who presents because he pulled out his PEG tube and inability to pass foley. Pt was started on ritalin last week for being sluggish. He was noted to be delirium over the weekend and ritalin was d/cd on saturday. Day of admission, pt was delirius, and pulled out his PEG tube. Reportedly, pt also with low back pain over the past week and adominal pain which is chronic. MEDICAL HISTORY: Subdural hematoma Hypertension Hypercholesterolemia Essential thrombocytopenia s/p placement of GJ tube infected GJ tube insertion site h/o C diff infection (diagnosed in [**Month (only) **] admit) MEDICATION ON ADMISSION: 1. Modafinil 50 mg qday 2. Celecoxib 100 [**Hospital1 **] 3. Metoprolol 25 tid 4. Lansoprazole 30 qhs 5. Cholestyramine 4 g [**Hospital1 **] 6. Paroxetine 30 mg qday 7. Clonidine 0.1 mg q8 hours 8. Paroxetine 30 mg qday 9. Cholestyramine 4 g [**Hospital1 **] 10. Dalteparin 2500 units qday ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: VS: T: 96.1; BP: 197/70; HR: 50; RR: 16; O2: 98 RA Gen: Confused laying in bed in NAD HEENT: PERRLA; Sclera anicteric CV: RRR S1S2. No M/R/G Lungs: CTA b/l anteriorly. Abd: +BS. Diffuse tenderness without rebound or guarding >er LLQ and suprapubic areas. G-tube removed. Site is not erythematous. Ext: No edema. DP 2+ Neuro: Did not know where he was, or day, or month. MS: [**4-23**] upper extremities b/l. LE: left flexion [**3-24**], all else [**4-23**]. FAMILY HISTORY: Non-contributory SOCIAL HISTORY: Pt is haitian Creole speaking. He is married with a son and a daughter. ### Response: {'Mechanical complication of gastrostomy,Urinary tract infection, site not specified,Blood in stool,Retention of urine, unspecified,Intestinal infection due to Clostridium difficile,Atrial fibrillation,Encephalopathy, unspecified,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Chronic ulcer of other specified sites,Unspecified essential hypertension'}

CHIEF COMPLAINT: s/p fall PRESENT ILLNESS: 48 M s/p [**2138**]0 feet off of a salt truck. The patient states that he lost his balance and fell ~10feet. He did not lose consciousness. He complains of pain at his left chest MEDICAL HISTORY: Polysubstabce abuse, Chronic neck/back pain after MVC, hypothyroid, GERD. MEDICATION ON ADMISSION: citalopram 40 mg daily clonazepam 1 mg tid daily levothyroxine 25 mcg daily heparin 5000 [**Hospital1 **] ketorlac 15 mg q6Hx3 days dilaudid 2-4 mg po q3 hr pain tizanidine 4 mg TID pain lithium 600 mg daily (dose verified by pcp) potassium chloride SS Mg sulfate SS Calcium gluconate SS ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: Admission physical HR:81 BP:170/ Resp:22 O(2)Sat:98% RA Normal FAMILY HISTORY: Noncontributory to this problem. SOCIAL HISTORY: H/o PSA.

Traumatic pneumothorax without mention of open wound into thorax,Closed fracture of dorsal [thoracic] vertebra without mention of spinal cord injury,Closed fracture of six ribs,Drug-induced delirium,Other noncollision motor vehicle traffic accident injuring passenger in motor vehicle other than motorcycle,Closed fracture of clavicle, unspecified part,Unspecified acquired hypothyroidism,Esophageal reflux,Other, mixed, or unspecified drug abuse, unspecified,Other opiates and related narcotics causing adverse effects in therapeutic use

Traum pneumothorax-close,Fx dorsal vertebra-close,Fracture six ribs-closed,Drug-induced delirium,Mv traff acc NEC-pasngr,Fx clavicle NOS-closed,Hypothyroidism NOS,Esophageal reflux,Drug abuse NEC-unspec,Adv eff opiates

Admission Date: [**2187-1-2**] Discharge Date: [**2187-1-6**] Date of Birth: [**2138-3-23**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2534**] Chief Complaint: s/p fall Major Surgical or Invasive Procedure: None History of Present Illness: 48 M s/p [**2138**]0 feet off of a salt truck. The patient states that he lost his balance and fell ~10feet. He did not lose consciousness. He complains of pain at his left chest Past Medical History: Polysubstabce abuse, Chronic neck/back pain after MVC, hypothyroid, GERD. Social History: H/o PSA. Family History: Noncontributory to this problem. Physical Exam: Admission physical HR:81 BP:170/ Resp:22 O(2)Sat:98% RA Normal Constitutional: Patient is boarded and collared, vocalizing loudly that he is in a lot of pain HEENT: Normocephalic, atraumatic, Extraocular muscles intact c-collar in place Chest: + L sided CW TTP Cardiovascular: Regular Rate and Rhythm Abdominal: Soft, Nontender Extr/Back: +TTP of midline T spine. eccymoses L ankle Skin: eccymoses L ankle, no abrasions, no lacerations Neuro: Speech fluent, MAEE Pertinent Results: [**1-2**] - CT CAP - SMall L PTX, First, 4-8th L rib fractures. [**1-2**] - CT Cspine - No acute cspine injury [**1-2**] - CT Head - No acute intracranial process Brief Hospital Course: The patient was seen in the trauma bay and was found to have a small pneumothorax as well as Left 1st and 4th-8th rib fractures. A chest tube was placed in the emergency department and placed on wall suction. He was admitted to the TSICU for further management. A pareventricular block was attempted but the patient was unable to tolerate this, and so his pain was controlled with IV dilaudid. This was reattempted the following day and the patient tolerated the procedure and had good pain relief from this. The acute pain service was consulted and he was started on tizanidine, PO dilaudid and toradol for adjunctive pain control. The patient had persistent mental status changes and was seen by psychiatry for this and his history of polysubstance abuse. They recommended he continue on his home psychiatric medications with the addition of seroquel. The patient was transferred to the floor for further management. While on the floor he was kept on telemetry with his chest tube. He was on a regular diet on all his home medications. His pain was controlled with dilaudid. His chest tube was removed on [**1-6**]. A chest xray taken afterwards and was preliminarily read as no residual pneumothorax. He was discharged home with narcotic pain relief, a sling for comfort for his left clavicle fracture, and an incentive spirometer. He was given instructions for close follow up with the orthopedic surgery clinic and the acute care surgery clinic. Medications on Admission: citalopram 40 mg daily clonazepam 1 mg tid daily levothyroxine 25 mcg daily heparin 5000 [**Hospital1 **] ketorlac 15 mg q6Hx3 days dilaudid 2-4 mg po q3 hr pain tizanidine 4 mg TID pain lithium 600 mg daily (dose verified by pcp) potassium chloride SS Mg sulfate SS Calcium gluconate SS Discharge Medications: 1. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). 3. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. lithium carbonate 300 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 5. tizanidine 2 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 6. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain: take with colace. Disp:*30 Tablet(s)* Refills:*0* 7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Discharge Disposition: Home Discharge Diagnosis: Pneumothorax Left First, Fourth-Eighth rib fractures Discharge Condition: Good Discharge Instructions: You were admitted to the acute care service after your fall. You had several broken ribs on the left side, a broken clavicle, and a punctured left lung. It is important for you to use your incentive spirometer every hour to keep your lungs inflated. You should wear a sling for comfort with your left clavicle fracture. Please follow up with the orthopedic clinic in one week for care of your clavicle fracture. You have also been discharged with some narcotic pain medication. You should not drive or operate heavy machinery while taking narcotic pain medication. You can also take tylenol to reduce your narcotic pain medicine requirement. Take tylenol as directed. Followup Instructions: Please follow up with the Acute Care service in 2 weeks. Please call [**Telephone/Fax (1) 600**] for an appointment. You should follow up with the orthopedic clinic in 1 week for care of your clavicle fracture. Please call [**Telephone/Fax (1) 1228**] to make this appointment.

860,805,807,292,E818,810,244,530,305,E935

{'Traumatic pneumothorax without mention of open wound into thorax,Closed fracture of dorsal [thoracic] vertebra without mention of spinal cord injury,Closed fracture of six ribs,Drug-induced delirium,Other noncollision motor vehicle traffic accident injuring passenger in motor vehicle other than motorcycle,Closed fracture of clavicle, unspecified part,Unspecified acquired hypothyroidism,Esophageal reflux,Other, mixed, or unspecified drug abuse, unspecified,Other opiates and related narcotics causing adverse effects in therapeutic use'}

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: s/p fall PRESENT ILLNESS: 48 M s/p [**2138**]0 feet off of a salt truck. The patient states that he lost his balance and fell ~10feet. He did not lose consciousness. He complains of pain at his left chest MEDICAL HISTORY: Polysubstabce abuse, Chronic neck/back pain after MVC, hypothyroid, GERD. MEDICATION ON ADMISSION: citalopram 40 mg daily clonazepam 1 mg tid daily levothyroxine 25 mcg daily heparin 5000 [**Hospital1 **] ketorlac 15 mg q6Hx3 days dilaudid 2-4 mg po q3 hr pain tizanidine 4 mg TID pain lithium 600 mg daily (dose verified by pcp) potassium chloride SS Mg sulfate SS Calcium gluconate SS ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: Admission physical HR:81 BP:170/ Resp:22 O(2)Sat:98% RA Normal FAMILY HISTORY: Noncontributory to this problem. SOCIAL HISTORY: H/o PSA. ### Response: {'Traumatic pneumothorax without mention of open wound into thorax,Closed fracture of dorsal [thoracic] vertebra without mention of spinal cord injury,Closed fracture of six ribs,Drug-induced delirium,Other noncollision motor vehicle traffic accident injuring passenger in motor vehicle other than motorcycle,Closed fracture of clavicle, unspecified part,Unspecified acquired hypothyroidism,Esophageal reflux,Other, mixed, or unspecified drug abuse, unspecified,Other opiates and related narcotics causing adverse effects in therapeutic use'}

CHIEF COMPLAINT: Dyspnea with exertion/Orthopnea PRESENT ILLNESS: Mrs. [**Known lastname 66252**] is a 72-year-old lady who has known rheumatic heart disease, status post mitral valve commissurotomy in the past through a median sternotomy. She has developed mitral stenosis, mitral regurgitation and moderate aortic regurgitation with rheumatic valve changes by echocardiography. SHe is now symptomatic with DOE and orthopnea. MEDICAL HISTORY: PMH: Rheumatic heart disease, Mitral stenosis, Mitral regurgitation, Aortic insufficiency, Chronic atrial fibrillation, R parietal stroke [**2156**], COPD, h/o acute bronchitis. MEDICATION ON ADMISSION: Lasix 20', coumadin, digoxin 0.125', albuterol inhaler prn ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: PE: 98.6 97.7 82 110/60 18 95RA NAD. A&Ox3. Anicteric. MMM. Irregularly, irregular. Sternotomy incision c/d/i. No crepitus. Diminished breath sounds at bases. Soft. ND. +BS. Minimally tender RUQ. No guarding, rebound, or other signs of peritonitis. Warm and well perfused. Trace peripheral edema. FAMILY HISTORY: Her brother also suffered from rheumatic heart disease. SOCIAL HISTORY: She is a retired factory worker. She quit tobacco approximately in [**2153**]. She admits to only a 10-pack year history. She has no history of alcohol, previously did not drink alcohol. She currently lives with her daughter who is employed as a nurse.

Multiple involvement of mitral and aortic valves,Acute respiratory failure,Ostium secundum type atrial septal defect,Hemorrhage complicating a procedure,Cardiac tamponade,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Atrial fibrillation,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Chronic airway obstruction, not elsewhere classified,Hypopotassemia,Hypocalcemia

Mitr/aortic mult involv,Acute respiratry failure,Secundum atrial sept def,Hemorrhage complic proc,Cardiac tamponade,Abn react-artif implant,Atrial fibrillation,Hx TIA/stroke w/o resid,Chr airway obstruct NEC,Hypopotassemia,Hypocalcemia

Admission Date: [**2161-10-13**] Discharge Date: [**2161-10-23**] Date of Birth: [**2089-8-31**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea with exertion/Orthopnea Major Surgical or Invasive Procedure: [**2161-10-18**] - Mediastinal Exploration and Evacuation of Clot [**2161-10-14**] - Redo sternotomy, Aortic and mitral valve replacement with St. [**Male First Name (un) 923**] mechanical valves. Closure of ASD. [**2161-10-13**] - Cardiac Catheterization History of Present Illness: Mrs. [**Known lastname 66252**] is a 72-year-old lady who has known rheumatic heart disease, status post mitral valve commissurotomy in the past through a median sternotomy. She has developed mitral stenosis, mitral regurgitation and moderate aortic regurgitation with rheumatic valve changes by echocardiography. SHe is now symptomatic with DOE and orthopnea. Past Medical History: PMH: Rheumatic heart disease, Mitral stenosis, Mitral regurgitation, Aortic insufficiency, Chronic atrial fibrillation, R parietal stroke [**2156**], COPD, h/o acute bronchitis. PSH: Mitral commissurotomy through a sternotomy in [**2135**], a hysterectomy in [**2141**], a hemorrhoid surgery in [**2148**] and [**2158**], and local cyst removal near her sternotomy in [**2160**]. Social History: She is a retired factory worker. She quit tobacco approximately in [**2153**]. She admits to only a 10-pack year history. She has no history of alcohol, previously did not drink alcohol. She currently lives with her daughter who is employed as a nurse. Family History: Her brother also suffered from rheumatic heart disease. Physical Exam: PE: 98.6 97.7 82 110/60 18 95RA NAD. A&Ox3. Anicteric. MMM. Irregularly, irregular. Sternotomy incision c/d/i. No crepitus. Diminished breath sounds at bases. Soft. ND. +BS. Minimally tender RUQ. No guarding, rebound, or other signs of peritonitis. Warm and well perfused. Trace peripheral edema. Pertinent Results: [**2161-10-13**] Cardiac Cath 1. Coronary angiography in this right-dominant system revealed: --the LMCA had no angiographically apparent disease. --the LAD had no angiographically apparent disease. --the LCX had no angiographically apparent disease. --the RCA had no angiographically apparent disease. 2. Resting hemodynamics revealed high-normal right-sided filling pressures with RVEDP 6 mmHg. The PCWP was elevated at 15 mmHg; the LVEDP was 9 mmHg. There was mild pulmonary arterial systolic hypertension with PASP 31 mmHg. The cardiac output was normal with CI 2.9 L/min/m2. There was normal systemic arterial systolic pressure, with SBP 115 mmHg. There was no gradient across the aortic valve upon pullback of the angled pigtail catheter from LV to ascending aorta. 3. Hemodynamic evaluation of the mitral valve revealed the mitral valve gradient to be approximately 5 mmHg with a calculated mitral valve area of 1.9 cm2. 4. Left ventriculography revealed normal wall motion, LVEF 61%, and [**2-24**]+ mitral regurgitation into a dilated left atrium. 5. Supravalvular aortography revealed 2+ aortic regurgitation. [**2161-10-14**] ECHO PRE-BYPASS: 1. The left atrium is markedly dilated. A left-to-right shunt across the interatrial septum is seen at rest. A small secundum atrial septal defect is present. 2. There is mild symmetric left ventricular hypertrophy. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. There is mild aortic valve stenosis (area 1.2-1.9cm2). Moderate (2+) aortic regurgitation is seen. 6. The mitral valve leaflets are severely thickened/deformed. There is moderate valvular mitral stenosis (area 1.0-1.5cm2). Moderate (2+) mitral regurgitation is seen. 7. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including epinephrine & phenylephrine and is AV paced. 1. A well-seated bileaflet valve is seen in the mitral position with normal leaflet motion and gradients (mean gradient = 3 mmHg). Trivial (normal for prosthesis) mitral regurgitation is seen. Washing jets are seen. 2. A wellseated bileaflet valve is seen in the Aortic position. Valve is not well seen due to shadowing, leaflets appear to move well. Mean Gradient is 3 mm of Hg. No significant valvular or paravalvular jets seen (however cannot exclude smaller jets) 3. Biventricular functions appears unchanged. 4. Aorta is intact post decannulation. 5. Other findings are unchanged. [**2161-10-17**] CT Scan 1. Mild-to-moderate free intraperitoneal air collecting underneath the diaphragm. No definite source is identified, but likely relates to recent surgery. Bowel is normal in appearance. There is no extravasation of oral contrast material or intra- abdominal or intrapelvic fluid collection. 2. Large left and small right pleural effusions. 3. Small amount of gas, fluid, and intermediate density material in the inferior-most portion of the imaged mediastinum, presumably related to recent surgery. 4. Bilateral hydroureteronephrosis, right worse than left. No stones or other filling defect is identified. [**2161-10-20**] ECHO Pre evacaution: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. There is mild regional left ventricular systolic dysfunction with anterior hypokinesis. Overall left ventricular systolic function is mildly depressed (LVEF= 40 %). The right ventricular cavity is unusually small. with moderate global free wall hypokinesis. There is severe compression of the right atrium and ventricle by a large retorcardiac mass which is consistent with organizing thrombus. The right atrium is slit like and severely compressed. There is a large left pleural effusion. There are simple atheroma in the ascending aorta. There are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. A bileaflet aortic valve prosthesis is present. No aortic regurgitation is seen. Aortic valve gradeints are normal for prosthesis. A mechanical mitral valve prosthesis is present. Gradients are normal for prosthesis. Mild (1+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. Post evacuation. The right atrium is now mildly dilated. RV free wall hypokiensis is mild to moderate. LVEF 40%. Remaining exam is unchanged. All findings disucssed with surgeons at the time of the exam Brief Hospital Course: Ms. [**Known lastname 66252**] was admitted to the [**Hospital1 18**] on [**2161-10-13**] for a cardiac catheterization in preparation for her redo valve surgery. Her cardiac catheterization showed normal coronary arteries, severe mitral rtegurgitation and moderate aortic regurgitation. On [**2161-10-14**], Ms. [**Known lastname 66252**] was taken to the operating room where she underwent [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 66253**], [**First Name3 (LF) **] aortic and mitral valve replacement with St. [**Male First Name (un) 923**] mechanical valves and closure of an atrial septal defect. Please see operative note for details. Postoperatively she was taken to the intensive care unit for monitoring. On postoperative day one, she awoke neurologically intact and was extubated. Heparin was tarted for anticoagulation and coumadin was resumed. On postoperative day two, she was transferred to the step down unit for further recovery. She was transfused with red blood cells for postoperative anemia. Gentle diuresis was initiated. Free air was noted in her belly on x-ray and a CT scan was obtained. No significant abnormalities were seen. On [**2161-10-18**], Ms. [**Known lastname 66252**] developed hypotension and and echo was suggestive of tamponade. She was returned to the operating room where her mediastinum was explored with evacuation of clot. No specific bleeding was identified and her sternum was closed. She was returned to the intensive care unit for monitoring. She was extubated the next day without issue and transferred back to the step down unit of [**2161-10-20**]. The physical therapy service was consulted for assistance with her postoperative strength and mobility. Coumadin was resumed. She remained in controlled atrial fibrillation consistent with her preoperative status. By post-operative day 8 she was ready for discharge to home. Medications on Admission: Lasix 20', coumadin, digoxin 0.125', albuterol inhaler prn Discharge Medications: 1. 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* 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): for constipation . Disp:*60 Capsule(s)* Refills:*0* 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 7. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses: take 2.5 mg daily or as directed by the office of Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]. Disp:*30 Tablet(s)* Refills:*0* 8. Outpatient Lab Work INR to be drawn on [**10-26**] with results sent to the office of Dr. [**Last Name (STitle) **],[**First Name3 (LF) 251**] T. [**Telephone/Fax (1) 4475**]. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Rheumatic heart disease with MR/MS/AI History of Mitral valve commissurotomy AF CVA COPD Tamponade Discharge Condition: Stable Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 1504**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month or while taking narcotics for pain. 7) Call with any questions or concerns. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 11763**]. Please follow-up with cardiologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in 2 weeks. Please follow-up with Dr. [**Last Name (STitle) **] in [**1-26**] weeks. ([**Telephone/Fax (1) 40360**]. Completed by:[**2161-10-23**]

396,518,745,998,423,E878,427,V125,496,276,275

{'Multiple involvement of mitral and aortic valves,Acute respiratory failure,Ostium secundum type atrial septal defect,Hemorrhage complicating a procedure,Cardiac tamponade,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Atrial fibrillation,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Chronic airway obstruction, not elsewhere classified,Hypopotassemia,Hypocalcemia'}

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: Dyspnea with exertion/Orthopnea PRESENT ILLNESS: Mrs. [**Known lastname 66252**] is a 72-year-old lady who has known rheumatic heart disease, status post mitral valve commissurotomy in the past through a median sternotomy. She has developed mitral stenosis, mitral regurgitation and moderate aortic regurgitation with rheumatic valve changes by echocardiography. SHe is now symptomatic with DOE and orthopnea. MEDICAL HISTORY: PMH: Rheumatic heart disease, Mitral stenosis, Mitral regurgitation, Aortic insufficiency, Chronic atrial fibrillation, R parietal stroke [**2156**], COPD, h/o acute bronchitis. MEDICATION ON ADMISSION: Lasix 20', coumadin, digoxin 0.125', albuterol inhaler prn ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: PE: 98.6 97.7 82 110/60 18 95RA NAD. A&Ox3. Anicteric. MMM. Irregularly, irregular. Sternotomy incision c/d/i. No crepitus. Diminished breath sounds at bases. Soft. ND. +BS. Minimally tender RUQ. No guarding, rebound, or other signs of peritonitis. Warm and well perfused. Trace peripheral edema. FAMILY HISTORY: Her brother also suffered from rheumatic heart disease. SOCIAL HISTORY: She is a retired factory worker. She quit tobacco approximately in [**2153**]. She admits to only a 10-pack year history. She has no history of alcohol, previously did not drink alcohol. She currently lives with her daughter who is employed as a nurse. ### Response: {'Multiple involvement of mitral and aortic valves,Acute respiratory failure,Ostium secundum type atrial septal defect,Hemorrhage complicating a procedure,Cardiac tamponade,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Atrial fibrillation,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Chronic airway obstruction, not elsewhere classified,Hypopotassemia,Hypocalcemia'}

CHIEF COMPLAINT: malignant central airway obstruction with necrotizing pneumonia PRESENT ILLNESS: 58F with COPD, anxiety and bipolar, transferred from [**Hospital 1562**] Hospital with new diagnosis of large central lung mass causing respiratory distress that required emergent intubation. She was intially admitted to [**Hospital 1562**] Hospital 3 days ago with shortness of breath, cough, malaise x2 weeks s/p failing a trial of Avalox as an outpatient. CXR done in the OSH ER showed (by report only) a very large left mid and lower lobe infiltrate with air fluid level suggesting emypema. CT chest (report) showed complex, large [**Location (un) 21851**] in mediastinum obliterating L main PA, L main bronchus, and resulting in near complete opacification of mid-to-lower left lung. She was started on Zosyn and Levaquin for pneumonia, Solumedrol for COPD flare, and sedation for extreme anxiety. MEDICAL HISTORY: PMH: 1. h/o ETOH dependence, sober x2 yrs 2. COPD - no record of PFT's, no h/o treatments for COPD in past 3. Hypothyroidism 4. Chronic anxiety disorder 5. Bipolar disorder 6. Osteoarthritis 7. Avascular necrosis of right hip 8. Anemia MEDICATION ON ADMISSION: Meds at home: Buspar 15'', Seroquel 300' + 100QHS, Synthroid 0.113' Meds on transfer: Levaquin, Zosyn, Solumedrol 125, Midaz, Propofol, Lovenox ALLERGIES: Penicillins PHYSICAL EXAM: VS: T 96.2 HR: 86-100 ST BP 138/80 Sats: 95% 4L NC General: appears in no apparent distress CV: RRR, normal S1,S2, no murmur/gallop or rub Pulm: Coarse rhonchi bilaterally Abd: soft, nondistended, normoactive bowel sounds Ext: no c/c/e Neuro: anxious, response appropiately, moves all extremities FAMILY HISTORY: Mother died at 58 of lung CA, father died at 57 of sudden death. She was 2 healthy children. SOCIAL HISTORY: Social history: >60 pack year smoking, currently smoking, h/o ETOH dependence, quit 2 yrs ago, currently not working - previously worked doing farm labor. Lives alone in [**Hospital1 1562**]

Malignant neoplasm of upper lobe, bronchus or lung,Abscess of lung,Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes,Bipolar I disorder, most recent episode (or current) manic, unspecified,Chronic airway obstruction, not elsewhere classified,Unspecified acquired hypothyroidism

Mal neo upper lobe lung,Abscess of lung,Mal neo lymph-intrathor,Bipol I currnt manic NOS,Chr airway obstruct NEC,Hypothyroidism NOS

Admission Date: [**2162-5-2**] Discharge Date: [**2162-5-6**] Date of Birth: [**2103-7-8**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 281**] Chief Complaint: malignant central airway obstruction with necrotizing pneumonia Major Surgical or Invasive Procedure: [**5-5**] flexible bronchoscopy [**2162-5-4**] Flexible and rigid bronchoscopy, endobronchial biopsy, transbronchial needle aspiration of precarinal and subcarinal lymph nodes, balloon dilation and metal covered stent placement. [**2162-5-3**] Flexible bronchoscopy History of Present Illness: 58F with COPD, anxiety and bipolar, transferred from [**Hospital 1562**] Hospital with new diagnosis of large central lung mass causing respiratory distress that required emergent intubation. She was intially admitted to [**Hospital 1562**] Hospital 3 days ago with shortness of breath, cough, malaise x2 weeks s/p failing a trial of Avalox as an outpatient. CXR done in the OSH ER showed (by report only) a very large left mid and lower lobe infiltrate with air fluid level suggesting emypema. CT chest (report) showed complex, large [**Location (un) 21851**] in mediastinum obliterating L main PA, L main bronchus, and resulting in near complete opacification of mid-to-lower left lung. She was started on Zosyn and Levaquin for pneumonia, Solumedrol for COPD flare, and sedation for extreme anxiety. She then underwent bronchoscopy with FNA on [**4-30**], which showed >75% narrowing of left mainstem bronchus at its most proximal portion and then quickly leading into 100% obliteration secondary to extrinsic compression. FNA was done, which showed malignant cells, unclear whether nonsmall cell vs. small cell vs. potential mix of pathology. L vocal cord was also noted to be immobile, suggesting involvement of the left recurrent laryngeal nerve. On [**5-1**], she developed respiratory distress and became apneic, and had to be emergently intubated during a code blue. She was transfused 1U PRBC's and started on Fe for anemia. She was stabilized and sedated, and transferred here for further care by Interventional Pulmonology. Per the chart, she has >60 pack year smoking history, quit drinking 2 years ago, and has no known exposure history. FH significant for mother who died of lung CA. Past Medical History: PMH: 1. h/o ETOH dependence, sober x2 yrs 2. COPD - no record of PFT's, no h/o treatments for COPD in past 3. Hypothyroidism 4. Chronic anxiety disorder 5. Bipolar disorder 6. Osteoarthritis 7. Avascular necrosis of right hip 8. Anemia Past surgical history: none Social History: Social history: >60 pack year smoking, currently smoking, h/o ETOH dependence, quit 2 yrs ago, currently not working - previously worked doing farm labor. Lives alone in [**Hospital1 1562**] Family History: Mother died at 58 of lung CA, father died at 57 of sudden death. She was 2 healthy children. Physical Exam: VS: T 96.2 HR: 86-100 ST BP 138/80 Sats: 95% 4L NC General: appears in no apparent distress CV: RRR, normal S1,S2, no murmur/gallop or rub Pulm: Coarse rhonchi bilaterally Abd: soft, nondistended, normoactive bowel sounds Ext: no c/c/e Neuro: anxious, response appropiately, moves all extremities Pertinent Results: [**2162-5-6**] WBC-12.7* RBC-4.20 Hgb-11.1* Hct-34.8* Plt Ct-324 [**2162-5-5**] WBC-11.7* RBC-3.61* Hgb-9.7* Hct-30.6* Plt Ct-267 [**2162-5-2**] WBC-17.4* RBC-3.81* Hgb-10.1* Hct-32.7* Plt Ct-294 [**2162-5-6**] Glucose-122* UreaN-11 Creat-0.5 Na-147* K-3.6 Cl-104 HCO3-30 [**2162-5-5**] Glucose-134* UreaN-9 Creat-0.5 Na-146* K-3.7 Cl-106 HCO3-31 [**2162-5-2**] Glucose-134* UreaN-6 Creat-0.6 Na-145 K-4.5 Cl-110* HCO3-26 [**2162-5-5**] Calcium-9.6 Phos-3.6 Mg-2.1 [**2162-5-2**] Type-ART Temp-36.2 Rates-16/3 Tidal V-350 PEEP-5 FiO2-40 pO2-149* pCO2-51* pH-7.33* calTCO2-28 Base XS-0 -ASSIST/CON Intubat-INTUBATED [**2162-5-4**] Type-ART Rates-/20 PEEP-5 FiO2-40 pO2-99 pCO2-46* pH-7.44 calTCO2-32* Base XS-5 Intubat-INTUBATED Date/Time: [**2162-5-3**] BRONCHOALVEOLAR LAVAGE GRAM STAIN (Final [**2162-5-3**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Preliminary): NO GROWTH, <1000 CFU/ml. FUNGAL CULTURE (Pending): ACID FAST SMEAR (Final [**2162-5-4**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Pending): CT CHEST W/CONTRAST [**2162-5-3**] IMPRESSION: 1. Central left upper lobe mas contiguous with a mediastinal lymph node conglomeration, most consistent with advanced lung cancer. There is direct contact and mild compression on the aortic arch, encasement and obstruction of the left pulmonary artery, and encasement of the left main stem bronchus with partially obstructing mass distally. 2. Dominant central cavity in left lung is likely related to necrotizing post- obstructive pneumonia, but cavity component of neoplasm is also possible. 3. Multifocal bilateral pneumonia. Multiple left-sided cavities are consistent with necrotizing pneumonia. 4. Diffuse right peribronchial thickening may be due to either neoplastic infiltration or infection. 5. Small bilateral pleural effusions and pericardial effusion. 6. Cirrhosis and small amount of ascites. CHEST (PORTABLE AP) [**2162-5-5**] 4:56 AM In the interim, there is worsening of calcification in the left hemithorax due to combined left pleural effusion and left post-obstructive pneumonitis from a left hilar mass, which is obscuring the left heart border and aortic shadow. There is also worsened air space disease in the right lung that is attributed either to pulmonary edema and/or pneumonia. A right subclavian central line is noted with tip in the mid-to-proximal SVC. Both diaphragms are partially visualized secondary to bibasilar atelectasis. A stent is noted in the left main bronchus. IMPRESSION: 1. Worsening of pneumonia and effusion in the left lung. Worsening edema and/or pneumonia in the right lung. Cytology Report PRE-COU Procedure Date of [**2162-5-3**] REPORT APPROVED DATE: [**2162-5-5**] DIAGNOSIS: Lymph node (precarinal), fine needle aspirate: Blood and mixed inflammatory cells. Note: Evidence of lymph node sampling is not identified. [**2162-5-5**] SPECIMEN RECEIVED: [**2162-5-3**] 08-[**Numeric Identifier **] MEDIASTINAL DIAGNOSIS: Mediastinal mass, fine needle aspirate: POSITIVE FOR MALIGNANT CELLS, consistent with squamous cell carcinoma. [**2162-5-5**] SPECIMEN RECEIVED: [**2162-5-3**] 08-[**Numeric Identifier **] BRONCHIAL WASHINGS CLINICAL DATA: BAL of left upper lobe. PREVIOUS BIOPSIES: [**2162-5-3**] 08-[**Numeric Identifier **] MEDIASTINAL DIAGNOSIS: Bronchial washing, left upper lobe: Necrotic debris and inflammatory cells. Brief Hospital Course: The patient was admitted [**2162-5-2**]. On HD 2, he had a flexible bronchoscopy was at the bedside in the intensive care unit through an endotracheal tube. There was near complete occlusion of the left main-stem bronchus with extrinsic compression was noted. The bronchoscope could not be advanced past this obstruction. Purulent sputum was seen emanating from the left main-stem bronchus. On the right, severe bronchomalacia was seen in the mainstem bronchus. A small amount of purulent secretions seen in the right upper lobe, bronchus intermedius, right middle and lower lobe segmental bronchi, were all suctioned clean. Vancomycin and Zosyn were started empirically for pneumonia. A BAL was sent. later on HD 2, she was taken to the OR for a rigid bronchoscopy. Please see operative note for full details. A biopsy of the occlusive airway lesion revealed a non small cell lung cancer. Her LMSB was balloon dilated to 12 mm. A 14 x 40 mm covered metal stent was placed. A CT scan was done which showed central left upper lobe Mass contiguous with a mediastinal lymph node conglomeration, most consistent with advanced lung cancer. There is direct contact and mild compression on the aortic arch, encasement and obstruction of the left pulmonary artery, and encasement of the left main stem bronchus with partially obstructing mass distally. Dominant central cavity in left lung is likely related to necrotizing post- obstructive pneumonia, but cavity component of neoplasm is also possible. Multifocal bilateral pneumonia. Multiple left-sided cavities are consistent with necrotizing pneumonia. Diffuse right peribronchial thickening may be due to either neoplastic infiltration or infection. Small bilateral pleural effusions and pericardial effusion. Cirrhosis and small amount of ascites. On HD 2, she was extubated successfully. A flexible bronchoscopy was done at the bedside- the stent was patent and secretions were aspirated. Saline nebs and Mucomyst nebs were started and Mucinex was started. On HD 3, she continued to be stable. A flexible bronch was again performed at the bedside for therapeutic aspiration of secretions. Overnight she had an episode of mania. Psych was consulted (see note)recommended continue Seroquel and Haldol prn for agitation. She was seen by radiation oncology who recommended starting XRT . She received the first of ten 300 cGy treatment today. She tolerated the treatment well but was mildly paranoid. The patient was stable and to [**Location (un) 21541**] Hospital. Medications on Admission: Meds at home: Buspar 15'', Seroquel 300' + 100QHS, Synthroid 0.113' Meds on transfer: Levaquin, Zosyn, Solumedrol 125, Midaz, Propofol, Lovenox Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 3. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Buspirone 10 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 7. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 8. Quetiapine 100 mg Tablet Sig: Three (3) Tablet PO QAM (once a day (in the morning)). 9. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 10. Lorazepam 2 mg/mL Syringe Sig: Two (2) mg Injection Q6H (every 6 hours) as needed for anxiety. 11. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: 2.5/3ml Inhalation Q4H (every 4 hours) as needed. 12. Ipratropium Bromide 0.02 % Solution Sig: 0.2 ml Inhalation Q6H (every 6 hours). 13. Mucinex 1,200 mg Tab, Multiphasic Release 12 hr Sig: One (1) Tab, Multiphasic Release 12 hr PO BID (2 times a day). 14. Piperacillin-Tazobactam 4.5 gram Recon Soln Sig: One (1) Intravenous every eight (8) hours. 15. Acetylcysteine 20 % (200 mg/mL) Solution Sig: Three (3) ML Miscellaneous TID (3 times a day). 16. Haloperidol 0.5 mg Tablet Sig: 0.5-1 Tablet PO TID (3 times a day) as needed for agitation. 17. Heparin Lock Flush (Porcine) 10 unit/mL Solution Sig: Five (5) ML Intravenous DAILY (Daily) as needed. Discharge Disposition: Extended Care Facility: Cape Code Hospital Discharge Diagnosis: Central airway obstruction s/p metal stent placement COPD - no record of PFT's, no h/o treatments for COPD in past Hypothyroidism Chronic anxiety disorder Bipolar disorder Osteoarthritis Avascular necrosis of right hip Anemia h/o ETOH dependence, sober x2 yrs Discharge Condition: Stable Discharge Instructions: Normal Saline nebs [**Hospital1 **] Mucomyst nebs tid Mucinex 1200 mg [**Hospital1 **] continue zosyn 6 weeks started [**2162-4-29**] TLC flushes Followup Instructions: Follow-up with Dr. [**Last Name (STitle) 7631**] [**Telephone/Fax (1) 77787**] Follow-up with Dr. [**Last Name (STitle) 61800**] [**Telephone/Fax (1) 61801**] Follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4467**] [**Telephone/Fax (1) 77788**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**] Completed by:[**2162-5-7**] Admission Date: [**2162-5-2**] Discharge Date: [**2162-5-6**] Date of Birth: [**2103-7-8**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 281**] Chief Complaint: Central airway obstruction Major Surgical or Invasive Procedure: [**5-5**] flexible bronchoscopy [**2162-5-4**] Flexible and rigid bronchoscopy, endobronchial biopsy, transbronchial needle aspiration of precarinal and subcarinal lymph nodes, balloon dilation and metal covered stent placement. [**2162-5-3**] Flexible bronchoscopy History of Present Illness: 58F with COPD, anxiety and bipolar, transferred from [**Hospital 1562**] Hospital with new diagnosis of large central lung mass causing respiratory distress that required emergent intubation. She was intially admitted to [**Hospital 1562**] Hospital 3 days ago with shortness of breath, cough, malaise x2 weeks s/p failing a trial of Avalox as an outpatient. CXR done in the OSH ER showed (by report only) a very large left mid and lower lobe infiltrate with air fluid level suggesting emypema. CT chest (report) showed complex, large [**Location (un) 21851**] in mediastinum obliterating L main PA, L main bronchus, and resulting in near complete opacification of mid-to-lower left lung. She was started on Zosyn and Levaquin for pneumonia, Solumedrol for COPD flare, and sedation for extreme anxiety. She then underwent bronchoscopy with FNA on [**4-30**], which showed>75% narrowing of left mainstem bronchus at its most proximal portion and then quickly leading into 100% obliteration secondary to extrinsic compression. FNA was done, which showed malignant cells, unclear whether nonsmall cell vs. small cell vs. potential mix of pathology. L vocal cord was also noted to be immobile, suggesting involvement of the left recurrent laryngeal nerve. On [**5-1**], she developed respiratory distress and became apneic, and had to be emergently intubated during a code blue. She was transfused 1U PRBC's and started on Fe for anemia. She was stabilized and sedated, and transferred here for further care by Interventional Pulmonology. Past Medical History: 1. h/o ETOH dependence, sober x2 yrs 2. COPD - no record of PFT's, no h/o treatments for COPD in past 3. Hypothyroidism 4. Chronic anxiety disorder 5. Bipolar disorder 6. Osteoarthritis 7. Avascular necrosis of right hip 8. Anemia Social History: Social history: >60 pack year smoking, currently smoking, h/o ETOH dependence, quit 2 yrs ago, currently not working - previously worked doing farm labor. Lives alone in [**Hospital1 1562**]. Family History: Family history: Mother died at 58 of lung CA, father died at 57 of sudden death. She was 2 healthy children. Physical Exam: VS: T 96.2 HR: 86-100 ST BP 138/80 Sats: 95% 4L NC General: appears in no apparent distress CV: RRR, normal S1,S2, no murmur/gallop or rub Pulm: Coarse rhonchi bilaterally Abd: soft, nondistended, normoactive bowel sounds Ext: no c/c/e Neuro: anxious, response appropiately, moves all extremities Pertinent Results: [**2162-5-5**] WBC-11.7* RBC-3.61* Hgb-9.7* Hct-30.6* Plt Ct-267 [**2162-5-2**] WBC-17.4* RBC-3.81* Hgb-10.1* Hct-32.7* Plt Ct-294 [**2162-5-5**] Glucose-134* UreaN-9 Creat-0.5 Na-146* K-3.7 Cl-106 HCO3-31 [**2162-5-2**] Glucose-134* UreaN-6 Creat-0.6 Na-145 K-4.5 Cl-110* HCO3-26 [**2162-5-5**] Calcium-9.6 Phos-3.6 Mg-2.1 [**2162-5-2**] Type-ART Temp-36.2 Rates-16/3 Tidal V-350 PEEP-5 FiO2-40 pO2-149* pCO2-51* pH-7.33* calTCO2-28 Base XS-0 -ASSIST/CON Intubat-INTUBATED [**2162-5-4**] Type-ART Rates-/20 PEEP-5 FiO2-40 pO2-99 pCO2-46* pH-7.44 calTCO2-32* Base XS-5 Intubat-INTUBATED Date/Time: [**2162-5-3**] BRONCHOALVEOLAR LAVAGE GRAM STAIN (Final [**2162-5-3**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Preliminary): NO GROWTH, <1000 CFU/ml. FUNGAL CULTURE (Pending): ACID FAST SMEAR (Final [**2162-5-4**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Pending): CT CHEST W/CONTRAST [**2162-5-3**] IMPRESSION: 1. Central left upper lobe mas contiguous with a mediastinal lymph node conglomeration, most consistent with advanced lung cancer. There is direct contact and mild compression on the aortic arch, encasement and obstruction of the left pulmonary artery, and encasement of the left main stem bronchus with partially obstructing mass distally. 2. Dominant central cavity in left lung is likely related to necrotizing post- obstructive pneumonia, but cavity component of neoplasm is also possible. 3. Multifocal bilateral pneumonia. Multiple left-sided cavities are consistent with necrotizing pneumonia. 4. Diffuse right peribronchial thickening may be due to either neoplastic infiltration or infection. 5. Small bilateral pleural effusions and pericardial effusion. 6. Cirrhosis and small amount of ascites. Brief Hospital Course: The patient was admitted [**2162-5-2**]. On HD 2, he had a flexible bronchoscopy was at the bedside in the intensive care unit through an endotracheal tube. There was near complete occlusion of the left main-stem bronchus with extrinsic compression was noted. The bronchoscope could not be advanced past this obstruction. Purulent sputum was seen emanating from the left main-stem bronchus. On the right, severe bronchomalacia was seen in the mainstem bronchus. A small amount of purulent secretions seen in the right upper lobe, bronchus intermedius, right middle and lower lobe segmental bronchi, were all suctioned clean. Vancomycin and Zosyn were started empirically for pneumonia. A BAL was sent. later on HD 2, she was taken to the OR for a rigid bronchoscopy. Please see operative note for full details. A biopsy of the occlusive airway lesion revealed a non small cell lung cancer. Her LMSB was balloon dilated to 12 mm. A 14 x 40 mm covered metal stent was placed. A CT scan was done which showed central left upper lobe Mass contiguous with a mediastinal lymph node conglomeration, most consistent with advanced lung cancer. There is direct contact and mild compression on the aortic arch, encasement and obstruction of the left pulmonary artery, and encasement of the left main stem bronchus with partially obstructing mass distally. Dominant central cavity in left lung is likely related to necrotizing post- obstructive pneumonia, but cavity component of neoplasm is also possible. Multifocal bilateral pneumonia. Multiple left-sided cavities are consistent with necrotizing pneumonia. Diffuse right peribronchial thickening may be due to either neoplastic infiltration or infection. Small bilateral pleural effusions and pericardial effusion. Cirrhosis and small amount of ascites. On HD 2, she was extubated successfully. A flexible bronchoscopy was done at the bedside- the stent was patent and secretions were aspirated. Saline nebs and Mucomyst nebs were started and Mucinex was started. On HD 3, she continued to be stable. A flexible bronch was again performed at the bedside for therapeutic aspiration of secretions. Overnight she had an episode of mania. Psych was consulted (see note)recommended continue Seroquel and Haldol prn for agitation. She was seen by radiation oncology who recommended starting XRT . She received the first of ten 300 cGy treatment today. She tolerated the treatment well but was mildly paranoid. The patient was stable and to [**Location (un) 21541**] Hospital. Medications on Admission: Meds at home: Buspar 15 mg [**Hospital1 **], Seroquel 300 mg qam & 100 mg qhs, Synthroid 0.113 mg daily Meds on transfer: Levaquin, Zosyn, Solumedrol 125 mg, Midaz, Propofol, Lovenox Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 3. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Buspirone 10 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 7. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 8. Quetiapine 100 mg Tablet Sig: Three (3) Tablet PO QAM (once a day (in the morning)). 9. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 10. Lorazepam 2 mg/mL Syringe Sig: Two (2) mg Injection Q6H (every 6 hours) as needed for anxiety. 11. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: 2.5/3ml Inhalation Q4H (every 4 hours) as needed. 12. Ipratropium Bromide 0.02 % Solution Sig: 0.2 ml Inhalation Q6H (every 6 hours). 13. Mucinex 1,200 mg Tab, Multiphasic Release 12 hr Sig: One (1) Tab, Multiphasic Release 12 hr PO BID (2 times a day). 14. Piperacillin-Tazobactam 4.5 gram Recon Soln Sig: One (1) Intravenous every eight (8) hours. 15. Acetylcysteine 20 % (200 mg/mL) Solution Sig: Three (3) ML Miscellaneous TID (3 times a day). 16. Haloperidol 0.5 mg Tablet Sig: 0.5-1 Tablet PO TID (3 times a day) as needed for agitation. 17. Heparin Lock Flush (Porcine) 10 unit/mL Solution Sig: Five (5) ML Intravenous DAILY (Daily) as needed. Discharge Disposition: Extended Care Facility: Cape Code Hospital Discharge Diagnosis: Central airway obstruction s/p metal stent placement COPD - no record of PFT's, no h/o treatments for COPD in past Hypothyroidism Chronic anxiety disorder Bipolar disorder Osteoarthritis Avascular necrosis of right hip Anemia h/o ETOH dependence, sober x2 yrs Discharge Condition: Stable Discharge Instructions: Normal Saline nebs [**Hospital1 **] Mucomyst nebs tid Mucinex 1200 mg [**Hospital1 **] continue zosyn 6 weeks started [**2162-4-29**] Right TLC cath flushes per protocol Followup Instructions: Follow-up with Dr. [**Last Name (STitle) 7631**] [**Telephone/Fax (1) 77787**] Follow-up with Dr. [**Last Name (STitle) 61800**] [**Telephone/Fax (1) 61801**] Follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4467**] [**Telephone/Fax (1) 77788**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**] Completed by:[**2162-5-12**]

162,513,196,296,496,244

{'Malignant neoplasm of upper lobe, bronchus or lung,Abscess of lung,Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes,Bipolar I disorder, most recent episode (or current) manic, unspecified,Chronic airway obstruction, not elsewhere classified,Unspecified acquired hypothyroidism'}

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: malignant central airway obstruction with necrotizing pneumonia PRESENT ILLNESS: 58F with COPD, anxiety and bipolar, transferred from [**Hospital 1562**] Hospital with new diagnosis of large central lung mass causing respiratory distress that required emergent intubation. She was intially admitted to [**Hospital 1562**] Hospital 3 days ago with shortness of breath, cough, malaise x2 weeks s/p failing a trial of Avalox as an outpatient. CXR done in the OSH ER showed (by report only) a very large left mid and lower lobe infiltrate with air fluid level suggesting emypema. CT chest (report) showed complex, large [**Location (un) 21851**] in mediastinum obliterating L main PA, L main bronchus, and resulting in near complete opacification of mid-to-lower left lung. She was started on Zosyn and Levaquin for pneumonia, Solumedrol for COPD flare, and sedation for extreme anxiety. MEDICAL HISTORY: PMH: 1. h/o ETOH dependence, sober x2 yrs 2. COPD - no record of PFT's, no h/o treatments for COPD in past 3. Hypothyroidism 4. Chronic anxiety disorder 5. Bipolar disorder 6. Osteoarthritis 7. Avascular necrosis of right hip 8. Anemia MEDICATION ON ADMISSION: Meds at home: Buspar 15'', Seroquel 300' + 100QHS, Synthroid 0.113' Meds on transfer: Levaquin, Zosyn, Solumedrol 125, Midaz, Propofol, Lovenox ALLERGIES: Penicillins PHYSICAL EXAM: VS: T 96.2 HR: 86-100 ST BP 138/80 Sats: 95% 4L NC General: appears in no apparent distress CV: RRR, normal S1,S2, no murmur/gallop or rub Pulm: Coarse rhonchi bilaterally Abd: soft, nondistended, normoactive bowel sounds Ext: no c/c/e Neuro: anxious, response appropiately, moves all extremities FAMILY HISTORY: Mother died at 58 of lung CA, father died at 57 of sudden death. She was 2 healthy children. SOCIAL HISTORY: Social history: >60 pack year smoking, currently smoking, h/o ETOH dependence, quit 2 yrs ago, currently not working - previously worked doing farm labor. Lives alone in [**Hospital1 1562**] ### Response: {'Malignant neoplasm of upper lobe, bronchus or lung,Abscess of lung,Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes,Bipolar I disorder, most recent episode (or current) manic, unspecified,Chronic airway obstruction, not elsewhere classified,Unspecified acquired hypothyroidism'}

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is a 68-year-old male who was first diagnosed with male diagnosed breast cancer in [**2190-5-19**]. During his course of the evaluation, he underwent a chest and abdominal CT that was performed on [**2190-7-2**], which demonstrated a left breast mass measuring 2.1 x 1.7 cm. Also work-up included a CT of the abdomen demonstrating a metastatic tumor. The CT of the abdomen demonstrated a 2.8 x 3.7 cm lesion in the segment VI of the liver, and a 3.9 x 4.1 cm mass in the midpole of the right kidney. MEDICAL HISTORY: Significant for hemachromatosis in [**2181**]. Intermittently has phlebotomy. Type 2 diabetes diagnosed in [**2181**]. History of TIA in [**2179**] and takes aspirin daily. History of a ruptured diverticular disease. History of mild COPD. Hypertension. Status post motor vehicle accident in [**2144**]. MEDICATION ON ADMISSION: ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: Significant for a sister with hemachromatosis. His mother died of neck cancer. Father died of lung cancer. SOCIAL HISTORY: The patient is married and lives with wife. [**Name (NI) **] has three adult children. He is a retired auto mechanic. He is on a diabetic diet. Occasional alcohol. History of tobacco; he smoked 2 packs per day for 50 years but quit in [**2180**]. Occasional cigar. No history of IV drug use, tattoos or piercing. The patient did have a blood transfusion 40 years ago.

Malignant neoplasm of liver, not specified as primary or secondary,Malignant neoplasm of kidney, except pelvis,Chronic airway obstruction, not elsewhere classified,Congestive heart failure, unspecified,Urinary tract infection, site not specified,Pneumonia, organism unspecified,Other and unspecified coagulation defects,Diabetes with unspecified complication, type II or unspecified type, uncontrolled,Malignant neoplasm of other and unspecified sites of male breast,Incisional hernia without mention of obstruction or gangrene,Peritoneal adhesions (postoperative) (postinfection),Unspecified essential hypertension,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction

Malignant neo liver NOS,Malig neopl kidney,Chr airway obstruct NEC,CHF NOS,Urin tract infection NOS,Pneumonia, organism NOS,Coagulat defect NEC/NOS,DMII unspf uncntrld,Mal neo male breast NEC,Incisional hernia,Peritoneal adhesions,Hypertension NOS,Cholelithiasis NOS

Admission Date: [**2190-9-24**] Discharge Date: [**2190-10-5**] Date of Birth: [**2122-1-2**] Sex: M Service: Hepatobiliary Surgery Service ADMISSION DIAGNOSIS: 1. Hepatocellular carcinoma. 2. Renal cell carcinoma. HISTORY OF PRESENT ILLNESS: The patient is a 68-year-old male who was first diagnosed with male diagnosed breast cancer in [**2190-5-19**]. During his course of the evaluation, he underwent a chest and abdominal CT that was performed on [**2190-7-2**], which demonstrated a left breast mass measuring 2.1 x 1.7 cm. Also work-up included a CT of the abdomen demonstrating a metastatic tumor. The CT of the abdomen demonstrated a 2.8 x 3.7 cm lesion in the segment VI of the liver, and a 3.9 x 4.1 cm mass in the midpole of the right kidney. On [**2190-7-13**], a PET scan was performed demonstrating a left breast FDG avid mass, and an anterior midpole right renal mass that is FDG avid, and a large non-FDG avid mediastinal lymph node. Biopsy was performed of the right renal mass on [**2190-8-10**], demonstrating no evidence of malignancy, but a fine- needle aspirate was positive for renal cell carcinoma. On [**2190-9-3**], a core liver biopsy of the liver mass was performed demonstrating moderately to poorly differentiated hepatocellular carcinoma. Follow-up MRI was performed on [**2190-9-1**], demonstrating a 3.3 x 2.5 cm lesion, segment V and VI, of the liver, and 3.5 x 4.0 cm lesion in the right kidney. Part of the work-up included head CT on [**2190-9-1**], which was negative for metastatic disease. The patient was referred to Dr. [**Last Name (STitle) **] for a possible hepatic resection. PAST MEDICAL HISTORY: Significant for hemachromatosis in [**2181**]. Intermittently has phlebotomy. Type 2 diabetes diagnosed in [**2181**]. History of TIA in [**2179**] and takes aspirin daily. History of a ruptured diverticular disease. History of mild COPD. Hypertension. Status post motor vehicle accident in [**2144**]. PAST SURGICAL HISTORY: In [**2182**] the patient underwent nasal/sinus surgery. In the [**2164**], the patient is status post colon resection for ruptured diverticulitis. On [**2190-8-24**], the patient had a mediastinoscopy and a bronchoscopy. ALLERGIES: No known drug allergies. CURRENT MEDICATIONS: Glucophage, Zestril 20 mg daily, Glyburide 5 mg q.h.s. and 10 mg q.a.m., Arimidex 1 mg daily, Avandia 8 mg daily. SOCIAL HISTORY: The patient is married and lives with wife. [**Name (NI) **] has three adult children. He is a retired auto mechanic. He is on a diabetic diet. Occasional alcohol. History of tobacco; he smoked 2 packs per day for 50 years but quit in [**2180**]. Occasional cigar. No history of IV drug use, tattoos or piercing. The patient did have a blood transfusion 40 years ago. FAMILY HISTORY: Significant for a sister with hemachromatosis. His mother died of neck cancer. Father died of lung cancer. PHYSICAL EXAMINATION: Vital signs: Blood pressure 142/78, pulse 88, respirations 28, temperature 97, height 6 ft 0 in, weight 192.6 lb. General: He is a well-developed, well- nourished male in no acute distress. Skin: Normal except for actinic changes in upper extremities and face. HEENT: No scleral icterus. Oropharynx clear. Neck: No lymphadenopathy or thyromegaly. Carotids 2+ out of 4 without bruits. Lungs: Clear to auscultation. Cardiac: Normal S1 and S2 without murmurs or rubs. Regular rate and rhythm. Abdomen: Positive bowel sounds. Well-healed lower, midline and right transverse abdominal incision. Small hernia in the upper third of the midline incision. No hepatosplenomegaly masses or tenderness. No peripheral edema. Neurologic: Grossly intact. LABORATORY DATA: Prior to admission, WBC 11.3, hematocrit 49.0, platelets 366; INR 1.2; sodium 142, 4.7, 105, 23, BUN and creatinine 23 and 1.4; AST 22, ALT 14, alkaline phosphatase 82, total bilirubin 0.3, albumin 4.1. In [**2190-6-18**], his AST was 4.2, and CEA was 5.5. The patient was admitted on [**2190-9-24**], for a right hepatic lobectomy, cholecystectomy, radical right nephrectomy, with intraoperative ultrasound, and two incisional hernia repairs, and lysis of adhesions performed by Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) 3826**]. Please see detailed information regarding surgery in the operative note. Postoperatively the patient went to the SICU. The patient had a right IJ placed. CVPs ranged from [**7-28**]. The patient was on an epidural infusion of Demerol. The patient was extubated on a shovel mask. NG tube was in place. The patient was placed on Unasyn 3 g every q.6 hours. Postoperatively the patient had a WBC of 15.8, hematocrit 40.1, platelets 191, PT 16.4, PTT 35.2, INR 1.9. The patient had a sodium of 146, 4.6, 117, 20, BUN 29 and 2.1. ALT 96, AST 135, alkaline phosphatase 67, 0.9. The patient had a postoperative chest x-ray demonstrating mild congestive heart failure which has improved, small bilateral pleural effusion, no evidence of pneumothorax identified. The patient was given FFP for an INR of 1.9. The patient continued with the epidural for pain control. NG was removed. The patient continued with FFP to correct his INR. Diet was slowly advanced. The patient was getting serial coags to keep INR less than 2.5. Repeat chest x-ray [**9-26**] revealed worsening bilateral pleural effusion and bilateral bibasilar atelectasis. The patient received 40 of Lasix, and IV maintenance was decreased. The Swan-Ganz catheter was removed. Unasyn was discontinued. On [**2190-9-28**], hospital day 5, postoperative day 4, the patient was tolerating clears and was transferred from the ICU. The patient continued with the JP draining clear serosanguineous fluid. Physical therapy was consulted. The central line was removed, and a peripheral line was placed. The epidural catheter was removed. The patient was placed on p.o. pain medications which he tolerated well. Because the patient was gaining weight and his lower extremities had edema, the patient was started on Lasix 20 mg IV t.i.d. which he responded well. The patient's blood sugars were intermittently elevated. He was on an insulin sliding scale, and [**Last Name (un) **] was consulted to recommend the best insulin medication since preoperatively he was on Avandia and Glyburide which are both cytotoxic. The patient was ambulating with a walker without shortness of breath or distress. The results of the pathology came back from his surgery demonstrated: 1. Gallbladder demonstrated cholelithiasis, cholesterol type. 2. Portal lymph node; 1 lymph node with sinus histiocytosis and lipophagic granulomas. No malignancy identified. 3. Liver, right lobe, resection (S-N) hepatocellular carcinoma and also non-carcinomatous liver tissue with a 1) trichome stain: Mild periportal fibrosis, 2) iron stain: No stainable iron, 3) reticulin stain: Condensation of reticulin fibers in periportal areas. 4. Right kidney resection demonstrated renal cell carcinoma. The patient had a few drains. One of the drains was removed on [**2190-10-2**]. LFTs were obtained demonstrating an ALT of 30, AST 33, alkaline phosphatase 167, total bilirubin 3.7, which both alkaline phosphatase and total bilirubin had increased from the day before. A liver duplex was obtained on [**2190-10-2**], demonstrating status post right hepatic lobectomy with patent vasculature and no large fluid collections identified. Also a CT of the abdomen and pelvis was obtained on [**2190-10-2**], demonstrated 1) no intrahepatic bile duct dilatation or perihepatic fluid collections, 2) no intraperitoneal or intrapelvic abscess, and 3) basilar lung changes with small effusions, emphysematous changes and areas of consolidations. An infectious process cannot be excluded in the lung bases based on these images. Because the patient's WBC had elevated, blood cultures, peritoneal fluid, urine cultures and sputum culture was obtained. From [**10-2**], two sets of blood cultures were obtained which are still pending. The peritoneal fluid that was obtained demonstrated no growth. Anaerobic culture demonstrated no growth. Gram-stain showed no microorganisms. Urine culture was obtained on [**2190-10-3**], demonstrating Morganella morganii. The patient was placed on Levaquin, which this is sensitive to. Physical therapy had been following the patient while he was on the floor and felt that the patient would be able to go home. [**Last Name (un) **] had closely monitored the patient's blood sugars. He continued to be afebrile with vital signs stable. On [**2190-10-3**], the patient complaining of some shortness of breath. The patient does have underlying emphysema. Another chest x-ray was obtained demonstrating improving pneumonia in both lower lobes, continued mild congestive heart failure with cardiomegaly superimposed on underlying emphysema. On [**2190-10-5**], the patient continued to be afebrile with vital signs stable. The second JP was removed making good urine output. WBC was 17.6 from 21.5 on [**2190-10-4**]. The patient had a hematocrit of 34.6 on [**2190-10-5**], with platelets of 248, sodium was 139, 4.2, 105, 24, BUN and creatinine of 59 and 2.6, glucose 108, ALT 31, AST 53, alkaline phosphatase 249, total bilirubin 4.1. The patient is tolerating a diet and urinating well. Wound is clean, dry and intact. Abdomen is soft and nontender. The patient can be monitored for blood sugar over night. He should be ready to go home with services tomorrow, which would be [**2190-10-6**]. [**Last Name (un) **] will be seeing him tomorrow to decide whether or not the patient needs to go home on a sliding scale or to be given doses of regular insulin. DISCHARGE MEDICATIONS: Anastrozole 1 mg daily, Percocet [**12-20**] p.o. q.4-6 hours p.r.n., Glipizide 10 mg p.o. b.i.d., levofloxacin 250 daily for 8 days. The patient will be going home on an insulin sliding scale, but there is a question of whether or not the patient will be going home on a fixed dose. FOLLOW UP: The patient will follow up with the transplant team next week. Please call [**Telephone/Fax (1) 673**] for an appointment. The patient needs to call the Chestnut Team immediately at the same number, [**Telephone/Fax (1) 673**], for any fevers, chills, nausea, vomiting, inability to eat or drink, any shortness of breath, chest pain, any changes in incision, any redness, discharge from the incision or swelling from the incision too. The patient should call Chestnut Surgery immediately if there is any swelling in the lower extremities, any increase in abdominal girth. FINAL DIAGNOSIS: 1. Hepatocellular carcinoma. 2. Renal cell carcinoma. SECONDARY DIAGNOSIS: 1. Pneumonia with history of emphysema. 2. Urinary tract infection. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD, PhD [**Numeric Identifier 8353**] Dictated By:[**Last Name (NamePattern1) 4835**] MEDQUIST36 D: [**2190-10-5**] 17:48:06 T: [**2190-10-5**] 19:16:31 Job#: [**Job Number 20824**] Name: [**Known lastname 3471**],[**Known firstname **] Unit No: [**Numeric Identifier 3472**] Admission Date: [**2190-9-24**] Discharge Date: [**2190-10-9**] Date of Birth: [**2122-1-2**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 48**] Addendum: The patient remained in the hospital until [**10-9**]. He had ongoing dyspnea and some mild confusion and he remained in the hospital until [**10-9**] for more diuresis and for nutritional and physical optimization. He had been taking percocet for pain and this was discontinued with a near resolution of his complaint of not being mentally alert. He had a V/Q scan to rule-out a pleural embolus which was negative. He was given more lasix resulting in a decrease of his edema, weight, and dyspnea. Aldactone 100mg daily was started and he will be maintained on this as an outpatient to continue diuresis. He continued to work with physical therapy and nutrition was consulted to a poor appetite. His glypizide was discontinued as he had slightly rising LFTs and we wanted to ensure that he wasn't having hepatotoxicity from this medication. He was doing well, tolerating a regular diet, ambulating, with good pain control, and decreased dyspnea. He was discharged to home with his supportive family on [**2190-10-9**]. He will have labs drawn on Monday and then he will follow up in the next week with Dr. [**Last Name (STitle) **]. Major Surgical or Invasive Procedure: on [**2190-9-24**]-1. Right hepatic lobectomy, cholecystectomy, radical right nephrectomy, intraoperative ultrasound. 2. Incisional hernia repair and lysis of adhesions. Discharge Disposition: Home With Service Facility: [**Hospital 197**] [**Name (NI) 198**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 51**] MD, [**MD Number(3) 52**] Completed by:[**2190-10-9**]

155,189,496,428,599,486,286,250,175,553,568,401,574

{'Malignant neoplasm of liver, not specified as primary or secondary,Malignant neoplasm of kidney, except pelvis,Chronic airway obstruction, not elsewhere classified,Congestive heart failure, unspecified,Urinary tract infection, site not specified,Pneumonia, organism unspecified,Other and unspecified coagulation defects,Diabetes with unspecified complication, type II or unspecified type, uncontrolled,Malignant neoplasm of other and unspecified sites of male breast,Incisional hernia without mention of obstruction or gangrene,Peritoneal adhesions (postoperative) (postinfection),Unspecified essential hypertension,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction'}

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 68-year-old male who was first diagnosed with male diagnosed breast cancer in [**2190-5-19**]. During his course of the evaluation, he underwent a chest and abdominal CT that was performed on [**2190-7-2**], which demonstrated a left breast mass measuring 2.1 x 1.7 cm. Also work-up included a CT of the abdomen demonstrating a metastatic tumor. The CT of the abdomen demonstrated a 2.8 x 3.7 cm lesion in the segment VI of the liver, and a 3.9 x 4.1 cm mass in the midpole of the right kidney. MEDICAL HISTORY: Significant for hemachromatosis in [**2181**]. Intermittently has phlebotomy. Type 2 diabetes diagnosed in [**2181**]. History of TIA in [**2179**] and takes aspirin daily. History of a ruptured diverticular disease. History of mild COPD. Hypertension. Status post motor vehicle accident in [**2144**]. MEDICATION ON ADMISSION: ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: Significant for a sister with hemachromatosis. His mother died of neck cancer. Father died of lung cancer. SOCIAL HISTORY: The patient is married and lives with wife. [**Name (NI) **] has three adult children. He is a retired auto mechanic. He is on a diabetic diet. Occasional alcohol. History of tobacco; he smoked 2 packs per day for 50 years but quit in [**2180**]. Occasional cigar. No history of IV drug use, tattoos or piercing. The patient did have a blood transfusion 40 years ago. ### Response: {'Malignant neoplasm of liver, not specified as primary or secondary,Malignant neoplasm of kidney, except pelvis,Chronic airway obstruction, not elsewhere classified,Congestive heart failure, unspecified,Urinary tract infection, site not specified,Pneumonia, organism unspecified,Other and unspecified coagulation defects,Diabetes with unspecified complication, type II or unspecified type, uncontrolled,Malignant neoplasm of other and unspecified sites of male breast,Incisional hernia without mention of obstruction or gangrene,Peritoneal adhesions (postoperative) (postinfection),Unspecified essential hypertension,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction'}

CHIEF COMPLAINT: agitation PRESENT ILLNESS: 43 yo male brought in to ED after arrest for [**Name (NI) **] (pt was reportedly preparing to drive, police observed his behvaior and became concenced, pt refused breathalizer and was arrested) and reportedly found to be carrying a knife. At the time of arrest he had endorsed methamphetamine and cocaine use. While in police custody, the pt was noted to be beating his head against the wall of his cell to attract attention. Reportedly no LOC; the pt endorsed HA but denied neck, chest, abd and back pain on arrival to ED. MEDICAL HISTORY: h/o self injurious behavior MVA in [**2106**], occured while intoxicated, thrown from car mugging with question head injury in [**2113**] Hep C probable ADD herniated L4/L5 discs s/p SDH evacuation in [**2113**] genital herpes depression MEDICATION ON ADMISSION: Valium 10 mg TID PRN acyclovir 400mg PRN herpes outbreaks Concerta 54 mg extended release daily Albuterol 2 puffs q6 PRN Fluoxetin 40mg daily MS [**Last Name (Titles) 1367**] 30mg PO bid oxycodone 5 mg q6 PRN trazaone 50-100 qhs PRN Viagra ALLERGIES: No Drug Allergy Information on File PHYSICAL EXAM: Gen: Well appearing adult male, no acute distress. HEENT: PERRL, EOMI. MMM. Conjunctiva well pigmented. Neck: Supple, without adenopathy or JVD. No tenderness with palpation. Chest: CTAB anterior and posterior. Cor: Normal S1, S2. RRR. No murmurs appreciated. Abdomen: Soft, non-tender and non-distended. +BS, no HSM. Extremity: Warm, without edema. 2+ DP pulses bilat. Neuro: Alert and oriented. CN 2-12 intact. Motor strength intact in all extremities. Sensation intact grossly. FAMILY HISTORY: Reportedly no FH of psychiatric disease. SOCIAL HISTORY: Known drug abuse.

Alcohol abuse, unspecified,Displacement of lumbar intervertebral disc without myelopathy,Attention deficit disorder without mention of hyperactivity,Depressive disorder, not elsewhere classified,Hepatitis C carrier

Alcohol abuse-unspec,Lumbar disc displacement,Attn defic nonhyperact,Depressive disorder NEC,Hepatitis C carrier

Admission Date: [**2119-10-5**] Discharge Date: [**2119-10-5**] Date of Birth: [**2075-12-21**] Sex: M Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 2817**] Chief Complaint: agitation Major Surgical or Invasive Procedure: none History of Present Illness: 43 yo male brought in to ED after arrest for [**Name (NI) **] (pt was reportedly preparing to drive, police observed his behvaior and became concenced, pt refused breathalizer and was arrested) and reportedly found to be carrying a knife. At the time of arrest he had endorsed methamphetamine and cocaine use. While in police custody, the pt was noted to be beating his head against the wall of his cell to attract attention. Reportedly no LOC; the pt endorsed HA but denied neck, chest, abd and back pain on arrival to ED. In the ED, initial vitals were 98.2, 75, 16, 124/73 and 98% RA. The pt was noted to be persistently agitated despite receiving multiple rounds of Haldol and Ativan, then 10mg IV valium. As his agitation could not be controlled, he was electively intubated so that an urgent head CT could be performed. ROS: Could not be obtained as pt is intubated and sedated. Past Medical History: h/o self injurious behavior MVA in [**2106**], occured while intoxicated, thrown from car mugging with question head injury in [**2113**] Hep C probable ADD herniated L4/L5 discs s/p SDH evacuation in [**2113**] genital herpes depression Social History: Known drug abuse. Family History: Reportedly no FH of psychiatric disease. Physical Exam: Gen: Well appearing adult male, no acute distress. HEENT: PERRL, EOMI. MMM. Conjunctiva well pigmented. Neck: Supple, without adenopathy or JVD. No tenderness with palpation. Chest: CTAB anterior and posterior. Cor: Normal S1, S2. RRR. No murmurs appreciated. Abdomen: Soft, non-tender and non-distended. +BS, no HSM. Extremity: Warm, without edema. 2+ DP pulses bilat. Neuro: Alert and oriented. CN 2-12 intact. Motor strength intact in all extremities. Sensation intact grossly. Pertinent Results: WBC-12.8* RBC-4.99 HGB-13.9* HCT-41.3 MCV-83 MCH-27.9 MCHC-33.7 RDW-14.6 NEUTS-73.4* LYMPHS-21.1 MONOS-4.0 EOS-1.2 BASOS-0.3 ASA-NEG ETHANOL-88* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG GLUCOSE-104 UREA N-7 CREAT-0.7 SODIUM-138 POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-25 ANION GAP-16 . ECG: SR at 80. Normal axis and intervals. Peaked p waves c/w with possible RAA. Poor baseline but no significant ST-T changes. Comparison made with tracing from [**1-21**]; no significant changes noted. . CXR: No acute cardiopulmonary process. ET tube ~9cm from carina. . Head CT: No acute intracranial abnormalities. Mucosal thickening of the paranasal sinuses. Brief Hospital Course: 43 yo male with h/o ADD, probable past TBI, substance abuse admitted for agitation in setting of acute methamphetamine and cocaine intoxication. . #Acute intoxication: Pt with urine tox positive for cocaine, serum tox positive for EtOH and admission of recent methamphetamine use. At admission, there was a concern for possible self-inflicted head trauma while in police custody. The pt was intubated in the ED so that adequet sedation for a head CT could be achieved. This was performed and was negative for acute findings. The pt was admitted to the ICU for monitoring and was quickly extubated. He awoke shortly thereafter and reported feeling well without any specific complaints. He denied trying to harm himself at any point in the days prior to admission. After several hours of monitoring without further findings, the pt was discharged to the custody of the police. Medications on Admission: Valium 10 mg TID PRN acyclovir 400mg PRN herpes outbreaks Concerta 54 mg extended release daily Albuterol 2 puffs q6 PRN Fluoxetin 40mg daily MS [**Last Name (Titles) 1367**] 30mg PO bid oxycodone 5 mg q6 PRN trazaone 50-100 qhs PRN Viagra Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheezing, SOB. 2. Fluoxetine 40 mg Capsule Sig: One (1) Capsule PO once a day. 3. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 4. Valium 10 mg Tablet Sig: One (1) Tablet PO three times a day as needed for anxiety. 5. CONCERTA 54 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO once a day. Discharge Disposition: Home with Service Discharge Diagnosis: polysubstance intoxication Discharge Condition: Improved; vitals stable, ambulating well, mental status cleared. Discharge Instructions: -You were admitted after being intoxicated with multiple substances and intentionally hitting your head while in police custody. We evaluated you and do not believe you have sustained any injuries. While in the hospital, a breathing tube was placed in your throat so you could be sedated for a scan of your head. This tube has now been removed and you are breathing well on your own. The toxic substances you ingested appear to have cleared from your body. You are now being discharged to the custody of the police. -It is important that you continue to take your medications as directed. No changes were made to your medications on this admission. -Contact your doctor or come to the Emergency Room should your symptoms return. Also seek medical attention if you develop any new fever, chills, trouble breathing, chest pain, nausea, vomiting or unusual stools. Followup Instructions: Please contact your PCP for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 702**] appointment within the next six weeks.

305,722,314,311,V026

{'Alcohol abuse, unspecified,Displacement of lumbar intervertebral disc without myelopathy,Attention deficit disorder without mention of hyperactivity,Depressive disorder, not elsewhere classified,Hepatitis C carrier'}

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: agitation PRESENT ILLNESS: 43 yo male brought in to ED after arrest for [**Name (NI) **] (pt was reportedly preparing to drive, police observed his behvaior and became concenced, pt refused breathalizer and was arrested) and reportedly found to be carrying a knife. At the time of arrest he had endorsed methamphetamine and cocaine use. While in police custody, the pt was noted to be beating his head against the wall of his cell to attract attention. Reportedly no LOC; the pt endorsed HA but denied neck, chest, abd and back pain on arrival to ED. MEDICAL HISTORY: h/o self injurious behavior MVA in [**2106**], occured while intoxicated, thrown from car mugging with question head injury in [**2113**] Hep C probable ADD herniated L4/L5 discs s/p SDH evacuation in [**2113**] genital herpes depression MEDICATION ON ADMISSION: Valium 10 mg TID PRN acyclovir 400mg PRN herpes outbreaks Concerta 54 mg extended release daily Albuterol 2 puffs q6 PRN Fluoxetin 40mg daily MS [**Last Name (Titles) 1367**] 30mg PO bid oxycodone 5 mg q6 PRN trazaone 50-100 qhs PRN Viagra ALLERGIES: No Drug Allergy Information on File PHYSICAL EXAM: Gen: Well appearing adult male, no acute distress. HEENT: PERRL, EOMI. MMM. Conjunctiva well pigmented. Neck: Supple, without adenopathy or JVD. No tenderness with palpation. Chest: CTAB anterior and posterior. Cor: Normal S1, S2. RRR. No murmurs appreciated. Abdomen: Soft, non-tender and non-distended. +BS, no HSM. Extremity: Warm, without edema. 2+ DP pulses bilat. Neuro: Alert and oriented. CN 2-12 intact. Motor strength intact in all extremities. Sensation intact grossly. FAMILY HISTORY: Reportedly no FH of psychiatric disease. SOCIAL HISTORY: Known drug abuse. ### Response: {'Alcohol abuse, unspecified,Displacement of lumbar intervertebral disc without myelopathy,Attention deficit disorder without mention of hyperactivity,Depressive disorder, not elsewhere classified,Hepatitis C carrier'}

CHIEF COMPLAINT: Chest Pain PRESENT ILLNESS: 71 y/o female with known coronary artery disease s/p myocardial infarction in [**2132**] with PCI to RCA in [**2140**]. Since then she has been doing well, but since [**4-6**] after a viral illness she has developed chest pain and dyspnea on exertion. Recent stress test was positive and therefor underwent a cardiac cath. Cath showed severe three vessel coronary artery disease and she was transferred from [**Hospital1 **] to [**Hospital1 18**] for surgical intervention. MEDICAL HISTORY: Coronary Artery Disease s/p Myocardial Infarction [**2132**], PCI of RCA [**2140**], Hypertension, Hypercholesterolemia, Hypothyroidism, Gastroesophageal Reflux Disease, s/p Hysterectomy, s/p Bladder suspension, s/p Cholecystectomy, s/p Cochlear implant MEDICATION ON ADMISSION: Aspirin 81mg qd, Synthroid .112mcg qd, Omeprazole 20mg qam, Crestor 20mg qd, Folic acid qd, MVI qd, Nadolol 20mg qd ALLERGIES: Codeine / Morphine Sulfate PHYSICAL EXAM: Gen: WDWN elderly female in NAD, lying supione in bed. Skin: W/D intact HEENT: EOMI, PERRL, NCAT Neck: Supple, FROM -JVD, -Carotid bruit Chest: CTAB -w/r/r Heart: RRR -c/r/m/g Abd: Soft, NT/ND, +BS Ext: Warm, well-perfused, -edema, superficial varicosities bilat. Neuro: A&O x 3, MAE, non-focal FAMILY HISTORY: +Multiple brothers with MI in 40-50's. SOCIAL HISTORY: Quit smoking in [**2132**] after 1ppd x 36yrs. Rare ETOH use.

Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Pure hypercholesterolemia,Esophageal reflux,Unspecified acquired hypothyroidism,Other and unspecified angina pectoris,Old myocardial infarction,Percutaneous transluminal coronary angioplasty status,Personal history of tobacco use

Crnry athrscl natve vssl,Hypertension NOS,Pure hypercholesterolem,Esophageal reflux,Hypothyroidism NOS,Angina pectoris NEC/NOS,Old myocardial infarct,Status-post ptca,History of tobacco use

Admission Date: [**2154-5-14**] Discharge Date: [**2154-5-20**] Date of Birth: [**2082-8-27**] Sex: F Service: CARDIOTHORACIC Allergies: Codeine / Morphine Sulfate Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: [**2154-5-15**] Coronary Artery Bypass Graft x 3 (LIMA to Diag, SVG to OM, SVG to PDA) History of Present Illness: 71 y/o female with known coronary artery disease s/p myocardial infarction in [**2132**] with PCI to RCA in [**2140**]. Since then she has been doing well, but since [**4-6**] after a viral illness she has developed chest pain and dyspnea on exertion. Recent stress test was positive and therefor underwent a cardiac cath. Cath showed severe three vessel coronary artery disease and she was transferred from [**Hospital1 **] to [**Hospital1 18**] for surgical intervention. Past Medical History: Coronary Artery Disease s/p Myocardial Infarction [**2132**], PCI of RCA [**2140**], Hypertension, Hypercholesterolemia, Hypothyroidism, Gastroesophageal Reflux Disease, s/p Hysterectomy, s/p Bladder suspension, s/p Cholecystectomy, s/p Cochlear implant Social History: Quit smoking in [**2132**] after 1ppd x 36yrs. Rare ETOH use. Family History: +Multiple brothers with MI in 40-50's. Physical Exam: Gen: WDWN elderly female in NAD, lying supione in bed. Skin: W/D intact HEENT: EOMI, PERRL, NCAT Neck: Supple, FROM -JVD, -Carotid bruit Chest: CTAB -w/r/r Heart: RRR -c/r/m/g Abd: Soft, NT/ND, +BS Ext: Warm, well-perfused, -edema, superficial varicosities bilat. Neuro: A&O x 3, MAE, non-focal Pertinent Results: CHEST (PA & LAT) [**2154-5-20**] 10:14 AM CHEST (PA & LAT) Reason: pna / effussions / pmneumo [**Hospital 93**] MEDICAL CONDITION: 71 year old woman with s/p cabg REASON FOR THIS EXAMINATION: pna / effussions / pmneumo HISTORY: Pneumonia. PA and lateral radiographs of the chest demonstrate interval removal of the right internal jugular central venous catheter seen on [**2154-5-18**]. No pneumothorax. The appearance of the heart and lungs is unchanged. There are persistent bilateral small pleural effusions. Trachea is midline. Patient is again noted to be status post CABG. [**2154-5-20**] 08:10AM BLOOD WBC-9.7 RBC-3.08* Hgb-9.8* Hct-28.4* MCV-92 MCH-31.9 MCHC-34.6 RDW-13.2 Plt Ct-177 [**2154-5-15**] 04:48PM BLOOD PT-13.9* PTT-30.9 INR(PT)-1.2* [**2154-5-20**] 08:10AM BLOOD Glucose-121* UreaN-9 Creat-0.6 Na-144 K-4.4 Cl-107 HCO3-31 AnGap-10 [**2154-5-14**] 12:50PM BLOOD ALT-14 AST-20 LD(LDH)-141 CK(CPK)-44 AlkPhos-76 Amylase-44 TotBili-0.6 Brief Hospital Course: As mentioned in the HPI, Mrs. [**Known lastname 77891**] was transferred from [**Hospital1 **] to [**Hospital1 18**] for surgery. Upon admission she underwent usual pre-operative work-up. On [**5-15**] she was brought to the operating room where she underwent a coronary artery bypass graft x 3. Please see operative report for surgical details. Following surgery she was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours she was weaned from sedation, awoke neurologically intact and extubated. On post-op day one she was restarted on pre-op medications along with beta blockers and diuretics. She was gently diuresed towards he pre-op weight. Later on this day she was transferred to the telemetry floor for further care. Her chest tubes were removed on post-op day two. Epicardial pacing wires were removed on post-op day three. She continued to recover well while working with physical therapy for strength and mobility. On post-op day 5 she was discharged to rehab with the appropriate medications and follow-up appointments. Medications on Admission: Aspirin 81mg qd, Synthroid .112mcg qd, Omeprazole 20mg qam, Crestor 20mg qd, Folic acid qd, MVI qd, Nadolol 20mg qd Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 3. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). Disp:*30 tablets* Refills:*0* 7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 8. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 9. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital **] Hospice and VNA Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3 PMH: Myocardial Infarction [**2132**], PCI of RCA [**2140**], Hypertension, Hypercholesterolemia, Hypothyroidism, Gastroesophageal Reflux Disease, s/p Hysterectomy, s/p Bladder suspension, s/p Cholecystectomy, s/p Cochlear implant Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Dr. [**Last Name (STitle) **] in 4 weeks Dr. [**Last Name (STitle) 27117**] in [**3-3**] weeks Dr. [**Last Name (STitle) **] in [**1-30**] weeks Completed by:[**2154-5-21**]

414,401,272,530,244,413,412,V458,V158

{'Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Pure hypercholesterolemia,Esophageal reflux,Unspecified acquired hypothyroidism,Other and unspecified angina pectoris,Old myocardial infarction,Percutaneous transluminal coronary angioplasty status,Personal history of tobacco use'}

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: Chest Pain PRESENT ILLNESS: 71 y/o female with known coronary artery disease s/p myocardial infarction in [**2132**] with PCI to RCA in [**2140**]. Since then she has been doing well, but since [**4-6**] after a viral illness she has developed chest pain and dyspnea on exertion. Recent stress test was positive and therefor underwent a cardiac cath. Cath showed severe three vessel coronary artery disease and she was transferred from [**Hospital1 **] to [**Hospital1 18**] for surgical intervention. MEDICAL HISTORY: Coronary Artery Disease s/p Myocardial Infarction [**2132**], PCI of RCA [**2140**], Hypertension, Hypercholesterolemia, Hypothyroidism, Gastroesophageal Reflux Disease, s/p Hysterectomy, s/p Bladder suspension, s/p Cholecystectomy, s/p Cochlear implant MEDICATION ON ADMISSION: Aspirin 81mg qd, Synthroid .112mcg qd, Omeprazole 20mg qam, Crestor 20mg qd, Folic acid qd, MVI qd, Nadolol 20mg qd ALLERGIES: Codeine / Morphine Sulfate PHYSICAL EXAM: Gen: WDWN elderly female in NAD, lying supione in bed. Skin: W/D intact HEENT: EOMI, PERRL, NCAT Neck: Supple, FROM -JVD, -Carotid bruit Chest: CTAB -w/r/r Heart: RRR -c/r/m/g Abd: Soft, NT/ND, +BS Ext: Warm, well-perfused, -edema, superficial varicosities bilat. Neuro: A&O x 3, MAE, non-focal FAMILY HISTORY: +Multiple brothers with MI in 40-50's. SOCIAL HISTORY: Quit smoking in [**2132**] after 1ppd x 36yrs. Rare ETOH use. ### Response: {'Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Pure hypercholesterolemia,Esophageal reflux,Unspecified acquired hypothyroidism,Other and unspecified angina pectoris,Old myocardial infarction,Percutaneous transluminal coronary angioplasty status,Personal history of tobacco use'}

CHIEF COMPLAINT: mechanical fall, neck pain PRESENT ILLNESS: Ms. [**Known lastname **] is an 81 yo F with h/o osteoporosis, COPD on home O2, and right hip fx s/p hemiarthroplasty who is transferred from [**Hospital **] Hospital ED s/p fall, found to have type II odontoid fracture. Patient was in her usual state of health until tonight, when she tripped over her oxygen tank and fell onto her back. She does admit to drinking two martinis tonight and feels this may have contributed to her fall. Denies chest pain, palpitations, dizziness, lightheadedness, weakness preceding fall. No LOC or headstrike with fall. Afterward she noticed significant posterior neck pain. Denies weakness, sensory loss, tingling, loss of bowel/bladder control. MEDICAL HISTORY: -COPD, on home O2 -Osteoporosis -Right hip fracture s/p hemiarthroplasty -Shingles MEDICATION ON ADMISSION: -Aspirin 325mg PO daily -Nexium -Advair -"Other inhalers" -"Blood pressure medication" ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: O: 97.7 110 162/85 16 97% RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: 2->1 BL. EOMs intact. 2cm laceration above right eyebrow with overlying gauze. Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. 6cm abrasion on right shoulder. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. FAMILY HISTORY: NC SOCIAL HISTORY: Lives with husband in [**State 350**] for half year, [**State 15946**] for other half of year. Drinks two cocktails per night. Significant smoking history, has recently quit. Denies illicits.

Closed fracture of second cervical vertebra,Hyposmolality and/or hyponatremia,Closed fracture of shaft of metacarpal bone(s),Open wound of forehead, without mention of complication,Fall from other slipping, tripping, or stumbling,Chronic airway obstruction, not elsewhere classified,Arthropathy, unspecified, hand,Osteoporosis, unspecified,Hip joint replacement,Personal history of tobacco use

Fx c2 vertebra-closed,Hyposmolality,Fx metacarpal shaft-clos,Open wound of forehead,Fall from slipping NEC,Chr airway obstruct NEC,Arthropathy NOS-hand,Osteoporosis NOS,Joint replaced hip,History of tobacco use

Admission Date: [**2173-8-29**] Discharge Date: [**2173-9-1**] Date of Birth: [**2092-2-12**] Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1835**] Chief Complaint: mechanical fall, neck pain Major Surgical or Invasive Procedure: Forehead suture for wound History of Present Illness: Ms. [**Known lastname **] is an 81 yo F with h/o osteoporosis, COPD on home O2, and right hip fx s/p hemiarthroplasty who is transferred from [**Hospital **] Hospital ED s/p fall, found to have type II odontoid fracture. Patient was in her usual state of health until tonight, when she tripped over her oxygen tank and fell onto her back. She does admit to drinking two martinis tonight and feels this may have contributed to her fall. Denies chest pain, palpitations, dizziness, lightheadedness, weakness preceding fall. No LOC or headstrike with fall. Afterward she noticed significant posterior neck pain. Denies weakness, sensory loss, tingling, loss of bowel/bladder control. Patient was transported by EMS to [**Hospital **] Hospital where CT C-spine showed type II odontoid fracture with posterior angulation and deformity, no significant spinal cord compromise. CT head showed no acute intracranial process. She was transferred to [**Hospital1 18**] ED for further evaluation. Neurosurgery was consulted for evaluation of her C2 fracture. Past Medical History: -COPD, on home O2 -Osteoporosis -Right hip fracture s/p hemiarthroplasty -Shingles Social History: Lives with husband in [**State 350**] for half year, [**State 15946**] for other half of year. Drinks two cocktails per night. Significant smoking history, has recently quit. Denies illicits. Family History: NC Physical Exam: O: 97.7 110 162/85 16 97% RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: 2->1 BL. EOMs intact. 2cm laceration above right eyebrow with overlying gauze. Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. 6cm abrasion on right shoulder. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Motor: D B T WE WF IP Q H AT [**Last Name (un) 938**] G R 5 5 5 5 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 5 5 5 5 Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: deferred Propioception intact Toes downgoing bilaterally Rectal exam normal sphincter control Discharge physical exam: AVSS NAD AxOx4 In C-collar Pupils: 2->1 BL. EOMs intact. 2cm laceration above right eyebrow, s/p sutures; Neck: Supple. L hand in splint, wwp, 2+cr Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Motor: D B T WE WF IP Q H AT [**Last Name (un) 938**] G R 5 5 5 5 5 5 5 5 5 5 5 L 5 not tested 5 5 5 5 5 Sensation: Intact to light touch Pertinent Results: C-SPINE SGL 1 VIEW PORT [**2173-8-29**] Type 2 dens fracture, with slight posterior displacement of the dens fragment and asymmetric widening of the fracture anteriorly. Alignment overall similar to the outside CT Brief Hospital Course: 81 y/o F s/p fall who presents with neck pain. C-spine imaging shows type II odontoid fracture with posterior angulation ad deformity. She was admitted to the ICU with a hard c-collar at all times. She was intact neurologically. On [**8-30**], patient remained stable. L wrist films were ordered for L wrist pain. Due to her history of alcohol consumption, she was placed on a CIWA scale. She did not require ativan per CIWA protocol. She was transferred to the floor in stable condition. Plastic Surgery (hand) splint the L hand and recommended follow-up 8/1 in hand clinic for further evaluation. Sodium was noted to be low throughout her hospital stay, likely secondary to inadequate PO intake while awaiting possible surgical correction for her hand and underlying lung disease. Fluids were discontinued and she was discharged in stable condition with instructions to have sodium checked at the rehabilitation facility to ensure normalization with diet. The odontoid fracture will need to be followed as an outpatient. The patient was discharged in stable condition with written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge and the patient expressed readiness for discharge. She will remain in collar for cervical spine protection until follow-up. Medications on Admission: -Aspirin 325mg PO daily -Nexium -Advair -"Other inhalers" -"Blood pressure medication" Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain 2. Amlodipine 2.5 mg PO DAILY hold for SBP <100 3. Docusate Sodium 100 mg PO BID 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **] 5. Ipratropium Bromide Neb 1 NEB IH Q6H 6. Omeprazole 20 mg PO DAILY 7. Senna 1 TAB PO BID:PRN constipation 8. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth Q6hr Disp #*60 Tablet Refills:*0 Discharge Disposition: Extended Care Facility: Blueberry [**Doctor Last Name **] Healthcare - [**Hospital1 **] Discharge Diagnosis: Type II odontoid fracture; L 2nd metacarpal (hand) midshaft fracture; low sodium Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ?????? You have a fracture of the cervical spine. It is important that you continue to wear you hard cervical collar at all times until seen in follow up. ?????? Increase your intake of fluids and fiber, as pain medicine (narcotics) can cause constipation. We recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? Pain that is continually increasing or not relieved by pain medicine. ?????? Any weakness, numbness, tingling in your extremities. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, and drainage. ?????? Fever greater than or equal to 10.5?????? F. ?????? Any change in your bowel or bladder habits (such as loss of bowl or urine control). Please have your forehead sutures removed in [**4-12**] days. Followup Instructions: Follow Up Instructions/Appointments ?????? Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) **] to be seen in 4 weeks. ??????You will need a CT-scan prior to your appointment. Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for your hand fracture on [**9-8**] for evaluation. Call [**Telephone/Fax (1) 1228**] to schedule appointment upon discharge. Please follow up with your PCP regarding this admission, any new medications/refills as well as your new diagnoses. Please have your sodium checked [**9-2**] at your rehabilitation facility. Eat a full diet. Please remove forehead sutures on [**9-2**]. Standard dry to dry dressings; if dry and non draining, no dressing needed. Completed by:[**2173-9-1**]

805,276,815,873,E885,496,716,733,V436,V158

{'Closed fracture of second cervical vertebra,Hyposmolality and/or hyponatremia,Closed fracture of shaft of metacarpal bone(s),Open wound of forehead, without mention of complication,Fall from other slipping, tripping, or stumbling,Chronic airway obstruction, not elsewhere classified,Arthropathy, unspecified, hand,Osteoporosis, unspecified,Hip joint replacement,Personal history of tobacco use'}

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: mechanical fall, neck pain PRESENT ILLNESS: Ms. [**Known lastname **] is an 81 yo F with h/o osteoporosis, COPD on home O2, and right hip fx s/p hemiarthroplasty who is transferred from [**Hospital **] Hospital ED s/p fall, found to have type II odontoid fracture. Patient was in her usual state of health until tonight, when she tripped over her oxygen tank and fell onto her back. She does admit to drinking two martinis tonight and feels this may have contributed to her fall. Denies chest pain, palpitations, dizziness, lightheadedness, weakness preceding fall. No LOC or headstrike with fall. Afterward she noticed significant posterior neck pain. Denies weakness, sensory loss, tingling, loss of bowel/bladder control. MEDICAL HISTORY: -COPD, on home O2 -Osteoporosis -Right hip fracture s/p hemiarthroplasty -Shingles MEDICATION ON ADMISSION: -Aspirin 325mg PO daily -Nexium -Advair -"Other inhalers" -"Blood pressure medication" ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: O: 97.7 110 162/85 16 97% RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: 2->1 BL. EOMs intact. 2cm laceration above right eyebrow with overlying gauze. Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. 6cm abrasion on right shoulder. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. FAMILY HISTORY: NC SOCIAL HISTORY: Lives with husband in [**State 350**] for half year, [**State 15946**] for other half of year. Drinks two cocktails per night. Significant smoking history, has recently quit. Denies illicits. ### Response: {'Closed fracture of second cervical vertebra,Hyposmolality and/or hyponatremia,Closed fracture of shaft of metacarpal bone(s),Open wound of forehead, without mention of complication,Fall from other slipping, tripping, or stumbling,Chronic airway obstruction, not elsewhere classified,Arthropathy, unspecified, hand,Osteoporosis, unspecified,Hip joint replacement,Personal history of tobacco use'}

CHIEF COMPLAINT: Fatigue/Dyspnea/Dizziness PRESENT ILLNESS: 76 year old female with known aortic stenosis who presented with acute onset of chest discomfort and shortness of breath in [**2123-6-28**]. She was admitted to the [**Hospital1 18**] and found to now have severe aortic stenosis with mild left ventricular hypertrophy. She also developed atrial fibrillation during the her hospital stay which resolved with a dose of diltiazem. During the admission, black tarry stools were noted suggesting a gastrointestinal bleed. Dr. [**Last Name (STitle) 1940**] was consulted and an EGD showed only mild gastritis with a duodenal ulcer. She was evaluated by Dr. [**Last Name (STitle) 914**] who felt and aortic valve replacement was warranted however wanted her GI issues resolved prior to proceeding. She returned to the EDon [**2123-8-17**] with shortness of breath. MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension MEDICATION ON ADMISSION: 1. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. donepezil 10 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 3. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). ALLERGIES: Niacin PHYSICAL EXAM: Pulse:61 Resp:20 O2 sat:98/RA B/P 112/58 Height:64" Weight:62.5 kgs FAMILY HISTORY: Her father died of an MI in his 50s. She has a paternal uncle who died suddenly in his 20s. She has a brother who recently had a stroke. SOCIAL HISTORY: married, lives with her husband. She has 4 adult children. Her daughter [**Name (NI) **] lives nearby. Denies ever drinking ETOH, smoking or using illicit drugs.

Aortic valve disorders,Chronic systolic heart failure,Thrombocytopenia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Atrial fibrillation,Anemia, unspecified,Coronary atherosclerosis of native coronary artery,Iatrogenic pneumothorax,Cardiac complications, not elsewhere classified,Pure hypercholesterolemia,Unspecified essential hypertension,Disorder of bone and cartilage, unspecified,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,Accidents occurring in residential institution

Aortic valve disorder,Chr systolic hrt failure,Thrombocytopenia NOS,DMII wo cmp nt st uncntr,Atrial fibrillation,Anemia NOS,Crnry athrscl natve vssl,Iatrogenic pneumothorax,Surg compl-heart,Pure hypercholesterolem,Hypertension NOS,Bone & cartilage dis NOS,Abn react-anastom/graft,Accid in resident instit

Admission Date: [**2123-9-9**] Discharge Date: [**2123-9-15**] Date of Birth: [**2046-7-14**] Sex: F Service: CARDIOTHORACIC Allergies: Niacin Attending:[**First Name3 (LF) 922**] Chief Complaint: Fatigue/Dyspnea/Dizziness Major Surgical or Invasive Procedure: [**2123-9-9**] - 1. Aortic valve replacement with a 23-mm [**Doctor Last Name **] Magna Ease aortic valve bioprosthesis. 2. Coronary artery bypass grafting x2 with left internal mammary artery to the left anterior descending coronary artery; reverse saphenous vein single graft from the aorta to the distal right coronary artery. History of Present Illness: 76 year old female with known aortic stenosis who presented with acute onset of chest discomfort and shortness of breath in [**2123-6-28**]. She was admitted to the [**Hospital1 18**] and found to now have severe aortic stenosis with mild left ventricular hypertrophy. She also developed atrial fibrillation during the her hospital stay which resolved with a dose of diltiazem. During the admission, black tarry stools were noted suggesting a gastrointestinal bleed. Dr. [**Last Name (STitle) 1940**] was consulted and an EGD showed only mild gastritis with a duodenal ulcer. She was evaluated by Dr. [**Last Name (STitle) 914**] who felt and aortic valve replacement was warranted however wanted her GI issues resolved prior to proceeding. She returned to the EDon [**2123-8-17**] with shortness of breath. Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: none -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: - HYPERTENSION - HYPERCHOLESTEROLEMIA - DIABETES MELLITUS - MEMORY DISORDER - OSTEOPENIA - Aortic valve stenosis severe Social History: married, lives with her husband. She has 4 adult children. Her daughter [**Name (NI) **] lives nearby. Denies ever drinking ETOH, smoking or using illicit drugs. Family History: Her father died of an MI in his 50s. She has a paternal uncle who died suddenly in his 20s. She has a brother who recently had a stroke. Physical Exam: Pulse:61 Resp:20 O2 sat:98/RA B/P 112/58 Height:64" Weight:62.5 kgs General: NAD, WGWN, appears stated age 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 [] grade 2/6 systolic Abdomen: Soft [x] non-distended [x] non-tender [x] +BS [x] Extremities: Warm [x], well-perfused [x] Edema: none Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: 2+ Left:2+ DP Right: 1+ Left:1+ PT [**Name (NI) 167**]: 1+ Left:1+ Radial Right: 2+ Left:2+ Carotid Bruit: radiation of cardiac murmur vs. bruits Pertinent Results: ECHO [**2123-9-9**]: PRE-BYPASS: The left atrium is mildly dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). No spontaneous echo contrast is seen in the body of the right atrium. No atrial septal defect is seen by 2D or color Doppler. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is top normal/borderline dilated. Overall left ventricular systolic function is normal (LVEF>55%). with normal free wall contractility. There are simple atheroma in the ascending aorta. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Mild to moderate ([**11-29**]+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in person of the results before surgical incision. POST_Bypass: The patient is AV paced on a low dose phenylephrine infusion. There is a well seated bioprosthetic valve in the aortic position. The mean gradient across the prosthetic valve is 5mmHg. The remaining valves are unchanged. Biventricular function is maintained. The aorta remains intact. Overall LVEF 55%. [**2123-9-15**] 04:26AM BLOOD WBC-5.3 RBC-3.13* Hgb-9.8* Hct-29.6* MCV-95 MCH-31.2 MCHC-32.9 RDW-13.4 Plt Ct-267 [**2123-9-10**] 12:17PM BLOOD PT-13.9* PTT-27.6 INR(PT)-1.2* [**2123-9-15**] 04:26AM BLOOD Glucose-92 UreaN-27* Creat-1.0 Na-142 K-4.1 Cl-102 HCO3-34* AnGap-10 Brief Hospital Course: Mrs. [**Known lastname **] was admitted to the [**Hospital1 18**] on 10/ 13/11 for surgical management of her aortic valve and coronary artery disease. She was taken to the operating room where she underwent coronary artery bypass grafting to two vessels and an aortic vlave replacement using a 23-mm [**Doctor Last Name **] Magna Ease aortic valve bioprosthesis. Please see operative note for details. Postoperatively she was taken to the intensive care unit for monitoring. She was transfused for postoperative anemia. Over the next several hours, she awoke neurologically intact and was extubated. On postoperative day one her beta blockade, aspirin, and a statin were resumed. She was started on amiodarone for transient atrial fibrillation. She was then transferred to the step down unit for further recovery. Her epicardial wires were removed. After chest tube removal she had bilateral pneumonthoraces which remained stable on multiple chest radiographs over several days. For anemia she was started on folic acid and iron. By post-operative day six she was ready for discharge to [**Hospital 4470**] Rehab. All follow-up appointments were advised. Medications on Admission: 1. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. donepezil 10 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 3. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. fenofibrate micronized 200 mg Capsule Sig: One (1) Capsule PO once a day. 7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 8. furosemide 20 mg Tablet Sig: One (1) Tablet, PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Medications: 1. 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:*2* 2. donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 3. lisinopril 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. fenofibrate micronized 145 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 6. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 7. metformin 500 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 9. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 12. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 13. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 14. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 15. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 14 days. Disp:*14 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital 4470**] HealthCare Center at [**Location (un) 38**] Discharge Diagnosis: Diabetes Dyslipidemia Hypertension Memory disorder Osteopenia Aortic valve stenosis Coronary artery disease Gastritis/Duodenal Ulcer [**6-/2123**] Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema Discharge Instructions: 1) 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. 2) Please NO lotions, cream, powder, or ointments to incisions. 3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart provided. 4) No driving for approximately one month and while taking narcotics. Driving will be discussed at follow up appointment with surgeon when you will likely be cleared to drive. 5) No lifting more than 10 pounds for 10 weeks 6) 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 [**Last Name (STitle) 914**] [**Telephone/Fax (1) 170**] on [**10-26**] at 1:00 pm Cardiologist: Dr [**First Name (STitle) **] on [**9-29**] at 2:40 pm in [**Location (un) 38**] office Please call to schedule appointments with your Primary Care Dr. [**First Name (STitle) 1356**] in [**3-2**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2123-9-15**]

424,428,287,250,427,285,414,512,997,272,401,733,E878,E849

{'Aortic valve disorders,Chronic systolic heart failure,Thrombocytopenia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Atrial fibrillation,Anemia, unspecified,Coronary atherosclerosis of native coronary artery,Iatrogenic pneumothorax,Cardiac complications, not elsewhere classified,Pure hypercholesterolemia,Unspecified essential hypertension,Disorder of bone and cartilage, unspecified,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,Accidents occurring in residential institution'}

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: Fatigue/Dyspnea/Dizziness PRESENT ILLNESS: 76 year old female with known aortic stenosis who presented with acute onset of chest discomfort and shortness of breath in [**2123-6-28**]. She was admitted to the [**Hospital1 18**] and found to now have severe aortic stenosis with mild left ventricular hypertrophy. She also developed atrial fibrillation during the her hospital stay which resolved with a dose of diltiazem. During the admission, black tarry stools were noted suggesting a gastrointestinal bleed. Dr. [**Last Name (STitle) 1940**] was consulted and an EGD showed only mild gastritis with a duodenal ulcer. She was evaluated by Dr. [**Last Name (STitle) 914**] who felt and aortic valve replacement was warranted however wanted her GI issues resolved prior to proceeding. She returned to the EDon [**2123-8-17**] with shortness of breath. MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension MEDICATION ON ADMISSION: 1. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. donepezil 10 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 3. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). ALLERGIES: Niacin PHYSICAL EXAM: Pulse:61 Resp:20 O2 sat:98/RA B/P 112/58 Height:64" Weight:62.5 kgs FAMILY HISTORY: Her father died of an MI in his 50s. She has a paternal uncle who died suddenly in his 20s. She has a brother who recently had a stroke. SOCIAL HISTORY: married, lives with her husband. She has 4 adult children. Her daughter [**Name (NI) **] lives nearby. Denies ever drinking ETOH, smoking or using illicit drugs. ### Response: {'Aortic valve disorders,Chronic systolic heart failure,Thrombocytopenia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Atrial fibrillation,Anemia, unspecified,Coronary atherosclerosis of native coronary artery,Iatrogenic pneumothorax,Cardiac complications, not elsewhere classified,Pure hypercholesterolemia,Unspecified essential hypertension,Disorder of bone and cartilage, unspecified,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,Accidents occurring in residential institution'}

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is a 49 year old male with a history of alcohol abuse transferred from the Medical Intensive Care Unit from an outside hospital with acute renal failure in the setting of worsening encephalopathy. The patient was admitted to [**Hospital3 15174**] approximately four days prior to admission with confusion and shaking chills. He received intravenous fluids and p.o. lactulose for hepatic encephalopathy. On admission there, his white blood cell count was elevated as were his transaminases. He was started on Unasyn. He was evaluated by GI and an abdominal ultrasound showed a small intestinal diverticula, gallstones, but no evidence of cholecystitis. MEDICAL HISTORY: MEDICATION ON ADMISSION: ALLERGIES: PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

Acute kidney failure, unspecified,Hepatic encephalopathy,Acute alcoholic hepatitis,Acute and subacute necrosis of liver,Unspecified septicemia,Acute respiratory failure,Other shock without mention of trauma,Alcohol abuse, unspecified,Hyperpotassemia

Acute kidney failure NOS,Hepatic encephalopathy,Ac alcoholic hepatitis,Acute necrosis of liver,Septicemia NOS,Acute respiratry failure,Shock w/o trauma NEC,Alcohol abuse-unspec,Hyperpotassemia

Admission Date: [**2111-2-21**] Discharge Date: [**2111-2-24**] Date of Birth: Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 49 year old male with a history of alcohol abuse transferred from the Medical Intensive Care Unit from an outside hospital with acute renal failure in the setting of worsening encephalopathy. The patient was admitted to [**Hospital3 15174**] approximately four days prior to admission with confusion and shaking chills. He received intravenous fluids and p.o. lactulose for hepatic encephalopathy. On admission there, his white blood cell count was elevated as were his transaminases. He was started on Unasyn. He was evaluated by GI and an abdominal ultrasound showed a small intestinal diverticula, gallstones, but no evidence of cholecystitis. The patient's admission creatinine was 2.5, which subsequently improved with hydration to 1.5 on [**2-21**]. Urine culture showed greater than 100,000 colonies of Staphylococcus aureus which was pan-sensitive. The patient was evaluated by Infectious Disease service and his antibiotics were changed to Nafcillin and Levaquin. On [**2-20**], the patient had some slight improvement in his mental status; his creatinine was trending down although he had a persistently elevated white blood cell count. CT scan of the abdomen revealed ascites, a gallstone, but no biliary obstruction; it was notable for pyelonephritis with a left kidney mass. The patient was started on Prednisone for a question of alcoholic hepatitis. On the day of transfer to the [**Hospital1 188**], the patient was noted to be hypotensive to the 70s with no urinary output over a six to eight hour period. He was bolused with intravenous fluids with no response. He was started on a low dose Dopamine drip. A PA catheter was placed for measure of intra-cardiac pressure which revealed a pulmonary capillary wedge pressure of 2. He did response to fluid boluses. HOSPITAL COURSE: The patient was admitted to the [**Hospital1 346**] where he underwent aggressive treatment for hepatic encephalopathy complicated by sepsis, thought to be of urinary origin. The patient was maintained on antibiotics and multiple pressor support. His abdomen became increasingly distended over his hospitalization. The patient developed worsening renal failure which was thought to be complicated by increased abdominal distention with increased bladder pressures. The patient ultimately developed shock liver likely complicated by alcoholic hepatitis. He had no evidence of spontaneous bacterial peritonitis but had significant ascites which was removed by paracentesis. In the setting of his sepsis, the patient's acute renal failure progressed to acute tubular necrosis. He was intermittently hyperkalemic and acidotic. The patient also with coagulopathy secondary to liver failure. After a three day hospital course during which the patient was treated aggressively with fluids, antibiotics and pressors as above, the patient died on [**2111-2-24**]. His family was contact[**Name (NI) **] regarding an autopsy and agreed to a post-mortem. The attending physician was also notified. DR.[**First Name (STitle) **],[**First Name3 (LF) **] 11-889 Dictated By:[**Last Name (NamePattern4) 4689**] MEDQUIST36 D: [**2111-8-11**] 16:50 T: [**2111-8-18**] 14:20 JOB#: [**Job Number 19317**]

584,572,571,570,038,518,785,305,276

{'Acute kidney failure, unspecified,Hepatic encephalopathy,Acute alcoholic hepatitis,Acute and subacute necrosis of liver,Unspecified septicemia,Acute respiratory failure,Other shock without mention of trauma,Alcohol abuse, unspecified,Hyperpotassemia'}

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 49 year old male with a history of alcohol abuse transferred from the Medical Intensive Care Unit from an outside hospital with acute renal failure in the setting of worsening encephalopathy. The patient was admitted to [**Hospital3 15174**] approximately four days prior to admission with confusion and shaking chills. He received intravenous fluids and p.o. lactulose for hepatic encephalopathy. On admission there, his white blood cell count was elevated as were his transaminases. He was started on Unasyn. He was evaluated by GI and an abdominal ultrasound showed a small intestinal diverticula, gallstones, but no evidence of cholecystitis. MEDICAL HISTORY: MEDICATION ON ADMISSION: ALLERGIES: PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: ### Response: {'Acute kidney failure, unspecified,Hepatic encephalopathy,Acute alcoholic hepatitis,Acute and subacute necrosis of liver,Unspecified septicemia,Acute respiratory failure,Other shock without mention of trauma,Alcohol abuse, unspecified,Hyperpotassemia'}

CHIEF COMPLAINT: Left parapharyngeal mass PRESENT ILLNESS: The patient is a 38 yo female with bilateral carotid body tumors and a large left skull base paraganglioma/left vagus glomus tumor. 3D CT angiogram [**2133-8-31**] demonstrated a glomus vagale 4.1x 2.2x 1.8cm that extends from below the region of the carotid bifurcation and up to the skull base. It does not enter the jugular foramen. She also has a small carotid body tumor on the contralateral side that is 1.7x 1.3x 2.1cm. An octreotide scan had tracer uptake in the area of the left glomus vagale. However, the carotid body tumor had no uptake. The SPECT/CT images also demonstrate a 5-mm nodule in the left anterior lung without evidence of tracer uptake. The patient carries the SDHD gene. She has been tested and found to have normal plasma normetanephrine, an undetectable calcitonin, and a normal ionized calcium. She underwent preoperative embolization which was successful for an upper portion of the tumor, however, a separate portion which was smaller and inferior could not be embolized adequately. In addition to this tumor, she has a contralateral carotid body tumor. MEDICAL HISTORY: Left vagal glomus tumor, as above Bilateral carotid body tumors, as above Hypertension. Gastroesophageal reflux. Head injury [**2130**]. question of history of [**First Name5 (NamePattern1) **] [**Last Name (Prefixes) 4516**] disease. MEDICATION ON ADMISSION: Tylenol prn ALLERGIES: Keflex PHYSICAL EXAM: On admission: 97.4, 66, 117/73, 20, 99% on room air NAD, A&Ox3 EOMI, PERRL CNII-XII intact, face symmetric Full neck ROM, soft, no LAD OC/OP: Clear, no lesions, uvula midline CV: RRR, no murmurs Lungs CTAB Abdomen soft, NTND Extremities warm and well perfused, faint peripheral pulses in lower extremities bilaterally. FAMILY HISTORY: Postive for FH of paragangiomas and pheochromocytomas. Brother treated for malignant paraganglioma. + SDHD gene SOCIAL HISTORY: She is employed as an executive administrator and is married. She currently smokes and has for 22 years. She has six to eight alcoholic drinks per month.

Neoplasm of uncertain behavior of paraganglia,Unspecified essential hypertension,Esophageal reflux,Unilateral paralysis of vocal cords or larynx, partial

Unc behav neo paragang,Hypertension NOS,Esophageal reflux,Vocal paral unilat part

Admission Date: [**2133-11-11**] Discharge Date: [**2133-11-17**] Date of Birth: [**2095-8-2**] Sex: F Service: OTOLARYNGOLOGY Allergies: Keflex Attending:[**First Name3 (LF) 7729**] Chief Complaint: Left parapharyngeal mass Major Surgical or Invasive Procedure: On [**2133-11-12**]: 1. Facial nerve monitoring. 2. Laryngeal nerve monitoring. 3. Transcervical resection of left glomus vagale tumor. 4. Transcervical resection of left carotid body tumor. 5. Left Mastoidectomy with sigmoid decompression History of Present Illness: The patient is a 38 yo female with bilateral carotid body tumors and a large left skull base paraganglioma/left vagus glomus tumor. 3D CT angiogram [**2133-8-31**] demonstrated a glomus vagale 4.1x 2.2x 1.8cm that extends from below the region of the carotid bifurcation and up to the skull base. It does not enter the jugular foramen. She also has a small carotid body tumor on the contralateral side that is 1.7x 1.3x 2.1cm. An octreotide scan had tracer uptake in the area of the left glomus vagale. However, the carotid body tumor had no uptake. The SPECT/CT images also demonstrate a 5-mm nodule in the left anterior lung without evidence of tracer uptake. The patient carries the SDHD gene. She has been tested and found to have normal plasma normetanephrine, an undetectable calcitonin, and a normal ionized calcium. She underwent preoperative embolization which was successful for an upper portion of the tumor, however, a separate portion which was smaller and inferior could not be embolized adequately. In addition to this tumor, she has a contralateral carotid body tumor. Past Medical History: Left vagal glomus tumor, as above Bilateral carotid body tumors, as above Hypertension. Gastroesophageal reflux. Head injury [**2130**]. question of history of [**First Name5 (NamePattern1) **] [**Last Name (Prefixes) 4516**] disease. Social History: She is employed as an executive administrator and is married. She currently smokes and has for 22 years. She has six to eight alcoholic drinks per month. Family History: Postive for FH of paragangiomas and pheochromocytomas. Brother treated for malignant paraganglioma. + SDHD gene Physical Exam: On admission: 97.4, 66, 117/73, 20, 99% on room air NAD, A&Ox3 EOMI, PERRL CNII-XII intact, face symmetric Full neck ROM, soft, no LAD OC/OP: Clear, no lesions, uvula midline CV: RRR, no murmurs Lungs CTAB Abdomen soft, NTND Extremities warm and well perfused, faint peripheral pulses in lower extremities bilaterally. Pertinent Results: [**2133-11-11**] 09:01PM WBC-16.0* RBC-3.58* HGB-11.2* HCT-31.5* MCV-88 MCH-31.1 MCHC-35.4* RDW-12.8 [**2133-11-11**] 09:01PM PLT COUNT-251 [**2133-11-11**] 09:01PM PT-12.8 PTT-25.0 INR(PT)-1.1 Brief Hospital Course: The patient is a 38 year old woman with history of bilateral carotid body tumors and left glomus vagale who was admitted pre-operatively on [**2133-11-11**]. She had undergone pre-operative embolization, which she tolerated without issue. She was taken to the OR on [**2133-11-12**] for left mastiodectomy, sigmoid decompression, transcervical resection of left glomus vagale tumor and resection of left carotid body tumor with facial and laryngeal nerve monitoring. For details, please see separately dictated note by Dr. [**Last Name (STitle) 3878**] and Dr. [**Last Name (STitle) 1837**]. The patient tolerated procedure without complications. She was taken to the ICU for first 24 hours for monitoring of neurological status, which remained stable, and was thereafter transfered to the floor. The details of her hospital course are reviewed below by ststems: Neuro: Postoperatively, the patient was taken to the ICU for closer monitoring of her vital signs and neurological function, given the proximity of the surgery to the carotid artery. Her exam remained stable and she was transfered to the floor on POD 1. Regarding her cranial nerve exam, post-operatively, she was noted to have some weakness with tongue movement to the left (left CN XII) as well as paralysis of the left true vocal cord, deceased peristalysis of left pharyngeal wall with some pooling of secretions on that side which was anticipated given intra-op resection of the left vagus nerve. As a result of anticipated difficulty with POs, an NGT was placed on POD #1; on POD #4, after evaluation by speech and swallow, a diet was initiated with compensatory maneuvers (see below) for her nerve deficits. Pain was initially controlled with IV dilaudid while she was NPO. After NGT placement on POD1, she was transitioned to pain medications through the NGT with good effect. CV: She had elevated BP to SBP 160-180 in the initial post-operative days which were attributed to pain and hemodynamic re-adjustment after carotid body removal. Her blood pressure normalized by POD #5. She was instructed to follow-up with PCP as an outpatient to have her blood pressure monitored. Resp: The patient had oxygen saturations >95% throughout admission. She demonstrated good cough and was able to control her oral secretions. She used suctioning as needed to help with any excess oropharyngeal secretions and arrangement were made for suction machine at home. GI: In light of vagus nerve resection secondary to the tumor, she was initially kept NPO pending further evaluation. An NGT was placed on POD #1 and she was started on continuous tube feed diet with Replete with fiber @ 60 cc/hr. Nutrition was consulted who agreed with plan. Speech/swallow was consulted on POD #4 and she underwent a video floroscopic examination to evaluate pharyngeal swallowing mechanism and aspiration. She had decrease mobility of the left side of her pharynx with some pooling on the left side, but this was compensated for by head turn to left, chin tuck and hand pressure to left neck. She was cleared for a pureed, moist thin food with thin liquid diet, which she tolerated. She was instructed on signs/symptoms to look for in terms of aspiration. She was discharged with a plan to continue on cycled tube feeds nocturnally with replete with fiber @ 80 cc/hr x 14 hrs and and diet as above with oral nutrition supplements as tolerated. She is to follow-up with Nutrition and Speech/Swallow as an outpatient. GU: The patient voided throughout admission without signs of retention or UTI. Heme: The patient ambulated frequently and was given SCH for DVT prophylaxis during admission. Endo: no issues ID: The patient recieved perioperative antibiotic prophylaxis with clindamycin until the drain was removed. Her wound remained clean, intact and with erythema or signs of infection. She was afebrile throughout her hospital stay. Wound: The patient had a neck drain in place, which was removed on POD#3 as it met output criteria. Her neck incision is closed with sutures which will be removed as an outpatient. Her wound remained clean, dry and intact. Patient is being discharged [**2133-11-17**], POD #5, to home with VNA services: afebrile, tolerating regular tube feeding via NGT with pureed, moist food with thin liquid oral diet, pain well controlled on oral/per tube medication, voiding, and ambulating well. Patient will follow-up with Dr. [**Last Name (STitle) 1837**] and Dr. [**Last Name (STitle) 3878**] in 1 week, nutrition and speech and swallow in [**2-14**] weeks as well as her primary care physician [**Last Name (NamePattern4) **] [**2-14**] weeks. Medications on Admission: Tylenol prn Discharge Medications: 1. Acetaminophen 650 mg/20.3 mL Solution Sig: One (1) 650 mg PO Q6H (every 6 hours) as needed for pain: PO or via NGT. 2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed for pain: PO or via NGT. Disp:*350 ML(s)* Refills:*0* 3. Tube feeding supplies Tube feeding tansfusion pump Tube feeding transfusion supplies 4. Suction machine Suction machine for suctioning of excess oral secretions 5. Tube feeding: replete with fiber Rx: Replete with fiber nutrition supplement patient to received 80 ml/hr x 14 hours daily. Dispense: 1 month supply. Refill: 3 months Discharge Disposition: Home With Service Facility: [**Hospital3 6011**] Care Discharge Diagnosis: 1. Glomus vagale left neck/skull base. 2. Carotid body tumor left neck. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Seek immediate medical attention for fever >101.5, chills, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. OK to shower. No strenuous exercise or heavy lifting until follow up appointment, at least. Do not drive or drink alcohol while taking narcotic pain medications. Narcotic pain medications may cause constipation, if this occurs take an over the counter stool softener. Resume all home medications. Call Dr.[**Name (NI) 20390**] office at [**Telephone/Fax (1) 41**] and Dr. [**Name (NI) 71084**] office at [**Telephone/Fax (1) 2349**] to make follow up appointment to be seen in 1 week. Call Speech and swallow to schedule follow-up in [**2-14**] weeks. Follow-up with your PCP [**Last Name (NamePattern4) **] [**2-14**] weeks. Followup Instructions: 1. Call Dr.[**Name (NI) 20390**] office at [**Telephone/Fax (1) 41**] to make follow up appointment to be seen in 1 week. 2. Call Dr.[**Name (NI) 37129**] office at [**Telephone/Fax (1) 2349**] to schedule a follow-up appointment in 1 week. 2. Call Speech and swallow team at [**Telephone/Fax (1) 3731**] to schedule follow-up in [**2-14**] weeks. 4. Call Nutrition at [**Telephone/Fax (1) 3681**] to schedule a follow-up appointment in [**2-14**] weeks as you are weaning off of Tube feeds and taking more POs to adjust your tube feed requirements. 5. Follow-up with your PCP [**Last Name (NamePattern4) **] [**2-14**] weeks. Please have you HR and Blood pressure checked at this time. Completed by:[**2133-11-17**]

237,401,530,478

{'Neoplasm of uncertain behavior of paraganglia,Unspecified essential hypertension,Esophageal reflux,Unilateral paralysis of vocal cords or larynx, partial'}

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: Left parapharyngeal mass PRESENT ILLNESS: The patient is a 38 yo female with bilateral carotid body tumors and a large left skull base paraganglioma/left vagus glomus tumor. 3D CT angiogram [**2133-8-31**] demonstrated a glomus vagale 4.1x 2.2x 1.8cm that extends from below the region of the carotid bifurcation and up to the skull base. It does not enter the jugular foramen. She also has a small carotid body tumor on the contralateral side that is 1.7x 1.3x 2.1cm. An octreotide scan had tracer uptake in the area of the left glomus vagale. However, the carotid body tumor had no uptake. The SPECT/CT images also demonstrate a 5-mm nodule in the left anterior lung without evidence of tracer uptake. The patient carries the SDHD gene. She has been tested and found to have normal plasma normetanephrine, an undetectable calcitonin, and a normal ionized calcium. She underwent preoperative embolization which was successful for an upper portion of the tumor, however, a separate portion which was smaller and inferior could not be embolized adequately. In addition to this tumor, she has a contralateral carotid body tumor. MEDICAL HISTORY: Left vagal glomus tumor, as above Bilateral carotid body tumors, as above Hypertension. Gastroesophageal reflux. Head injury [**2130**]. question of history of [**First Name5 (NamePattern1) **] [**Last Name (Prefixes) 4516**] disease. MEDICATION ON ADMISSION: Tylenol prn ALLERGIES: Keflex PHYSICAL EXAM: On admission: 97.4, 66, 117/73, 20, 99% on room air NAD, A&Ox3 EOMI, PERRL CNII-XII intact, face symmetric Full neck ROM, soft, no LAD OC/OP: Clear, no lesions, uvula midline CV: RRR, no murmurs Lungs CTAB Abdomen soft, NTND Extremities warm and well perfused, faint peripheral pulses in lower extremities bilaterally. FAMILY HISTORY: Postive for FH of paragangiomas and pheochromocytomas. Brother treated for malignant paraganglioma. + SDHD gene SOCIAL HISTORY: She is employed as an executive administrator and is married. She currently smokes and has for 22 years. She has six to eight alcoholic drinks per month. ### Response: {'Neoplasm of uncertain behavior of paraganglia,Unspecified essential hypertension,Esophageal reflux,Unilateral paralysis of vocal cords or larynx, partial'}

CHIEF COMPLAINT: [**First Name3 (LF) 10964**] overdose Pyelonephritis C.difficle colitis PRESENT ILLNESS: Patient is a 43 year-old female with a complicated history of multiple sclerosis with a resultant neurogenic bladder and chronic pyelonephritis, who was transferred from an OSH for a liver transplant consult s/p [**First Name3 (LF) 10964**] overdose. She has been taking large amounts of [**First Name3 (LF) 10964**] (3.5-5gm/day) for the last two years to help alleviate her chronic abdominal pain and flank pain from pyelonephritis. She was in her usual state of health, until approximately three weeks ago, when she presented to an OSH with abdominal pain, flank pain, vomiting, hypoglycemia, high wbc count, and dysphagia. Six days prior to admission at [**Hospital1 18**], after spending two weeks at the OSH, she returned home with the diagnosis of viral enteritis. Upon returning home, she developed severe right upper quadrant pain at rest that was rated a [**11-22**]. The pain was of similar quality to her previous pain at the OSH, constant, sharp, non-radiating, and increasing with palpation. She experienced N/V (no blood) and a decreased appetite, but denied any shortness of breath, chest pain, bright red blood per rectum, or melena. To alleviate her abdominal pain, she increased her pain medication to 10 tabs of [**Month/Year (2) 10964**] (5 gm/day) and Percocet 2 tabs q3hr (16tab x .325 = 5.2gm). Two days prior to admission, she took an additional 10 tablets of Darvoset. Her boyfriend found her unresponsive at home, and took her to the OSH. . At the OSH, patient??????s vital signs were temp 97, heart rate 74, blood pressure 98/52, respiratory rate 15, and O2 sat 96% RA. She was noted to be lethargic with slurred speech. Her serum acetominophen level, measured approximately 6 hours after overdose, was found to be 220mg/ml. There was no clear time of last ingestion. She was started on acetylcysteine. For her blood sugar of 21, she was given D50W. A nasogastric tube was placed, which yielded heme positive coffee grounds followed by bilious material. She was guaiac positive. A KUB showed increased stool without obstruction. . Labs at OSH included: WBC 14.8 HCT 43, plt 226. NA 145, K 3.8, Cl 112, HCO3 19, BUN 26, CR 1.0. Glucose 21. AST 1394 ALT 2995 LDH 4039 Ammonia 16. Urine toxicology screen was positive for Benzo, THC, Prophoxypteme . One day prior to admission, the patient was transferred to the [**Hospital1 18**] for a liver transplant consult. Her vital signs were stable. In the [**Hospital1 18**] ED, she was given acetylcysteine @ 3.2 gm q4h IV, D5W @75cc/hr, and then switched to D10W for a finger stick blood glucose in the 50s. For her N/V, she was given ativan 2mg IV and anzemet 12.5mg. Her abdominal pain was treated with dilaudid 0.5 mg IV. . In the MICU, acetylcysteine was continued at @ 3.2 gm q4h IV, ativan was continued at 1mg IV q4hours for nausea, and dilaudid was given 0.5mg IV q3hours for abdominal pain. She was maintained on D5NS 100cc/hr. During this time, she became febrile to 101.2. Urine cultures grew E.coli, and she was started on Ceftriaxone. . After 24 hours of observation in the MICU, she was transferred to medicine. At the time of the interview, the patient complained of RUQ and RLQ pain [**11-22**] which was dulled to an [**9-22**] with dilaudid. In addition, she reported left flank pain that developed one day prior to admission. She reports constipation, +N/V, and a decreased appetite. MEDICAL HISTORY: 1. Chronic pyelonephritis. S/p right nephrectomy in [**2097**]. 2. Recurrent UTIs, up to 12 over the last 12 months. Similar microbiology patterns with resistance to many antibiotics, but sensitive to cefotetan. 3. Multiple sclerosis leading to a neurogenic bladder. Patient had a chronic suprapubic catheter in place, which was removed due to the multiple UTIs. Currently, patient self-catheterizes bladder. 4. Pituitary adenoma resected in [**2103**]. 5. Cholecystectomy. Date unknown. 6. Bowel resection secondary to obstruction. Date unknown. 7. Anxiety and depression. Patient is seen by a psychiatrist once a month. MEDICATION ON ADMISSION: At home: MVI I tab daily Clonazepam (Klonopin) (dose unknown) Venlafaxine (Effexor) (dose unknown) Docusate (Colace) (dose unknown) Folate (dose unknown) Fentanyl patch 100mcg/hour Acetominophen ([**Name10 (NameIs) 10964**]) 500mg PO q4-6hours Percocet 2 tabs q3hr . Meds on transfer Hydromorphone (Dilaudid) 0.5-1 mg IV Q3-4H:PRN Ipratropium Bromide (Atrovent) MDI 2 PUFF IH Q4-6H:PRN Acetylcysteine 20% 3200 mg IV Q4H Lorazepam (Ativan) 0.5-2 mg PO/IV Q4H:PRN Albuterol [**2-14**] PUFF IH Q6H:PRN Nicotine 14 mg TD DAILY Bisacodyl (Dulcolax) 10 mg PO/PR DAILY:PRN Pantoprazole (Protonix) 40 mg IV Q24H Ceftriaxone (Rocephin) 1 gm IV Q24H Dolasetron Mesylate (Anzemet)25 mg IV Q8H:PRN ALLERGIES: Compazine / Reglan / Sulfa (Sulfonamides) / Morphine / Tetracycline / Seroquel PHYSICAL EXAM: Vitals: Tm 100.8, HR 66, BP 120/66, RR 12, O2 sat 100RA Gen: Thin, frail woman lying in bed uncomfortable and in pain. HEENT:Head: NC/AT Eyes: PERRL 3.5mm-> 3mm sluggish response. EOMI, No scleral icterus. Ears: Hears finger rub at 3 inches. Nose: septum midline, intact. Membranes normal; no polyps, discharge, sinus tenderness Mouth: lips and membranes unremarkable. Moist. Top dentures. Tonsils present. Neck: full ROM. Thyroid palpable. Trachea midline. Nodes: no palpable cervical, supraclavicular adenopathy. CV: No JVD. RRR, normal S1/S2, no M/R/G. No carotids bruits Resp: Thorax symmetrical; no increased AP diameter or use of accessory muscles. Normal to percussion. CTAB, no rales, wheezing. Abd: Scaphoid +BS in all four quadrants, no aortic bruits. Soft, nondistended. Liver percusses 8cm in midclavicular line; 3cm below 12th rib. + right upper and lower quadrant abdominal tenderness. Liver tip is not palpable (area was too painful for deep palpation), + rebounding, minimal guarding. + left CVA tenderness. No hepatosplenomegaly or masses. Ext: No clubbing/cyanosis/edema. Cool and dry. 2+ tibialis anterior, posterior pedis, and radial pulses bilaterally Rect: Guaiac positive Skin: Right port-a-cath in place for approximately 1 month. FAMILY HISTORY: Mother has Type 2 Diabetes Mellitus. Aunt (on mother??????s side) had pancreatic cancer. Father is healthy. No family history of heart disease SOCIAL HISTORY: Patient was living with her 12 year-old daughter, who is now staying with her ex-husband during this hospitalization. Patient??????s boyfriend, [**Name (NI) **], is her main source of support. Her father lives in the area and her mother, who is currently in [**Name (NI) 108**] for the winter with her step-father, are also extremely supportive. She used to work as a telephone operator, but stopped after her diagnosis with a pituitary adenoma. She has a 19 pack-year smoking history, and denies any alcohol or recreational/IV drug use.

Poisoning by aromatic analgesics, not elsewhere classified,Hepatitis, unspecified,Intestinal infection due to Clostridium difficile,Acute pyelonephritis without lesion of renal medullary necrosis,Multiple sclerosis,Acute posthemorrhagic anemia,Accidental poisoning by aromatic analgesics, not elsewhere classified,Neurogenic bladder NOS,Other specified hypoglycemia

Pois-arom analgesics NEC,Hepatitis NOS,Int inf clstrdium dfcile,Ac pyelonephritis NOS,Multiple sclerosis,Ac posthemorrhag anemia,Acc poison-arom analgesc,Neurogenic bladder NOS,Oth spcf hypoglycemia

Admission Date: [**2106-3-30**] Discharge Date: [**2106-4-15**] Date of Birth: [**2062-5-17**] Sex: F Service: MEDICINE Allergies: Compazine / Reglan / Sulfa (Sulfonamides) / Morphine / Tetracycline / Seroquel Attending:[**First Name3 (LF) 10223**] Chief Complaint: [**First Name3 (LF) 10964**] overdose Pyelonephritis C.difficle colitis Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a 43 year-old female with a complicated history of multiple sclerosis with a resultant neurogenic bladder and chronic pyelonephritis, who was transferred from an OSH for a liver transplant consult s/p [**First Name3 (LF) 10964**] overdose. She has been taking large amounts of [**First Name3 (LF) 10964**] (3.5-5gm/day) for the last two years to help alleviate her chronic abdominal pain and flank pain from pyelonephritis. She was in her usual state of health, until approximately three weeks ago, when she presented to an OSH with abdominal pain, flank pain, vomiting, hypoglycemia, high wbc count, and dysphagia. Six days prior to admission at [**Hospital1 18**], after spending two weeks at the OSH, she returned home with the diagnosis of viral enteritis. Upon returning home, she developed severe right upper quadrant pain at rest that was rated a [**11-22**]. The pain was of similar quality to her previous pain at the OSH, constant, sharp, non-radiating, and increasing with palpation. She experienced N/V (no blood) and a decreased appetite, but denied any shortness of breath, chest pain, bright red blood per rectum, or melena. To alleviate her abdominal pain, she increased her pain medication to 10 tabs of [**Month/Year (2) 10964**] (5 gm/day) and Percocet 2 tabs q3hr (16tab x .325 = 5.2gm). Two days prior to admission, she took an additional 10 tablets of Darvoset. Her boyfriend found her unresponsive at home, and took her to the OSH. . At the OSH, patient??????s vital signs were temp 97, heart rate 74, blood pressure 98/52, respiratory rate 15, and O2 sat 96% RA. She was noted to be lethargic with slurred speech. Her serum acetominophen level, measured approximately 6 hours after overdose, was found to be 220mg/ml. There was no clear time of last ingestion. She was started on acetylcysteine. For her blood sugar of 21, she was given D50W. A nasogastric tube was placed, which yielded heme positive coffee grounds followed by bilious material. She was guaiac positive. A KUB showed increased stool without obstruction. . Labs at OSH included: WBC 14.8 HCT 43, plt 226. NA 145, K 3.8, Cl 112, HCO3 19, BUN 26, CR 1.0. Glucose 21. AST 1394 ALT 2995 LDH 4039 Ammonia 16. Urine toxicology screen was positive for Benzo, THC, Prophoxypteme . One day prior to admission, the patient was transferred to the [**Hospital1 18**] for a liver transplant consult. Her vital signs were stable. In the [**Hospital1 18**] ED, she was given acetylcysteine @ 3.2 gm q4h IV, D5W @75cc/hr, and then switched to D10W for a finger stick blood glucose in the 50s. For her N/V, she was given ativan 2mg IV and anzemet 12.5mg. Her abdominal pain was treated with dilaudid 0.5 mg IV. . In the MICU, acetylcysteine was continued at @ 3.2 gm q4h IV, ativan was continued at 1mg IV q4hours for nausea, and dilaudid was given 0.5mg IV q3hours for abdominal pain. She was maintained on D5NS 100cc/hr. During this time, she became febrile to 101.2. Urine cultures grew E.coli, and she was started on Ceftriaxone. . After 24 hours of observation in the MICU, she was transferred to medicine. At the time of the interview, the patient complained of RUQ and RLQ pain [**11-22**] which was dulled to an [**9-22**] with dilaudid. In addition, she reported left flank pain that developed one day prior to admission. She reports constipation, +N/V, and a decreased appetite. Past Medical History: 1. Chronic pyelonephritis. S/p right nephrectomy in [**2097**]. 2. Recurrent UTIs, up to 12 over the last 12 months. Similar microbiology patterns with resistance to many antibiotics, but sensitive to cefotetan. 3. Multiple sclerosis leading to a neurogenic bladder. Patient had a chronic suprapubic catheter in place, which was removed due to the multiple UTIs. Currently, patient self-catheterizes bladder. 4. Pituitary adenoma resected in [**2103**]. 5. Cholecystectomy. Date unknown. 6. Bowel resection secondary to obstruction. Date unknown. 7. Anxiety and depression. Patient is seen by a psychiatrist once a month. Social History: Patient was living with her 12 year-old daughter, who is now staying with her ex-husband during this hospitalization. Patient??????s boyfriend, [**Name (NI) **], is her main source of support. Her father lives in the area and her mother, who is currently in [**Name (NI) 108**] for the winter with her step-father, are also extremely supportive. She used to work as a telephone operator, but stopped after her diagnosis with a pituitary adenoma. She has a 19 pack-year smoking history, and denies any alcohol or recreational/IV drug use. Family History: Mother has Type 2 Diabetes Mellitus. Aunt (on mother??????s side) had pancreatic cancer. Father is healthy. No family history of heart disease Physical Exam: Vitals: Tm 100.8, HR 66, BP 120/66, RR 12, O2 sat 100RA Gen: Thin, frail woman lying in bed uncomfortable and in pain. HEENT:Head: NC/AT Eyes: PERRL 3.5mm-> 3mm sluggish response. EOMI, No scleral icterus. Ears: Hears finger rub at 3 inches. Nose: septum midline, intact. Membranes normal; no polyps, discharge, sinus tenderness Mouth: lips and membranes unremarkable. Moist. Top dentures. Tonsils present. Neck: full ROM. Thyroid palpable. Trachea midline. Nodes: no palpable cervical, supraclavicular adenopathy. CV: No JVD. RRR, normal S1/S2, no M/R/G. No carotids bruits Resp: Thorax symmetrical; no increased AP diameter or use of accessory muscles. Normal to percussion. CTAB, no rales, wheezing. Abd: Scaphoid +BS in all four quadrants, no aortic bruits. Soft, nondistended. Liver percusses 8cm in midclavicular line; 3cm below 12th rib. + right upper and lower quadrant abdominal tenderness. Liver tip is not palpable (area was too painful for deep palpation), + rebounding, minimal guarding. + left CVA tenderness. No hepatosplenomegaly or masses. Ext: No clubbing/cyanosis/edema. Cool and dry. 2+ tibialis anterior, posterior pedis, and radial pulses bilaterally Rect: Guaiac positive Skin: Right port-a-cath in place for approximately 1 month. Neuro: No asterixes MS: Awake and alert, oriented to ??????[**Known firstname **] [**Known lastname 61332**]??????, ??????hospital??????, ??????[**2106-3-16**]??????. Slow speech, comprehends. Registers [**4-15**], recalls 0/3 at 5 mins. No hallucinations/delusions. No suicidal ideations. CN: EOMI without nystagmus, no ptosis. Sensation intact to LT, masseters strong symmetrically. Face symmetric. Mild facial motor weakness. Voice normal, palate symmetric. [**6-17**] SS bilaterally. Tongue midline, no atrophy or fasciculation. Motor: D [**Hospital1 **] Tri IO Grip Q H [**Last Name (un) 938**] G L 4+ 5 5 5 5 5 5 5 5 R 4 4 4 4 4 5 5 5 5 Reflexes: [**Hospital1 **] Tri BR Pat Ach Plantar L 2 2 2 2+ 2+ no response R 2+ 2+ 2+ 2+ 2+ no response [**Last Name (un) **]: intact to LT Pertinent Results: Admission labs [**2106-3-30**] 05:24AM BLOOD WBC-13.4* RBC-4.51 Hgb-13.4 Hct-40.6 MCV-90 MCH-29.6 MCHC-32.9 RDW-17.5* Plt Ct-189 [**2106-3-30**] 05:24AM BLOOD Neuts-88.3* Bands-0 Lymphs-9.9* Monos-0.4* Eos-1.2 Baso-0.2 [**2106-3-30**] 05:24AM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-OCCASIONAL Polychr-NORMAL Tear Dr[**Last Name (STitle) 833**] [**2106-3-30**] 05:24AM BLOOD PT-16.2* PTT-26.4 INR(PT)-1.7 [**2106-3-30**] 05:24AM BLOOD Glucose-95 UreaN-21* Creat-0.8 Na-141 K-3.5 Cl-111* HCO3-19* AnGap-15 [**2106-3-30**] 05:24AM BLOOD ALT-2449* AST-1044* LD(LDH)-754* AlkPhos-97 Amylase-62 TotBili-0.8 [**2106-3-30**] 05:24AM BLOOD Albumin-3.7 Calcium-9.0 Phos-2.1* Mg-1.8 [**2106-3-30**] 05:24AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-106.7* Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2106-3-30**] 12:02PM BLOOD Type-ART pO2-92 pCO2-33* pH-7.35 calHCO3-19* Base XS--6 KUB:([**3-30**]):No evidence of bowel obstruction or perforation. Nasogastric tube in satisfactory position. Focal narrowing of gas column in transverse colon likely represents peristalsis, although clinical correlation with patient's history is recommended Labs on transfer to floor [**2106-3-31**] 05:07AM BLOOD WBC-7.6 RBC-3.62* Hgb-10.9* Hct-32.6* MCV-90 MCH-30.0 MCHC-33.3 RDW-17.7* Plt Ct-154 [**2106-3-31**] 05:07AM BLOOD PT-15.4* PTT-28.0 INR(PT)-1.5 [**2106-3-31**] 05:07AM BLOOD Plt Ct-154 [**2106-3-31**] 05:07AM BLOOD Glucose-110* UreaN-10 Creat-0.7 Na-145 K-3.5 Cl-117* HCO3-22 AnGap-10 [**2106-3-31**] 05:07AM BLOOD ALT-1384* AST-195* AlkPhos-82 Amylase-82 TotBili-0.5 [**2106-3-31**] 05:07AM BLOOD Lipase-32 [**2106-3-31**] 05:07AM BLOOD Calcium-8.5 Phos-2.3* Mg-1.5* ALT/AST 1110/117; hct 33; PT 14 PTT 25 INR 1.4 Bld cx [**3-30**] Urine cx [**3-30**] e coli >100,000 Brief Hospital Course: Patient is a 43 year-old female with a complicated history of multiple sclerosis with a resultant neurogenic bladder and chronic pyelonephritis, who presented approximately 24 hours s/p [**Month/Year (2) 10964**] overdose. Her hospitalization was complicated by pyelonephritis, c.difficle colitis, and hypotension. 1. [**Month/Year (2) 10964**] Overdose/Liver failure. Patient reported that large quantities of [**Month/Year (2) 10964**] were taken for pain control, with no intent of hurting self. There is no clear time of patient??????s last ingestion, and given her chronic use of [**Month/Year (2) 10964**] and recent increase in acetominophen intake, the obtained concentration is may not represent her peak concentration. Serum acetominophen at 6 hours 220, 12 hours 107, 18 hours 24. During the hospital course, the patient's liver function improved. She was monitored by the hepatology team for the need of a liver transplantation with [**Doctor Last Name 3728**] college criteria for liver transplantation. No transplantation was needed. Liver enzymes were measured q12 hours and steadily improved and NAC was continued until her liver function tests normalized on hospital day #5. normalized within first week of hospitalization. Amylase and lipase were also monitored, and although nml on admission, reached peaks on [**4-11**] and have subsequently trended down. PT/INR/PTT were measured q6h with no evidence of coagulopathy. There were no signs of hepatic encephalopathy - no changes in MS no signs of asterixes during admission. 2. UTI/Pyelonephritis: Pt with h/o recurrent UTIs likely [**3-17**] neurogenic bladder. Pt has MS and, although + UOP, often must straight cath herself at home. Patient developed a severe [**11-22**] L flank on day 1 of hospitalization, which increased with palpation and did not radiate. She spiked a fever to 101.2 and complained of N/V. Given patient??????s history of chronic pyelonephritis, self-catherization, and clinical findings, this is most likely pyelonephritis. Urine culture + for E.coli and Enterococcus. Patient was initially started on ceftriaxone 1 gm IV q24hours. On day 4, the urine culture was + for E.coli. Imipenum 500mg IV q6hours was started and ceftriaxone was d/c'ed. On day 7, the urine culture was + enterococcus, and the patient was started on Vancomycin 1000mg IV q12. Repeat urine cx from [**4-10**] had no growth. Mr. [**Known lastname 61332**] complete 2 week course of imipenem while in house. She was discharged on day 10 of vancomycin, with home health arranged to administer last 4 doses. She had foley in during most of admission, but was making good UOP after foley removed. Given neurogenic bladder, pt self caths as needed at home. 3. Colitis/diffuse abdominal pain. Patient with diarrhea, abdominal pain, leukocytosis occurring after antibiotic administration. Pt has chronic abd pain and [**Month (only) **] peristalsis, thought to be [**3-17**] autonomic dysfunction. Pt had NGT in place on transfer to [**Hospital1 18**]. Given abd pain and large amount of drainage suctioned on arrival, she had KUB/CT scan r/o obstrcution. KUB/CT from [**3-31**] without evidence of obstruction. However, given interval increase in pain of RUQ and RLQ repeat abd CT was done on [**4-3**] with evidence of development of colonic wall thickening, involving the transverse colon, splenic flexure, and descending colon, findings that are consistent with colitis. Stool culture + for c. diff. Patient was maintained on 1000 ml NS continuous at 150 ml/hr. On hospital day 5, Flagyl 500mg IV tid was started and continued throught admission. Follow up CT on [**4-11**] with diffuse mesenteric and subcutaneous edema. Unremarkable appearance of small bowel and colon on this examination with no wall thickening and apparent resolution of colitis. Pt continued to have abd pain during admission which was managed to her satisfaction with dilaudid. On [**4-14**] she noted inc distention of abd/no BMX3 days and repeat KUB was done to r/u obstruction. KUB significant only for small dilated loop of bowel in small int which is attributed to her chronic poor gut motility/peristalsis. Given that she was on broad spectrum IV abx until day of discharge, 14 day course of PO flagyl was started on discharge. Please see nutrition section for more info, but briefly pt not tolerating PO and inc secretions via NGT early during admission - so TPN started on [**4-2**]. Attempted clamping of NGT periodically but not tolerated until [**4-12**]. Finally, pt tolerating liquids and soft custards and NGT pulled out on [**4-14**]. Pt continued on cycled TPN, which was continued on discharge. 3. Anemia and upper GI bleed. On admission, patient's HCT had dropped from 40.6-32.6 (In 24 hours). NG lavage at OSH showed coffee ground particles and LBM tonight consisted of a scant amt of dark red blood. Given [**Month/Day (2) **] o/d, differential for Upper GI bleed at that time included gastritis, esophagitis, [**Doctor First Name **]-[**Doctor Last Name **] tear (from vomiting), PUD, Dieulafoy??????s lesion. Endoscopy was done at OSH. NGT aspirate and stools were guaiac positive. Patient remained stable throughout hospital course until evening of [**4-2**] when she experienced inc bloody aspirate from NGT - hct remained stable but GI was consulted for further management. Given stable hct and recent EGD at OSH, she was managed conservatively with serial hct checks. Hct slowly drifted down from 31.0 on [**4-2**] to 24.8 on [**4-6**] at which time she was transfused 1 unit of PRBCs. Hct bumped appropriately and was stable throughout remainder of admission. Will cont PPI on discharge 4. Hypoglycemia. Resolved during hospitalziation. This was most likely secondary from hepatic dysfunction -> decrease in glucose production in setting of [**Month/Year (2) **] overdose. 6. N/V. Pt has had nausea for many years, but much increased during this admisison. Likely multifactorial including decrease gastric mobility from MS [**First Name (Titles) **] [**Last Name (Titles) 10964**] overdose vs pyelonephritis. Has tried multiple antiemetics but has found that most relieving regimen is phenergan with ativan prn. 7. Weight loss. Patient reports 81b weight loss over last 2 years, attributed to decreased appetite s/p pituitary resection. Also concerning for neoplasm or eating disorders ?????? anorexia or bulemia. Given inability to tolerate POs, PICC line was placed on [**4-2**] and pt was started on TPN. Nutrition followed pt throughout hospitalization. Pt tolerating PO liquid, but very slow to tolerate soft diet. She has tolerated custards and italian ice and jello and is slowly starting to tolerate soups. Will continue to SLOWLY advance diet on discharge. Began cycling TPN on [**4-13**] and she is now receiving TPN 12 hours overnight. On discharge, she will continue overnight TPN cycling for 12 hours. Heparin can be stopped as she is ambulatory. Will have weekly labs drawn and sent to [**Hospital1 18**] nutrionist/TPN group who will adjust TPN additives as necessary. Will also wean off TPN as tolerated. 8. Hypotension: pt with baseline SBP in 100's but [**Month (only) **] to 80-90s during admission; min response to fluid bolus - unclear etiology - hct stable despite UGI bleed earlier during admit. Likely multifactorial including her h/o autonomic dysfunction vs [**Month (only) **] fluid volume from [**Month (only) **] PO intake/HGT suction vs SE of pain meds. She was completely asymptomatic with SBPs in 90s. 9. Tobacco use. Patient has a 19 pack-year smoking history. She was continued on Nicotine 14 mg TD daily. DIscussed smoking cessation with pt who feels that this hospitalization may be the beginning of her smoking cessation. WIll cont the patch on d/c and discussed with pt that she cannot smoke while wearing the patch. Prior to discharge, discussed all of the above events/complications with Ms. [**Known lastname 61333**] [**Last Name (Titles) 3390**]. [**Name10 (NameIs) **] will see her in clinic the day after discharge and will follow her progress closely. Medications on Admission: At home: MVI I tab daily Clonazepam (Klonopin) (dose unknown) Venlafaxine (Effexor) (dose unknown) Docusate (Colace) (dose unknown) Folate (dose unknown) Fentanyl patch 100mcg/hour Acetominophen ([**Name10 (NameIs) 10964**]) 500mg PO q4-6hours Percocet 2 tabs q3hr . Meds on transfer Hydromorphone (Dilaudid) 0.5-1 mg IV Q3-4H:PRN Ipratropium Bromide (Atrovent) MDI 2 PUFF IH Q4-6H:PRN Acetylcysteine 20% 3200 mg IV Q4H Lorazepam (Ativan) 0.5-2 mg PO/IV Q4H:PRN Albuterol [**2-14**] PUFF IH Q6H:PRN Nicotine 14 mg TD DAILY Bisacodyl (Dulcolax) 10 mg PO/PR DAILY:PRN Pantoprazole (Protonix) 40 mg IV Q24H Ceftriaxone (Rocephin) 1 gm IV Q24H Dolasetron Mesylate (Anzemet)25 mg IV Q8H:PRN Discharge Medications: 1. Vancomycin HCl 1,000 mg Recon Soln Sig: One (1) gm Intravenous once a day for 4 days. Disp:*4 gms* Refills:*0* 2. Outpatient Lab Work Please check CBC, Chem-7, glucose, triglycerides, calcium, magnesium, and phosphorus weekly from port-a-cath Please fax results to [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) 18971**] at [**Telephone/Fax (1) **] 3. Infusion pump Infusion pump for TPN, 60/60 4. Catheter care Catheter care per NEHT protocol 5. heparin flush Heparin 100u/ml, 5mL flush SASH and prn, or QD for line maintenance 6. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Transdermal once a day. Disp:*30 * Refills:*2* 7. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day for 14 days. Disp:*42 Tablet(s)* Refills:*0* 8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. Disp:*1 inhaler* Refills:*2* 9. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4-6H (every 4 to 6 hours) as needed for shortness of breath or wheezing. Disp:*1 inhaler* Refills:*2* 10. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO DAILY (Daily). Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*2* 11. Fentanyl 100 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). Disp:*10 Patch 72HR(s)* Refills:*2* 12. Clonazepam 0.5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 13. Promethazine HCl 25 mg Suppository Sig: One (1) Suppository Rectal Q4H (every 4 hours) as needed for nausea. Disp:*50 Suppository(s)* Refills:*1* 14. Promethazine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea: please use if not tolerating suppository. Disp:*30 Tablet(s)* Refills:*1* 15. Ativan 2 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for nausea. Disp:*30 Tablet(s)* Refills:*0* 16. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Chartwell Home therapies Discharge Diagnosis: Primary Diagnosis: 1. [**Telephone/Fax (1) 10964**] overdose 2. complicated UTI 3. Persistent Nausea/emesis requiring TPN 4. C. Diff Colitis 5. Pyelonephritis Discharge Condition: stable Discharge Instructions: Please call your [**Telephone/Fax (1) 3390**] or return to the emergency department if you develop fevers, chills, worsening abdominal pain, nausea , vomiting, or other worrisome symptom. Please follow up with your [**Telephone/Fax (1) 3390**] this [**Name9 (PRE) 2974**] [**2106-4-16**] as scheduled. Please take all medications as prescribed. You will continue to recieve TPN for 12 hours at night, but continue to eat food by mouth as tolerated. Followup Instructions: Please follow up at Dr.[**Name (NI) 61334**] office this friday, [**2106-4-16**] at 3:30 PM.

965,573,008,590,340,285,E850,596,251

{'Poisoning by aromatic analgesics, not elsewhere classified,Hepatitis, unspecified,Intestinal infection due to Clostridium difficile,Acute pyelonephritis without lesion of renal medullary necrosis,Multiple sclerosis,Acute posthemorrhagic anemia,Accidental poisoning by aromatic analgesics, not elsewhere classified,Neurogenic bladder NOS,Other specified hypoglycemia'}

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: [**First Name3 (LF) 10964**] overdose Pyelonephritis C.difficle colitis PRESENT ILLNESS: Patient is a 43 year-old female with a complicated history of multiple sclerosis with a resultant neurogenic bladder and chronic pyelonephritis, who was transferred from an OSH for a liver transplant consult s/p [**First Name3 (LF) 10964**] overdose. She has been taking large amounts of [**First Name3 (LF) 10964**] (3.5-5gm/day) for the last two years to help alleviate her chronic abdominal pain and flank pain from pyelonephritis. She was in her usual state of health, until approximately three weeks ago, when she presented to an OSH with abdominal pain, flank pain, vomiting, hypoglycemia, high wbc count, and dysphagia. Six days prior to admission at [**Hospital1 18**], after spending two weeks at the OSH, she returned home with the diagnosis of viral enteritis. Upon returning home, she developed severe right upper quadrant pain at rest that was rated a [**11-22**]. The pain was of similar quality to her previous pain at the OSH, constant, sharp, non-radiating, and increasing with palpation. She experienced N/V (no blood) and a decreased appetite, but denied any shortness of breath, chest pain, bright red blood per rectum, or melena. To alleviate her abdominal pain, she increased her pain medication to 10 tabs of [**Month/Year (2) 10964**] (5 gm/day) and Percocet 2 tabs q3hr (16tab x .325 = 5.2gm). Two days prior to admission, she took an additional 10 tablets of Darvoset. Her boyfriend found her unresponsive at home, and took her to the OSH. . At the OSH, patient??????s vital signs were temp 97, heart rate 74, blood pressure 98/52, respiratory rate 15, and O2 sat 96% RA. She was noted to be lethargic with slurred speech. Her serum acetominophen level, measured approximately 6 hours after overdose, was found to be 220mg/ml. There was no clear time of last ingestion. She was started on acetylcysteine. For her blood sugar of 21, she was given D50W. A nasogastric tube was placed, which yielded heme positive coffee grounds followed by bilious material. She was guaiac positive. A KUB showed increased stool without obstruction. . Labs at OSH included: WBC 14.8 HCT 43, plt 226. NA 145, K 3.8, Cl 112, HCO3 19, BUN 26, CR 1.0. Glucose 21. AST 1394 ALT 2995 LDH 4039 Ammonia 16. Urine toxicology screen was positive for Benzo, THC, Prophoxypteme . One day prior to admission, the patient was transferred to the [**Hospital1 18**] for a liver transplant consult. Her vital signs were stable. In the [**Hospital1 18**] ED, she was given acetylcysteine @ 3.2 gm q4h IV, D5W @75cc/hr, and then switched to D10W for a finger stick blood glucose in the 50s. For her N/V, she was given ativan 2mg IV and anzemet 12.5mg. Her abdominal pain was treated with dilaudid 0.5 mg IV. . In the MICU, acetylcysteine was continued at @ 3.2 gm q4h IV, ativan was continued at 1mg IV q4hours for nausea, and dilaudid was given 0.5mg IV q3hours for abdominal pain. She was maintained on D5NS 100cc/hr. During this time, she became febrile to 101.2. Urine cultures grew E.coli, and she was started on Ceftriaxone. . After 24 hours of observation in the MICU, she was transferred to medicine. At the time of the interview, the patient complained of RUQ and RLQ pain [**11-22**] which was dulled to an [**9-22**] with dilaudid. In addition, she reported left flank pain that developed one day prior to admission. She reports constipation, +N/V, and a decreased appetite. MEDICAL HISTORY: 1. Chronic pyelonephritis. S/p right nephrectomy in [**2097**]. 2. Recurrent UTIs, up to 12 over the last 12 months. Similar microbiology patterns with resistance to many antibiotics, but sensitive to cefotetan. 3. Multiple sclerosis leading to a neurogenic bladder. Patient had a chronic suprapubic catheter in place, which was removed due to the multiple UTIs. Currently, patient self-catheterizes bladder. 4. Pituitary adenoma resected in [**2103**]. 5. Cholecystectomy. Date unknown. 6. Bowel resection secondary to obstruction. Date unknown. 7. Anxiety and depression. Patient is seen by a psychiatrist once a month. MEDICATION ON ADMISSION: At home: MVI I tab daily Clonazepam (Klonopin) (dose unknown) Venlafaxine (Effexor) (dose unknown) Docusate (Colace) (dose unknown) Folate (dose unknown) Fentanyl patch 100mcg/hour Acetominophen ([**Name10 (NameIs) 10964**]) 500mg PO q4-6hours Percocet 2 tabs q3hr . Meds on transfer Hydromorphone (Dilaudid) 0.5-1 mg IV Q3-4H:PRN Ipratropium Bromide (Atrovent) MDI 2 PUFF IH Q4-6H:PRN Acetylcysteine 20% 3200 mg IV Q4H Lorazepam (Ativan) 0.5-2 mg PO/IV Q4H:PRN Albuterol [**2-14**] PUFF IH Q6H:PRN Nicotine 14 mg TD DAILY Bisacodyl (Dulcolax) 10 mg PO/PR DAILY:PRN Pantoprazole (Protonix) 40 mg IV Q24H Ceftriaxone (Rocephin) 1 gm IV Q24H Dolasetron Mesylate (Anzemet)25 mg IV Q8H:PRN ALLERGIES: Compazine / Reglan / Sulfa (Sulfonamides) / Morphine / Tetracycline / Seroquel PHYSICAL EXAM: Vitals: Tm 100.8, HR 66, BP 120/66, RR 12, O2 sat 100RA Gen: Thin, frail woman lying in bed uncomfortable and in pain. HEENT:Head: NC/AT Eyes: PERRL 3.5mm-> 3mm sluggish response. EOMI, No scleral icterus. Ears: Hears finger rub at 3 inches. Nose: septum midline, intact. Membranes normal; no polyps, discharge, sinus tenderness Mouth: lips and membranes unremarkable. Moist. Top dentures. Tonsils present. Neck: full ROM. Thyroid palpable. Trachea midline. Nodes: no palpable cervical, supraclavicular adenopathy. CV: No JVD. RRR, normal S1/S2, no M/R/G. No carotids bruits Resp: Thorax symmetrical; no increased AP diameter or use of accessory muscles. Normal to percussion. CTAB, no rales, wheezing. Abd: Scaphoid +BS in all four quadrants, no aortic bruits. Soft, nondistended. Liver percusses 8cm in midclavicular line; 3cm below 12th rib. + right upper and lower quadrant abdominal tenderness. Liver tip is not palpable (area was too painful for deep palpation), + rebounding, minimal guarding. + left CVA tenderness. No hepatosplenomegaly or masses. Ext: No clubbing/cyanosis/edema. Cool and dry. 2+ tibialis anterior, posterior pedis, and radial pulses bilaterally Rect: Guaiac positive Skin: Right port-a-cath in place for approximately 1 month. FAMILY HISTORY: Mother has Type 2 Diabetes Mellitus. Aunt (on mother??????s side) had pancreatic cancer. Father is healthy. No family history of heart disease SOCIAL HISTORY: Patient was living with her 12 year-old daughter, who is now staying with her ex-husband during this hospitalization. Patient??????s boyfriend, [**Name (NI) **], is her main source of support. Her father lives in the area and her mother, who is currently in [**Name (NI) 108**] for the winter with her step-father, are also extremely supportive. She used to work as a telephone operator, but stopped after her diagnosis with a pituitary adenoma. She has a 19 pack-year smoking history, and denies any alcohol or recreational/IV drug use. ### Response: {'Poisoning by aromatic analgesics, not elsewhere classified,Hepatitis, unspecified,Intestinal infection due to Clostridium difficile,Acute pyelonephritis without lesion of renal medullary necrosis,Multiple sclerosis,Acute posthemorrhagic anemia,Accidental poisoning by aromatic analgesics, not elsewhere classified,Neurogenic bladder NOS,Other specified hypoglycemia'}

CHIEF COMPLAINT: Upper GI Bleed PRESENT ILLNESS: 77F hx of a right breast cancer s/p lumpectomy and chemo, anxiety/OCD here with 2 days of crampy abdominal pain and dark back stools. Pt reports her symptoms began on Sunday night where she first noted to have black stools with small ammounts of visible bright red blood. The pt has felt fine with the exception of a vague abdominal discomfort. The pt presented to her psychiatrist today for routine. No lighteheadedness or dizziness, no hemoptysis, no chest pain, shortness of breath. Pt denies recent NSAID use, ETOH, steroid use, no prior hx of GIBs. No prior EGD or Endoscopy. . In the emergency department initial vitals 99.0 94 159/61 15 100. NG lavage with blood that cleared after 200cc. 2 large bore PIVs placed. Pt received protonix 80mg IV x1. The patient remained hemodynamically stable. Most recent 82 16 112/89 95%RA. MEDICAL HISTORY: # Right breast cancer (ER positive, HER-2/neu negative) in [**2185**] status post lumpectomy, tamoxifen as well as Arimidex; # history of left lower extremity thrombophlebitis and venous stasis changes; # OCD with some element of anxiety as well as depression. # Rheumatoid Arthritis # Psoriasis (unclear etiology) MEDICATION ON ADMISSION: ASPIRIN 81mg PO Daily SIMVASTATIN 20mg PO Daily LORAZEPAM 0.5mg PO BID SERTRALINE 75mg PO Daily CALCIUM CARBONATE-VITAMIN D3 500 mg (1,250 mg)- 400units Daily CYANOCOBALAMIN MULTIVITAMIN PO Daily ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: T=98.7 BP=115/55 HR=94 RR= 16 O2= 94 PHYSICAL EXAM GENERAL: Pleasant, well appearing female in NAD. HEENT: Normocephalic, atraumatic. Mild conjunctival pallor. No scleral icterus. PERRLA/EOMI. Dry MM. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. JVP= 8 LUNGS: CTAB, good air movement biaterally. ABDOMEN: Soft, Mildly tender to palpation in RUQ, LUQ, No rebound or guarding. ND. No HSM EXTREMITIES: LLE chronic venous stasis changes. No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. [**1-11**]+ reflexes, equal BL. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant FAMILY HISTORY: gastric cancer-cousin SOCIAL HISTORY: Patient lives alone and is widowed. Previously separated from her physically abusive husband who was also an alcoholic. She manages her own building which is a three family building and has two children, a daughter and a son. The daughter is a lesbian and the patient stated to me that she seems to cut off communication with her when she takes on new relationship. She is mournful over the lack of communication with her daughter. [**Name (NI) **] son has a mental disability and does not seem to provide her with a lot of social support. She denied any alcohol, smoking, or illicit drug use. She has a high school education and used to work in sales.

Hemorrhage of gastrointestinal tract, unspecified,Acute posthemorrhagic anemia,Other esophagitis,Other psoriasis,Venous (peripheral) insufficiency, unspecified,Obsessive-compulsive disorders,Rheumatoid arthritis,Personal history of malignant neoplasm of breast

Gastrointest hemorr NOS,Ac posthemorrhag anemia,Other esophagitis,Other psoriasis,Venous insufficiency NOS,Obsessive-compulsive dis,Rheumatoid arthritis,Hx of breast malignancy

Admission Date: [**2194-1-7**] Discharge Date: [**2194-1-10**] Date of Birth: [**2117-1-3**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1257**] Chief Complaint: Upper GI Bleed Major Surgical or Invasive Procedure: EGD History of Present Illness: 77F hx of a right breast cancer s/p lumpectomy and chemo, anxiety/OCD here with 2 days of crampy abdominal pain and dark back stools. Pt reports her symptoms began on Sunday night where she first noted to have black stools with small ammounts of visible bright red blood. The pt has felt fine with the exception of a vague abdominal discomfort. The pt presented to her psychiatrist today for routine. No lighteheadedness or dizziness, no hemoptysis, no chest pain, shortness of breath. Pt denies recent NSAID use, ETOH, steroid use, no prior hx of GIBs. No prior EGD or Endoscopy. . In the emergency department initial vitals 99.0 94 159/61 15 100. NG lavage with blood that cleared after 200cc. 2 large bore PIVs placed. Pt received protonix 80mg IV x1. The patient remained hemodynamically stable. Most recent 82 16 112/89 95%RA. . Upon arrival to the floor patient denies lightheadedness, dizziness, nasueas, vomitting, chest pain, shortness of breath or edema. Past Medical History: # Right breast cancer (ER positive, HER-2/neu negative) in [**2185**] status post lumpectomy, tamoxifen as well as Arimidex; # history of left lower extremity thrombophlebitis and venous stasis changes; # OCD with some element of anxiety as well as depression. # Rheumatoid Arthritis # Psoriasis (unclear etiology) Social History: Patient lives alone and is widowed. Previously separated from her physically abusive husband who was also an alcoholic. She manages her own building which is a three family building and has two children, a daughter and a son. The daughter is a lesbian and the patient stated to me that she seems to cut off communication with her when she takes on new relationship. She is mournful over the lack of communication with her daughter. [**Name (NI) **] son has a mental disability and does not seem to provide her with a lot of social support. She denied any alcohol, smoking, or illicit drug use. She has a high school education and used to work in sales. Family History: gastric cancer-cousin Physical Exam: T=98.7 BP=115/55 HR=94 RR= 16 O2= 94 PHYSICAL EXAM GENERAL: Pleasant, well appearing female in NAD. HEENT: Normocephalic, atraumatic. Mild conjunctival pallor. No scleral icterus. PERRLA/EOMI. Dry MM. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. JVP= 8 LUNGS: CTAB, good air movement biaterally. ABDOMEN: Soft, Mildly tender to palpation in RUQ, LUQ, No rebound or guarding. ND. No HSM EXTREMITIES: LLE chronic venous stasis changes. No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. [**1-11**]+ reflexes, equal BL. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: [**2194-1-7**] 02:50PM BLOOD WBC-8.7 RBC-3.07*# Hgb-9.7*# Hct-27.7*# MCV-90 MCH-31.5 MCHC-35.0 RDW-13.9 Plt Ct-236 [**2194-1-8**] 08:15AM BLOOD Hct-29.9* [**2194-1-7**] 02:50PM BLOOD Neuts-78.2* Lymphs-14.1* Monos-5.6 Eos-1.8 Baso-0.3 [**2194-1-7**] 02:50PM BLOOD PT-12.9 PTT-25.4 INR(PT)-1.1 [**2194-1-7**] 02:50PM BLOOD Glucose-109* UreaN-13 Creat-0.5 Na-141 K-3.8 Cl-105 HCO3-27 AnGap-13 [**2194-1-7**] 02:50PM BLOOD ALT-20 AST-27 AlkPhos-53 TotBili-0.4 Brief Hospital Course: 77 year old woman with history of right breast cancer presented with 2 days of crampy abdominal pain, dark black stools, and blood on NG lavage. Her admission Hct was 27.7 from baseline of 38. She was otherwise asymptomatic. Her discharge HCt was 28.1 after 3 days hospitalization. DDx included peptic ulcer disease, erosive gastritis, gastric CA, and Dieulafoy. She received Protonix 80 mg IV x1 in ED and then Protonix drip. She also received one unit of blood transfusion. She had upper endoscopy followed by colonoscopy, and both were normal. She was placed on oral Protonix. She had no further episodes or bleeding or progressive anemia. She did not develop any symptom of blood loss (weakness, DOE, lightheartedness, etc..). She was discharged to follow up with GI for Capsule Endoscopy. She was provided with phone numbers to [**Month/Day/Year **] appointment as I could not make one because of the holidays. All her questions were answered. She understood the plan despite severe anxiety. She was seen by SW to address her anxiety and was asked to see her psychiatrics. She was provided with prescriptions for Iron and Protonix. Medications on Admission: ASPIRIN 81mg PO Daily SIMVASTATIN 20mg PO Daily LORAZEPAM 0.5mg PO BID SERTRALINE 75mg PO Daily CALCIUM CARBONATE-VITAMIN D3 500 mg (1,250 mg)- 400units Daily CYANOCOBALAMIN MULTIVITAMIN PO Daily Discharge Medications: 1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day. 4. Aspir-81 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 5. Calcium 500 With D 500 mg(1,250mg) -400 unit Tablet Sig: One (1) Tablet PO once a day. 6. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: gastrointestinal bleeding Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You had a gastrointestinal bleeding. We could not identify the source despite performing EGD and Colonoscopy. Please see your PCP/GI doctor [**First Name (Titles) **] [**Last Name (Titles) **] capsule endoscopy. Please avoid NSAID medications ( like Ibuprofen, Advail, Indocin, etc). Return to ER if you develop any recurrent bleeding. Followup Instructions: Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 1125**] Date/Time:[**2194-10-22**] 2:00 if any questions or you need to [**Month/Day/Year **] an office appointment [**Telephone/Fax (1) 682**] or email at [**University/College 21854**]

578,285,530,696,459,300,714,V103

{'Hemorrhage of gastrointestinal tract, unspecified,Acute posthemorrhagic anemia,Other esophagitis,Other psoriasis,Venous (peripheral) insufficiency, unspecified,Obsessive-compulsive disorders,Rheumatoid arthritis,Personal history of malignant neoplasm of breast'}

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: Upper GI Bleed PRESENT ILLNESS: 77F hx of a right breast cancer s/p lumpectomy and chemo, anxiety/OCD here with 2 days of crampy abdominal pain and dark back stools. Pt reports her symptoms began on Sunday night where she first noted to have black stools with small ammounts of visible bright red blood. The pt has felt fine with the exception of a vague abdominal discomfort. The pt presented to her psychiatrist today for routine. No lighteheadedness or dizziness, no hemoptysis, no chest pain, shortness of breath. Pt denies recent NSAID use, ETOH, steroid use, no prior hx of GIBs. No prior EGD or Endoscopy. . In the emergency department initial vitals 99.0 94 159/61 15 100. NG lavage with blood that cleared after 200cc. 2 large bore PIVs placed. Pt received protonix 80mg IV x1. The patient remained hemodynamically stable. Most recent 82 16 112/89 95%RA. MEDICAL HISTORY: # Right breast cancer (ER positive, HER-2/neu negative) in [**2185**] status post lumpectomy, tamoxifen as well as Arimidex; # history of left lower extremity thrombophlebitis and venous stasis changes; # OCD with some element of anxiety as well as depression. # Rheumatoid Arthritis # Psoriasis (unclear etiology) MEDICATION ON ADMISSION: ASPIRIN 81mg PO Daily SIMVASTATIN 20mg PO Daily LORAZEPAM 0.5mg PO BID SERTRALINE 75mg PO Daily CALCIUM CARBONATE-VITAMIN D3 500 mg (1,250 mg)- 400units Daily CYANOCOBALAMIN MULTIVITAMIN PO Daily ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: T=98.7 BP=115/55 HR=94 RR= 16 O2= 94 PHYSICAL EXAM GENERAL: Pleasant, well appearing female in NAD. HEENT: Normocephalic, atraumatic. Mild conjunctival pallor. No scleral icterus. PERRLA/EOMI. Dry MM. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. JVP= 8 LUNGS: CTAB, good air movement biaterally. ABDOMEN: Soft, Mildly tender to palpation in RUQ, LUQ, No rebound or guarding. ND. No HSM EXTREMITIES: LLE chronic venous stasis changes. No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. [**1-11**]+ reflexes, equal BL. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant FAMILY HISTORY: gastric cancer-cousin SOCIAL HISTORY: Patient lives alone and is widowed. Previously separated from her physically abusive husband who was also an alcoholic. She manages her own building which is a three family building and has two children, a daughter and a son. The daughter is a lesbian and the patient stated to me that she seems to cut off communication with her when she takes on new relationship. She is mournful over the lack of communication with her daughter. [**Name (NI) **] son has a mental disability and does not seem to provide her with a lot of social support. She denied any alcohol, smoking, or illicit drug use. She has a high school education and used to work in sales. ### Response: {'Hemorrhage of gastrointestinal tract, unspecified,Acute posthemorrhagic anemia,Other esophagitis,Other psoriasis,Venous (peripheral) insufficiency, unspecified,Obsessive-compulsive disorders,Rheumatoid arthritis,Personal history of malignant neoplasm of breast'}

CHIEF COMPLAINT: drug overdose PRESENT ILLNESS: Patient is a 35M with bipolar disorder, polysubstance abuse who is being transferred out of the MICU after being admitted with change in mental status after drug overdose (cocaine, lithium, seroquel). Also found to have CSF lymphocytosis with elevated protein, but no signs of systemic infection, and was covered broadly with Vancomycin, Ceftriaxone, and Acyclovir in the ED, which was continued in the MICU. . On admission, Lithium level 0.8. Given ativan 2mg IV x1 in ER and became lethargic -> GCS of 4. Unclear whether lethargy due to Ativan or from overdose. VS 98.6, 150, 138/67. CT head done for change in MS, which was negative. LP done in ER with 24->14 WBC, 98% lymphs. Given 2 g ceftriaxone, vancomycin and acyclovir in ED. MEDICAL HISTORY: Bipolar disorder "Sleep disorder" ETOH abuse - reports h/o withdrawal seizures Cocaine abuse MEDICATION ON ADMISSION: Home Meds Lithium Seroquel Cogentin ALLERGIES: Erythromycin/Sulfisoxazole / Codeine / Compazine PHYSICAL EXAM: VITALS: T ; BP 107/64; HR 76; RR 16; O2 Sat GEN: Extremely lethargic, responsive HEENT: MMM. OP clear. CV: S1S2 RRR. No MRG LUNGS: CTA B/L ABD: soft, NT/ND. hypoactive BS EXT: 2+ DPs. No CCE NEURO: Drowsy, AO x 2. Too lethargic to cooperate with extremity testing. Babinski downgoing toes. FAMILY HISTORY: nc SOCIAL HISTORY: +ETOH (drinks 12 pack beer and hard alcohol most days of week, notes h/o withdrawal seizures), + tobacco 1 PPD, + cocaine use, denies other drugs

Cocaine dependence, continuous,Other and unspecified alcohol dependence, continuous,Toxic effect of other specified metals,Poisoning by other antipsychotics, neuroleptics, and major tranquilizers,Suicide and self-inflicted poisoning by other specified drugs and medicinal substances,Bipolar disorder, unspecified

Cocaine depend-contin,Alcoh dep NEC/NOS-contin,Toxic effect metals NEC,Poison-antipsychotic NEC,Poison-drug/medicin NEC,Bipolar disorder NOS

Admission Date: [**2111-6-26**] Discharge Date: [**2111-7-1**] Date of Birth: [**2075-7-7**] Sex: M Service: MEDICINE Allergies: Erythromycin/Sulfisoxazole / Codeine / Compazine Attending:[**First Name3 (LF) 2159**] Chief Complaint: drug overdose Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a 35M with bipolar disorder, polysubstance abuse who is being transferred out of the MICU after being admitted with change in mental status after drug overdose (cocaine, lithium, seroquel). Also found to have CSF lymphocytosis with elevated protein, but no signs of systemic infection, and was covered broadly with Vancomycin, Ceftriaxone, and Acyclovir in the ED, which was continued in the MICU. . On admission, Lithium level 0.8. Given ativan 2mg IV x1 in ER and became lethargic -> GCS of 4. Unclear whether lethargy due to Ativan or from overdose. VS 98.6, 150, 138/67. CT head done for change in MS, which was negative. LP done in ER with 24->14 WBC, 98% lymphs. Given 2 g ceftriaxone, vancomycin and acyclovir in ED. Past Medical History: Bipolar disorder "Sleep disorder" ETOH abuse - reports h/o withdrawal seizures Cocaine abuse Social History: +ETOH (drinks 12 pack beer and hard alcohol most days of week, notes h/o withdrawal seizures), + tobacco 1 PPD, + cocaine use, denies other drugs Family History: nc Physical Exam: VITALS: T ; BP 107/64; HR 76; RR 16; O2 Sat GEN: Extremely lethargic, responsive HEENT: MMM. OP clear. CV: S1S2 RRR. No MRG LUNGS: CTA B/L ABD: soft, NT/ND. hypoactive BS EXT: 2+ DPs. No CCE NEURO: Drowsy, AO x 2. Too lethargic to cooperate with extremity testing. Babinski downgoing toes. Pertinent Results: EKG: NSR rate 94, nl axis, nl int, no ischemic changes [**2111-6-26**] 11:50AM WBC-8.2 RBC-4.56* HGB-14.4 HCT-40.2 MCV-88 MCH-31.5 MCHC-35.8* RDW-14.0 [**2111-6-26**] 11:50AM NEUTS-58.3 LYMPHS-33.4 MONOS-6.2 EOS-1.3 BASOS-0.8 [**2111-6-26**] 11:50AM PLT COUNT-169 [**2111-6-26**] 11:50AM ASA-6 ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2111-6-26**] 11:50AM LITHIUM-0.8 [**2111-6-26**] 11:50AM TOT PROT-6.6 CALCIUM-9.1 PHOSPHATE-3.3 MAGNESIUM-2.2 [**2111-6-26**] 11:50AM ALT(SGPT)-54* AST(SGOT)-39 CK(CPK)-244* ALK PHOS-68 TOT BILI-0.2 [**2111-6-26**] 11:50AM CK-MB-3 . HSV PCR negative. Brief Hospital Course: 35 yom with bioplar disorder admitted on [**6-26**] after recent drug overdose with cocaine, seroquel and lithium. At that time his Li level was 0.8. He was given ativan 2mg IV x1 in ER and became lethargic ->GCS of 4. He had a CT head done for change in MS, which was negative. An LP done in ER showed 24->14 WBC and 98% lymphs. He was started on ceftriaxone, vancomycin and acyclovir at the time for possible menigitis. LP was done. Tox screen positive for cocaine, lithium level 0.8. The patient was admitted to the ICU and his MS improved over the next day. He was transferred to the floor the next day. On [**6-28**] the patient stated that he ingested 32 tablets of seroquel and lithium (thinks 10 tabs were lithium). His 1:1 sitter saw him stuff multiple tablets in his mouth but it is unclear what he took. He had an NG lavage and was given activated charcol. Per the lab, a tablet fragment was recovered and was noted to be acetaminophen. The pt states he took the medications to get some sleep b/c he was being ignored. He denied suicidal or homicidal ideation. He was admitted to the MICU again and course notable for agitation and acting out. He was transferred to back to medicine floor and once HSV pcr returned negative he was transferred to inpatient psych facility. Below is a list by problems and his course. Medications on Admission: Home Meds Lithium Seroquel Cogentin Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). 3. Quetiapine 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for PRN agitation. 4. Haloperidol 20 mg IV BID:PRN if initial 5 mg IV haldol does not control agitation; please no more than 50 mg haldol qd 5. Haloperidol 5 mg IV Q 1 HR PRN acute agitation max dose 50 mg haldol qd Discharge Disposition: Extended Care Facility: [**Hospital1 **] 4- [**Hospital1 18**] Discharge Diagnosis: Coccaine, lithium and seroquel overdose Mood disorder Substance abuse Discharge Condition: Good Discharge Instructions: Please continue to take your medications and follow up with your appointments as below. If you have fevers, chills, nausea, vomiting or confusion please contact your PCP or return to the emergency room. Followup Instructions: Please follow up with your psychiatrist after discharge from the psych facility. You should also call your PCP and setup an appointment in [**1-12**] weeks after discharge. Completed by:[**2111-7-1**]

304,303,985,969,E950,296

{'Cocaine dependence, continuous,Other and unspecified alcohol dependence, continuous,Toxic effect of other specified metals,Poisoning by other antipsychotics, neuroleptics, and major tranquilizers,Suicide and self-inflicted poisoning by other specified drugs and medicinal substances,Bipolar disorder, 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: drug overdose PRESENT ILLNESS: Patient is a 35M with bipolar disorder, polysubstance abuse who is being transferred out of the MICU after being admitted with change in mental status after drug overdose (cocaine, lithium, seroquel). Also found to have CSF lymphocytosis with elevated protein, but no signs of systemic infection, and was covered broadly with Vancomycin, Ceftriaxone, and Acyclovir in the ED, which was continued in the MICU. . On admission, Lithium level 0.8. Given ativan 2mg IV x1 in ER and became lethargic -> GCS of 4. Unclear whether lethargy due to Ativan or from overdose. VS 98.6, 150, 138/67. CT head done for change in MS, which was negative. LP done in ER with 24->14 WBC, 98% lymphs. Given 2 g ceftriaxone, vancomycin and acyclovir in ED. MEDICAL HISTORY: Bipolar disorder "Sleep disorder" ETOH abuse - reports h/o withdrawal seizures Cocaine abuse MEDICATION ON ADMISSION: Home Meds Lithium Seroquel Cogentin ALLERGIES: Erythromycin/Sulfisoxazole / Codeine / Compazine PHYSICAL EXAM: VITALS: T ; BP 107/64; HR 76; RR 16; O2 Sat GEN: Extremely lethargic, responsive HEENT: MMM. OP clear. CV: S1S2 RRR. No MRG LUNGS: CTA B/L ABD: soft, NT/ND. hypoactive BS EXT: 2+ DPs. No CCE NEURO: Drowsy, AO x 2. Too lethargic to cooperate with extremity testing. Babinski downgoing toes. FAMILY HISTORY: nc SOCIAL HISTORY: +ETOH (drinks 12 pack beer and hard alcohol most days of week, notes h/o withdrawal seizures), + tobacco 1 PPD, + cocaine use, denies other drugs ### Response: {'Cocaine dependence, continuous,Other and unspecified alcohol dependence, continuous,Toxic effect of other specified metals,Poisoning by other antipsychotics, neuroleptics, and major tranquilizers,Suicide and self-inflicted poisoning by other specified drugs and medicinal substances,Bipolar disorder, unspecified'}

CHIEF COMPLAINT: Acute mental status changes PRESENT ILLNESS: Pt is an 87 yo Cantonese Speaking woman with dementia, h/o CVA, HTN, hyponatremia (thought [**3-17**] SIADH), who was brought to the ED by her family for lethargy, refusing to eat or get out of bed. She was recently admitted from [**8-2**] - [**8-7**] for weakness, poor po intake, fever, and bilateral pleural effusions. She was diagnosed with pneumonia and treated with levofloxacin. Of note, the family was becoming overwhelmed with the required care. Palliative care was consulted, and the family decided not to pursue aggressive treatment, including intubation/CPR, given that the patient has previously refused hospital, aggressive interventions/evaluations. . She has full-time care at home and lives with her daughter & grandson. At baseline, the patient spends most of her day in bed, sleeping. She will wake up to eat. She ambulates with a walker to the bathroom. The extent of her speaking is asking to go bed. She does not respond to questions. . Upon arrival to the [**Name (NI) **], pt was noted to have agonal breathing. She was immediately intubated. After intubation, pt was found to be pulseless, received CPR for 20 seconds. A left femoral CVL was placed (semi-sterile). Initial blood pressures were up to 224/150 briefly, then settled in 90s/50s. HR in 70-80s, ?junctional at one point. Temp was 99.8 rectally. Labs were sig. for WBC 6.3, HCT 33.8, Plt 87, PTT 47, INR 1.5, fibrinogen 104, lactate 9.2. ABG was 7.24/61/473 on AC 400 x 14, peep 5, FiO2 100%. CT head showed no acute process. CT torso showed bilateral pleural effusions, R>L, gallstones, heavy atherosclerotic disease of coronaries and aorta, and cardiomegaly with marked right atrial enlargement. Pt received vanc/zosyn and tylenol. With 2.7 L IVFs, lactate improved to 4.1 MEDICAL HISTORY: - CVA v. Vertebrobasilar insufficiency in [**2143**] - Hyponatremia thought to be [**3-17**] SIADH from her CVA + sellar mass - 3.2-cm sellar mass noted on CT, with right parasellar extension; followed by Dr. [**Last Name (STitle) **] of Endocrine. - Osteoporosis - Hypertension - Hypercholesterolemia - COPD (per records) - S/P Appendectomy. MEDICATION ON ADMISSION: Levofloxacin 500 mg PO once a day for 5 days. Aspirin 81 mg PO once a day. Simvastatin 10 mg PO once a day. Calcium 500 with Vitamin D 500 mg(1,250mg) -200 unit PO three times a day. ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: (on admission) . General Appearance: No acute distress, Thin, lethargic . Eyes / Conjunctiva: sclerae anicteric, unable to assess MM as pt does not open mouth . Head, Ears, Nose, Throat: unable to assess JVP due to TLC . Cardiovascular: (S1: Normal), (S2: Normal), no m/r/g appreciated . Peripheral Vascular: (Right radial pulse: Diminished), (Left radial pulse: Diminished), (Right DP pulse: Diminished), (Left DP pulse: Diminished) . Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Diminished: at right base ), limited as pt occasionally moaning and not taking deep breaths. no wheezes, rales, rhonchi appreciated . Abdominal: Soft, Non-tender, Bowel sounds present, Distended, mod distention, PEG in place with surrounding denuded area with some maceration. dressing c/d/i . Extremities: Right: Absent, Left: Absent . Musculoskeletal: Muscle wasting . Skin: Warm, no rashes . Neurologic: Responds to: Noxious stimuli, Movement: No spontaneous movement, Tone: Not assessed, RUE tone increased, LUE tone flaccid. lethargic, briefly opens eyes to sternal rub. No spontaneous movement of any 4 extremities. All 4 extremities with contractures. Increased tone of RUE. LUE flaccid. [**3-18**]+ DTRs b/l. Upgoing toe on left, equivocal on right. Unable to assess remaining neurologic exam due to MS. . FAMILY HISTORY: Noncontributory SOCIAL HISTORY: Pt lives with her daughter [**Name (NI) **] [**Known lastname **] and grandson [**Name (NI) 3924**] [**Name (NI) 13260**]. Her granddaughter [**Name (NI) 3040**] [**Name (NI) 13260**] & grandson help care for her. She stays in bed most of the day. She never smoked cigarettes, drank alcohol, or use illicit drugs.

Unspecified acquired hypothyroidism,Other nonspecific abnormal serum enzyme levels,Osteoporosis, unspecified,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Other postprocedural status,Hypocalcemia,Anemia, unspecified,Thrombocytopenia, unspecified,Acute respiratory failure,Cardiac arrest,Acute kidney failure, unspecified,Pneumonia, organism unspecified,Acute and subacute necrosis of liver,Hyposmolality and/or hyponatremia,Unspecified pleural effusion,Other and unspecified coagulation defects,Encounter for palliative care,Unspecified essential hypertension,Other persistent mental disorders due to conditions classified elsewhere,Chronic airway obstruction, not elsewhere classified,Unspecified condition of brain,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction,Coronary atherosclerosis of native coronary artery,Atherosclerosis of aorta,Pure hypercholesterolemia

Hypothyroidism NOS,Abn serum enzy level NEC,Osteoporosis NOS,Hx TIA/stroke w/o resid,Post-proc states NEC,Hypocalcemia,Anemia NOS,Thrombocytopenia NOS,Acute respiratry failure,Cardiac arrest,Acute kidney failure NOS,Pneumonia, organism NOS,Acute necrosis of liver,Hyposmolality,Pleural effusion NOS,Coagulat defect NEC/NOS,Encountr palliative care,Hypertension NOS,Mental disor NEC oth dis,Chr airway obstruct NEC,Brain condition NOS,Cholelithiasis NOS,Crnry athrscl natve vssl,Aortic atherosclerosis,Pure hypercholesterolem

Admission Date: [**2149-8-10**] Discharge Date: [**2149-8-20**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: Acute mental status changes Major Surgical or Invasive Procedure: 1. Intubation 2. Femoral Central Venous Line History of Present Illness: Pt is an 87 yo Cantonese Speaking woman with dementia, h/o CVA, HTN, hyponatremia (thought [**3-17**] SIADH), who was brought to the ED by her family for lethargy, refusing to eat or get out of bed. She was recently admitted from [**8-2**] - [**8-7**] for weakness, poor po intake, fever, and bilateral pleural effusions. She was diagnosed with pneumonia and treated with levofloxacin. Of note, the family was becoming overwhelmed with the required care. Palliative care was consulted, and the family decided not to pursue aggressive treatment, including intubation/CPR, given that the patient has previously refused hospital, aggressive interventions/evaluations. . She has full-time care at home and lives with her daughter & grandson. At baseline, the patient spends most of her day in bed, sleeping. She will wake up to eat. She ambulates with a walker to the bathroom. The extent of her speaking is asking to go bed. She does not respond to questions. . Upon arrival to the [**Name (NI) **], pt was noted to have agonal breathing. She was immediately intubated. After intubation, pt was found to be pulseless, received CPR for 20 seconds. A left femoral CVL was placed (semi-sterile). Initial blood pressures were up to 224/150 briefly, then settled in 90s/50s. HR in 70-80s, ?junctional at one point. Temp was 99.8 rectally. Labs were sig. for WBC 6.3, HCT 33.8, Plt 87, PTT 47, INR 1.5, fibrinogen 104, lactate 9.2. ABG was 7.24/61/473 on AC 400 x 14, peep 5, FiO2 100%. CT head showed no acute process. CT torso showed bilateral pleural effusions, R>L, gallstones, heavy atherosclerotic disease of coronaries and aorta, and cardiomegaly with marked right atrial enlargement. Pt received vanc/zosyn and tylenol. With 2.7 L IVFs, lactate improved to 4.1 Past Medical History: - CVA v. Vertebrobasilar insufficiency in [**2143**] - Hyponatremia thought to be [**3-17**] SIADH from her CVA + sellar mass - 3.2-cm sellar mass noted on CT, with right parasellar extension; followed by Dr. [**Last Name (STitle) **] of Endocrine. - Osteoporosis - Hypertension - Hypercholesterolemia - COPD (per records) - S/P Appendectomy. Social History: Pt lives with her daughter [**Name (NI) **] [**Known lastname **] and grandson [**Name (NI) 3924**] [**Name (NI) 13260**]. Her granddaughter [**Name (NI) 3040**] [**Name (NI) 13260**] & grandson help care for her. She stays in bed most of the day. She never smoked cigarettes, drank alcohol, or use illicit drugs. Family History: Noncontributory Physical Exam: (on admission) . General Appearance: No acute distress, Thin, lethargic . Eyes / Conjunctiva: sclerae anicteric, unable to assess MM as pt does not open mouth . Head, Ears, Nose, Throat: unable to assess JVP due to TLC . Cardiovascular: (S1: Normal), (S2: Normal), no m/r/g appreciated . Peripheral Vascular: (Right radial pulse: Diminished), (Left radial pulse: Diminished), (Right DP pulse: Diminished), (Left DP pulse: Diminished) . Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Diminished: at right base ), limited as pt occasionally moaning and not taking deep breaths. no wheezes, rales, rhonchi appreciated . Abdominal: Soft, Non-tender, Bowel sounds present, Distended, mod distention, PEG in place with surrounding denuded area with some maceration. dressing c/d/i . Extremities: Right: Absent, Left: Absent . Musculoskeletal: Muscle wasting . Skin: Warm, no rashes . Neurologic: Responds to: Noxious stimuli, Movement: No spontaneous movement, Tone: Not assessed, RUE tone increased, LUE tone flaccid. lethargic, briefly opens eyes to sternal rub. No spontaneous movement of any 4 extremities. All 4 extremities with contractures. Increased tone of RUE. LUE flaccid. [**3-18**]+ DTRs b/l. Upgoing toe on left, equivocal on right. Unable to assess remaining neurologic exam due to MS. . Pertinent Results: [**8-2**]: CXR FINDINGS: No previous images. Severe scoliosis of the thoracic spine. Cardiac silhouette is at the upper limits of normal or slightly enlarged. No acute focal pneumonia. Opacification at the left base could reflect some atelectasis and effusion. . There are several rib fractures in the left mid zone. No evidence of pneumothorax. . [**8-2**]: Head CT IMPRESSION: Slightly motion limited, without evidence of acute intracranial hemorrhage or fracture. . [**8-2**]: Abd/pelvis 1. Moderate-to-large bilateral pleural effusions, with associated atelectasis/consolidation of the adjacent lung. 2. Focal outpouching of the aorta at the aortic arch, which demonstrates a rim calcification. This likely reflects a pseudoaneurysm, likely chronic. 3. Diffuse cachexia, with anasarca. 4. Cholelithiasis without evidence of cholecystitis. 5. Multiple old fractures scattered throughout the pelvis, lumbar spine, as well as left ribs. No evidence of acute injury. . [**8-2**]: Chest CT 1. Moderate-to-large bilateral pleural effusions, with associated atelectasis/consolidation of the adjacent lung. 2. Focal outpouching of the aorta at the aortic arch, which demonstrates a rim calcification. This likely reflects a pseudoaneurysm, likely chronic. 3. Diffuse cachexia, with anasarca. 4. Cholelithiasis without evidence of cholecystitis. 5. Multiple old fractures scattered throughout the pelvis, lumbar spine, as well as left ribs. No evidence of acute injury. . [**8-10**]: C-spine CT 1. Multilevel degenerative changes, without evidence of fracture. 2. Left pleural effusion partially visualized. 3. Large left thyroid nodule. . [**8-10**]: Head CT No acute intracranial process. Chronic white matter, involutional parenchymal, and sinus changes, as detailed above. . [**8-10**]: Abd and pelvis/chest 1. No sign of acute traumatic injury in the chest, abdomen, or pelvis. 2. Moderate bilateral pleural effusions and relaxation atelectasis. 3. Mild periportal edema, mesenteric and small amount of free pelvic fluid, likely related to recent IV hydration. 4. Cardiac enlargement, with marked isolated enlargement of the right atrium, with overall appearance suggestive of Ebstein anomaly. If there has been no prior evaluation, consider echocardiography to evaluate for structural abnormality. 5. Cholelithiasis. 6. Diffuse atherosclerosis and coronary artery calcifications. 7. Likely old and partially-calcified pseudoaneurysm arising off the lateral aspect of the apex of the aortic arch. 8. Heterogeneous, enlarged thyroid gland. Correlate with thyroid function tests and ultrasound, as clinically indicated. 9. Multiple small pulmonary nodules measure up to 3 mm in size in the right lower lobe. Without risk factors such as smoking, or known malignancy, no specific follow-up is necessary. Otherwise, follow-up with chest CT should be performed in 12 months to evaluate for stability. 10. Hyperenhancing adrenal glands of uncertain significance. This finding has been described in the setting of hypoperfusion ("shock") complex, but other findings often seen in this setting such as bowel wall mucosal hyperenhancement and flattening of the inferior vena cava are absent. . [**8-11**]: Echo The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. . [**8-11**] CXR: Little overall change. . Recent labs: [**8-19**] WBC: 5.3 RBC: 3.36 Hct: 32.9 Plt: 157 PT: 12.8 PTT: 31.4 INR: 1.1 . Na: 139 K: 4.2 Cl: 104 HCO3: 18 BUN: 23 Creat: 0.7 Gluc: 46 . AST: 54 ALT: 144 AP: 51 Amylase: 80 Tbili: 0.9 Alb: 3.0 . Ca:8.4 Phos: 2.5 Mg: 1.9 . [**9-11**] TSH: 28 Free T4:0.65 . [**9-10**] HB-negative HAV Ab-positive . [**8-18**] pO2 55 pCO2 39 pH 7.34 . Lactate 1.1 Free Ca 1.20 . [**8-11**] urine: unremarkable . Cxs: [**8-10**] blood cx x1 coag negative staph Brief Hospital Course: # Respiratory distress: Upon arrival to the hospital, the patient was intubated for respiratory distress. Although the patient had bilateral pulmonary edema and was being treated for hospital aquired pneumonia from previous admission, she did not appear to have significant lung parenchymal disease. The patient completed an 8 day course of antibiotics on Vanco and Zosyn and oxygen requirements on the ventilator remained low. She self- extubated on [**8-11**] but had to be reintubated for hypoventilation likely secondary to sedation and central apnea. Throughout hospitalization, patient repeatedly failed pressure support ventilation and SBT secondary to these episodes of apnea. Repeat conversations with family discussing goals of care (see below) and patient was almost terminally extubated multiple times. Eventually on [**8-19**] the patient respiratory status and drive to breathe improved enough for an uncomplicated extubation. Upon discharge, the patient was breathing comfortably on room air. . # Unclear goals of care: Although the patient had been seen in palliative care and was made DNR/DNI prior to hospitalization, she was intubated in the ED. At the time, the family decided to make the patient DNR but ok to intubate. Throughout the hospitalization multiple family meetings were held to determine goals of care eventually involving consults with social work and an ethics committee. Eventually the patient was made comfort measures only. As a result, all nonessential medications were held and labortary studies were limited. . # Hypotension: Patient's initial hypotension was felt to be multifactorial, related to hypovolemia in the setting of poor PO intake, sedation and bradycardia. Sepsis was thought to be less likely as patient had no leucocytosis, fever or obvious source of infection (blood cultures, CXR, urine culture showed no abnormalities. Initial elevation of lactate was probably secondary to anaerobic metabolism in context of CPR. Initially a left femoral line was placed to allow adequate fluid resucitation. Antihypertensive home medications were held. Over her hospital course, the patient's hypotension resolved with IVF boluses as needed. At time of discharge the patient was normotensive. . # Coagulopathy: The patient initally presented with elevated PTT, INR, low platelet and low fibrinogen concerning for DIC vs liver disease (see below). On physical exam, the patient had multiple ecchymoses and oozing from femoral line. Coagulopathy was reversed using vitamin K and 2 units FFP. A complete workup of etiology of coagulopathy was deferred as the family wished to limit care. Patient was monitored initally with serial laboratory studies and then via physicqal exam alone in accordance with goals of care. . # Bradycardia: The patient had sinus bradycardia throughout most of her hospital course, HR ranging from 40-60s bpm. Etiology was secondary to cardiac dysfunction and hypothyroidism (initial TSH 28). . # Elevated troponin: The patient presented with elevated troponins without any changes in EKG, thought to be related to cardiac arrest. Troponins trended downward and serially EKGs were stable. The patient was initially started on ASA but this was held after patient became comfort measures only . # ARF: After her cardiac arrest, the patient's creatinine was elevated from baseline of 0.8 in the setting of hypovolemia and having receiving IV contrast. As goals of care were limited, extensive workup was not done. The patient's kidney function returned to baseline over her hospitalization course with IV fluid hydration. . # Transaminitis: The patient's elevated liver function tests were felt to be secondary to shock liver following cardiac arrest vs acute hepatitis. The patient had HAV IgG although a PCR was never done to confirm active infection. Serial LFTs were initially followed and trended downward. The patient had no overt signs of hepatic failure. . # Hypercholesterolemia: stable. The patient's simvistatin was discontinued once she was made comfort measures only . # Osteoporosis: stable. The patient's calcium and vitamin D were discontinued once patient was made comfort measures only . # Communication: With family. Grandson [**Doctor Last Name 3924**] can be reached by phone: C - [**Telephone/Fax (1) 79577**]; H - [**Telephone/Fax (1) 79578**]. - granddaughter [**Name (NI) 3040**] (HCP) [**Telephone/Fax (1) 79578**] (h) or [**Telephone/Fax (1) 79579**] (w) Medications on Admission: Levofloxacin 500 mg PO once a day for 5 days. Aspirin 81 mg PO once a day. Simvastatin 10 mg PO once a day. Calcium 500 with Vitamin D 500 mg(1,250mg) -200 unit PO three times a day. Discharge Medications: 1. Morphine Concentrate 20 mg/mL Solution Sig: [**7-2**] mL PO Q1H as needed for Respiratory distress. Disp:*20 mL* Refills:*0* 2. Ativan 1 mg Tablet Sig: 1-2 Tablets PO Q2H as needed for Agitation. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital **] HOSPICE Discharge Diagnosis: 1. Respiratory Failure 2. Cardiac Arrest Discharge Condition: Pt was discharged in stable condition Discharge Instructions: You were admitted becasue you were in respiratory failure. You were intubated during the admission and subsequently extubated. There were numerous family meetings and goals of care were discussed and care was transitioned towards comfort measures only. Followup Instructions: none

244,790,733,V125,V458,275,285,287,518,427,584,486,570,276,511,286,V667,401,294,496,348,574,414,440,272

{'Unspecified acquired hypothyroidism,Other nonspecific abnormal serum enzyme levels,Osteoporosis, unspecified,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Other postprocedural status,Hypocalcemia,Anemia, unspecified,Thrombocytopenia, unspecified,Acute respiratory failure,Cardiac arrest,Acute kidney failure, unspecified,Pneumonia, organism unspecified,Acute and subacute necrosis of liver,Hyposmolality and/or hyponatremia,Unspecified pleural effusion,Other and unspecified coagulation defects,Encounter for palliative care,Unspecified essential hypertension,Other persistent mental disorders due to conditions classified elsewhere,Chronic airway obstruction, not elsewhere classified,Unspecified condition of brain,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction,Coronary atherosclerosis of native coronary artery,Atherosclerosis of aorta,Pure hypercholesterolemia'}

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: Acute mental status changes PRESENT ILLNESS: Pt is an 87 yo Cantonese Speaking woman with dementia, h/o CVA, HTN, hyponatremia (thought [**3-17**] SIADH), who was brought to the ED by her family for lethargy, refusing to eat or get out of bed. She was recently admitted from [**8-2**] - [**8-7**] for weakness, poor po intake, fever, and bilateral pleural effusions. She was diagnosed with pneumonia and treated with levofloxacin. Of note, the family was becoming overwhelmed with the required care. Palliative care was consulted, and the family decided not to pursue aggressive treatment, including intubation/CPR, given that the patient has previously refused hospital, aggressive interventions/evaluations. . She has full-time care at home and lives with her daughter & grandson. At baseline, the patient spends most of her day in bed, sleeping. She will wake up to eat. She ambulates with a walker to the bathroom. The extent of her speaking is asking to go bed. She does not respond to questions. . Upon arrival to the [**Name (NI) **], pt was noted to have agonal breathing. She was immediately intubated. After intubation, pt was found to be pulseless, received CPR for 20 seconds. A left femoral CVL was placed (semi-sterile). Initial blood pressures were up to 224/150 briefly, then settled in 90s/50s. HR in 70-80s, ?junctional at one point. Temp was 99.8 rectally. Labs were sig. for WBC 6.3, HCT 33.8, Plt 87, PTT 47, INR 1.5, fibrinogen 104, lactate 9.2. ABG was 7.24/61/473 on AC 400 x 14, peep 5, FiO2 100%. CT head showed no acute process. CT torso showed bilateral pleural effusions, R>L, gallstones, heavy atherosclerotic disease of coronaries and aorta, and cardiomegaly with marked right atrial enlargement. Pt received vanc/zosyn and tylenol. With 2.7 L IVFs, lactate improved to 4.1 MEDICAL HISTORY: - CVA v. Vertebrobasilar insufficiency in [**2143**] - Hyponatremia thought to be [**3-17**] SIADH from her CVA + sellar mass - 3.2-cm sellar mass noted on CT, with right parasellar extension; followed by Dr. [**Last Name (STitle) **] of Endocrine. - Osteoporosis - Hypertension - Hypercholesterolemia - COPD (per records) - S/P Appendectomy. MEDICATION ON ADMISSION: Levofloxacin 500 mg PO once a day for 5 days. Aspirin 81 mg PO once a day. Simvastatin 10 mg PO once a day. Calcium 500 with Vitamin D 500 mg(1,250mg) -200 unit PO three times a day. ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: (on admission) . General Appearance: No acute distress, Thin, lethargic . Eyes / Conjunctiva: sclerae anicteric, unable to assess MM as pt does not open mouth . Head, Ears, Nose, Throat: unable to assess JVP due to TLC . Cardiovascular: (S1: Normal), (S2: Normal), no m/r/g appreciated . Peripheral Vascular: (Right radial pulse: Diminished), (Left radial pulse: Diminished), (Right DP pulse: Diminished), (Left DP pulse: Diminished) . Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Diminished: at right base ), limited as pt occasionally moaning and not taking deep breaths. no wheezes, rales, rhonchi appreciated . Abdominal: Soft, Non-tender, Bowel sounds present, Distended, mod distention, PEG in place with surrounding denuded area with some maceration. dressing c/d/i . Extremities: Right: Absent, Left: Absent . Musculoskeletal: Muscle wasting . Skin: Warm, no rashes . Neurologic: Responds to: Noxious stimuli, Movement: No spontaneous movement, Tone: Not assessed, RUE tone increased, LUE tone flaccid. lethargic, briefly opens eyes to sternal rub. No spontaneous movement of any 4 extremities. All 4 extremities with contractures. Increased tone of RUE. LUE flaccid. [**3-18**]+ DTRs b/l. Upgoing toe on left, equivocal on right. Unable to assess remaining neurologic exam due to MS. . FAMILY HISTORY: Noncontributory SOCIAL HISTORY: Pt lives with her daughter [**Name (NI) **] [**Known lastname **] and grandson [**Name (NI) 3924**] [**Name (NI) 13260**]. Her granddaughter [**Name (NI) 3040**] [**Name (NI) 13260**] & grandson help care for her. She stays in bed most of the day. She never smoked cigarettes, drank alcohol, or use illicit drugs. ### Response: {'Unspecified acquired hypothyroidism,Other nonspecific abnormal serum enzyme levels,Osteoporosis, unspecified,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Other postprocedural status,Hypocalcemia,Anemia, unspecified,Thrombocytopenia, unspecified,Acute respiratory failure,Cardiac arrest,Acute kidney failure, unspecified,Pneumonia, organism unspecified,Acute and subacute necrosis of liver,Hyposmolality and/or hyponatremia,Unspecified pleural effusion,Other and unspecified coagulation defects,Encounter for palliative care,Unspecified essential hypertension,Other persistent mental disorders due to conditions classified elsewhere,Chronic airway obstruction, not elsewhere classified,Unspecified condition of brain,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction,Coronary atherosclerosis of native coronary artery,Atherosclerosis of aorta,Pure hypercholesterolemia'}

CHIEF COMPLAINT: Decreased exercise tolerance PRESENT ILLNESS: Mr. [**Known lastname **] is a 56 year old male with strong family history of premature coronary artery disease and several additional cardiac risk factors. He has undergone surveillance stress testing in the past with normal results. Approximately one month ago, he began to notice a decrease in exercise tolerance. Subsequent stress test was abnormal. He therefore underwent cardiac cathterization on [**2186-9-28**] which revealed severe three vessel coronary artery disease. LVEDP was 23mmHg and LV gram showed an EF of 52% with mild inferior hypokinesis. Based upon the above, he was referred for surgical revascularization. MEDICAL HISTORY: Coronary artery disease Hypertension Hypercholesterolemia History of possible lacunar infarction [**2179**] Gastroesophogeal Reflux Disease Knee Arthritis s/p right knee surgery Hemorrhoids Seasonal Allergies MEDICATION ON ADMISSION: Aspirin 81 qd, Lotrel 10/20 qd, Crestor 10 qd, Metoprolol Succinate 25 qd, Vitamin E 400 IU qd, Viagra prn, Zantac prn, Fexofenadine prn, Motrin prn, Flexeril prn ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: General: WDWN male in no acute distress HEENT: Oropharynx benign, EOMI Neck: Supple, no JVD Lungs: CTA bilaterally Heart: Regular rate and rhythm Abdomen: Soft, nontender with normoactive bowel sounds Ext: Warm, no edema Pulses: 2+ distally Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal deficits noted FAMILY HISTORY: Brother died from MI at age 37. Father had angina but died of cancer in his 50's. SOCIAL HISTORY: Denies tobacco history. Married with two children. Works as a bus driver.

Coronary atherosclerosis of native coronary artery,Intermediate coronary syndrome,Atrial fibrillation,Unspecified essential hypertension,Pure hypercholesterolemia,Personal history of other diseases of circulatory system,Family history of ischemic heart disease,Esophageal reflux,Internal hemorrhoids without mention of complication,Other allergy, other than to medicinal agents

Crnry athrscl natve vssl,Intermed coronary synd,Atrial fibrillation,Hypertension NOS,Pure hypercholesterolem,Hx-circulatory dis NEC,Fam hx-ischem heart dis,Esophageal reflux,Int hemorrhoid w/o compl,Hx-allergy NEC

Admission Date: [**2186-10-4**] Discharge Date: [**2186-10-9**] Date of Birth: [**2129-12-9**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Decreased exercise tolerance Major Surgical or Invasive Procedure: [**2186-10-4**] Four Vessel CABG(LIMA to LAD, SVG to PDA, SVG to OM with vein to vein graft to diagonal artery) History of Present Illness: Mr. [**Known lastname **] is a 56 year old male with strong family history of premature coronary artery disease and several additional cardiac risk factors. He has undergone surveillance stress testing in the past with normal results. Approximately one month ago, he began to notice a decrease in exercise tolerance. Subsequent stress test was abnormal. He therefore underwent cardiac cathterization on [**2186-9-28**] which revealed severe three vessel coronary artery disease. LVEDP was 23mmHg and LV gram showed an EF of 52% with mild inferior hypokinesis. Based upon the above, he was referred for surgical revascularization. Past Medical History: Coronary artery disease Hypertension Hypercholesterolemia History of possible lacunar infarction [**2179**] Gastroesophogeal Reflux Disease Knee Arthritis s/p right knee surgery Hemorrhoids Seasonal Allergies Social History: Denies tobacco history. Married with two children. Works as a bus driver. Family History: Brother died from MI at age 37. Father had angina but died of cancer in his 50's. Physical Exam: General: WDWN male in no acute distress HEENT: Oropharynx benign, EOMI Neck: Supple, no JVD Lungs: CTA bilaterally Heart: Regular rate and rhythm Abdomen: Soft, nontender with normoactive bowel sounds Ext: Warm, no edema Pulses: 2+ distally Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal deficits noted Pertinent Results: [**2186-10-4**] INTRAOP TEE PRE-BYPASS: 1. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses are normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 5. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. 6. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. [**2186-10-4**] INTRAOP TEE POST-BYPASS: 1. Biventricular function is maintained (LVEF 50-55%). 2. Aortic contours are intact post-decannulaton. CHEST (PA & LAT) [**2186-10-9**] 8:16 AM There has been previous median sternotomy and coronary artery bypass surgery. Postoperative mediastinal widening has improved with only minimal residual widening remaining compared to the preoperative radiograph. Very small left apical pneumothorax is present and is in retrospect unchanged from the previous study but was more difficult to identify prospectively due to portable technique on the previous exam. Bibasilar retrocardiac areas of atelectasis are present, with slight improvement in the left retrocardiac area. Bilateral small pleural effusions are present, left greater than right. On the lateral view, a small focus of gas is present in the retrosternal region, and is likely related to recent surgery. IMPRESSION: 1. Very small left apical pneumothorax. 2. Bibasilar atelectasis and small pleural effusions, left greater than right. [**2186-10-9**] 07:10AM BLOOD WBC-6.4 RBC-3.58* Hgb-10.9* Hct-31.7* MCV-89 MCH-30.4 MCHC-34.2 RDW-13.4 Plt Ct-294# [**2186-10-7**] 01:20PM BLOOD WBC-7.0 RBC-3.42* Hgb-10.4* Hct-30.2* MCV-88 MCH-30.5 MCHC-34.5 RDW-13.3 Plt Ct-193# [**2186-10-9**] 07:10AM BLOOD Plt Ct-294# [**2186-10-7**] 01:20PM BLOOD Plt Ct-193# [**2186-10-5**] 02:19AM BLOOD PT-12.9 PTT-30.0 INR(PT)-1.1 [**2186-10-9**] 07:10AM BLOOD Glucose-96 UreaN-19 Creat-1.0 Na-144 K-4.3 Cl-106 HCO3-30 AnGap-12 Brief Hospital Course: Mr. [**Known lastname **] was admitted and underwent four vessel coronary artery bypass grafting by Dr. [**Last Name (STitle) **]. For surgical details, please see seperate dictated operative note. Following the operation, he was brought to the CVICU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated without incident. He maintained stable hemodynamics and transferred to the SDU on postoperative day two. He developed atrial fibrillation on postoperative day two and was treated with an increase in his beta blockade and amiodarone. He remained in a sinus rhythm and was ready for dicharge home on POD #5. Medications on Admission: Aspirin 81 qd, Lotrel 10/20 qd, Crestor 10 qd, Metoprolol Succinate 25 qd, Vitamin E 400 IU qd, Viagra prn, Zantac prn, Fexofenadine prn, Motrin prn, Flexeril prn Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*30 Capsule(s)* Refills:*0* 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 3. 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* 4. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*50 Tablet(s)* Refills:*0* 6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400 mg [**Hospital1 **] x 3 day then 400 mg daily x 1 week, then 200 mg ongoing until discontinued by Dr. [**Last Name (STitle) 4469**]. Disp:*120 Tablet(s)* Refills:*0* 7. Lopressor 50 mg Tablet Sig: 1.5 Tablets PO three times a day. Disp:*135 Tablet(s)* Refills:*0* 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. Disp:*10 Tablet(s)* Refills:*0* 9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 5 days. Disp:*20 Capsule, Sustained Release(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Coronary artery disease - s/p CABG Postop Atrial Fibrillation Hypertension Hypercholesterolemia History of possible lacunar infarction [**2179**] Discharge Condition: Good Good Discharge Instructions: 1)Please shower daily. No baths. Pat dry incisions, do not rub. 2)Avoid creams and lotions to surgical incisions. 3)Call cardiac surgeon if there is concern for wound infection. 4)No lifting more than 10 lbs for at least 10 weeks from surgical date. 5)No driving for at least one month. Followup Instructions: Dr. [**Last Name (STitle) **] in [**3-16**] weeks, call for appt Dr. [**Last Name (STitle) 4469**] in [**1-14**] weeks, call for appt Dr. [**Last Name (STitle) **] in [**3-16**] weeks, call for appt [**Telephone/Fax (1) 170**] Dr. [**Last Name (STitle) 4469**] in [**1-14**] weeks, call for appt [**Telephone/Fax (1) 4475**] Wound check appointment - please schedule with RN [**Telephone/Fax (1) 3633**] Completed by:[**2186-10-9**]

414,411,427,401,272,V125,V173,530,455,V150

{'Coronary atherosclerosis of native coronary artery,Intermediate coronary syndrome,Atrial fibrillation,Unspecified essential hypertension,Pure hypercholesterolemia,Personal history of other diseases of circulatory system,Family history of ischemic heart disease,Esophageal reflux,Internal hemorrhoids without mention of complication,Other allergy, other than to medicinal agents'}

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: Decreased exercise tolerance PRESENT ILLNESS: Mr. [**Known lastname **] is a 56 year old male with strong family history of premature coronary artery disease and several additional cardiac risk factors. He has undergone surveillance stress testing in the past with normal results. Approximately one month ago, he began to notice a decrease in exercise tolerance. Subsequent stress test was abnormal. He therefore underwent cardiac cathterization on [**2186-9-28**] which revealed severe three vessel coronary artery disease. LVEDP was 23mmHg and LV gram showed an EF of 52% with mild inferior hypokinesis. Based upon the above, he was referred for surgical revascularization. MEDICAL HISTORY: Coronary artery disease Hypertension Hypercholesterolemia History of possible lacunar infarction [**2179**] Gastroesophogeal Reflux Disease Knee Arthritis s/p right knee surgery Hemorrhoids Seasonal Allergies MEDICATION ON ADMISSION: Aspirin 81 qd, Lotrel 10/20 qd, Crestor 10 qd, Metoprolol Succinate 25 qd, Vitamin E 400 IU qd, Viagra prn, Zantac prn, Fexofenadine prn, Motrin prn, Flexeril prn ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: General: WDWN male in no acute distress HEENT: Oropharynx benign, EOMI Neck: Supple, no JVD Lungs: CTA bilaterally Heart: Regular rate and rhythm Abdomen: Soft, nontender with normoactive bowel sounds Ext: Warm, no edema Pulses: 2+ distally Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal deficits noted FAMILY HISTORY: Brother died from MI at age 37. Father had angina but died of cancer in his 50's. SOCIAL HISTORY: Denies tobacco history. Married with two children. Works as a bus driver. ### Response: {'Coronary atherosclerosis of native coronary artery,Intermediate coronary syndrome,Atrial fibrillation,Unspecified essential hypertension,Pure hypercholesterolemia,Personal history of other diseases of circulatory system,Family history of ischemic heart disease,Esophageal reflux,Internal hemorrhoids without mention of complication,Other allergy, other than to medicinal agents'}

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is a 68-year-old male with substernal chest pain, status post cardiac catheterization two years prior. He has positive stress teat and cardiac catheterization at an outside hospital revealed a 50% to 55% stenosis of his left main and 80% of the LAD. The patient was transferred to the [**Hospital1 188**] for further management. MEDICAL HISTORY: 1. Hypertension. 2. Coronary artery disease. 3. Status post salivary gland removal in [**2121**]. MEDICATION ON ADMISSION: ALLERGIES: The patient is allergic to SULFA DRUGS. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: No cigarette smoking, no ethanol abuse.

Coronary atherosclerosis of native coronary artery,Atrial fibrillation,Dermatitis due to drugs and medicines taken internally,Other specified antibiotics causing adverse effects in therapeutic use,Examination of participant in clinical trial,Anemia, unspecified,Unspecified essential hypertension

Crnry athrscl natve vssl,Atrial fibrillation,Drug dermatitis NOS,Adv eff antibiotics NEC,Exam-clincal trial,Anemia NOS,Hypertension NOS

Admission Date: [**2146-1-4**] Discharge Date: Date of Birth: [**2076-12-7**] Sex: M Service: HISTORY OF THE PRESENT ILLNESS: The patient is a 68-year-old male with substernal chest pain, status post cardiac catheterization two years prior. He has positive stress teat and cardiac catheterization at an outside hospital revealed a 50% to 55% stenosis of his left main and 80% of the LAD. The patient was transferred to the [**Hospital1 188**] for further management. PAST MEDICAL HISTORY: 1. Hypertension. 2. Coronary artery disease. 3. Status post salivary gland removal in [**2121**]. MEDICATIONS: 1. Atenolol 25 once a day. 2. Aspirin 325 once a day. 3. Lipitor 10 once a day. ALLERGIES: The patient is allergic to SULFA DRUGS. SOCIAL HISTORY: No cigarette smoking, no ethanol abuse. After review of films, it was determined that the right RCA also had 60% occlusion and his ER 60% by echocardiogram. He had preserved EF. HOSPITAL COURSE: He was taken to the operating room on [**2146-1-5**] with the diagnosis of coronary artery disease. He had a CABG times four done by Dr. [**Last Name (STitle) 70**]. Postoperatively, the patient was transferred to the Cardiothoracic Intensive Care Unit, where he was extubated and transferred to the floor on postoperative day #1. The patient required some Neodrips for pressor support. He was not transferred to the floor until the evening of [**2146-1-7**], after being weaned. Postoperatively, the patient was doing well. Foley catheter was discontinued. Wires were discontinued. Chest tube was discontinued. However, the patient pulled the wires, suffered some atrial fibrillation. The patient was given Lopressor and Amiodarone. A light rash was noted and the patient's physical examination remained benign. This was discussed and some Benadryl was started. On [**2146-1-9**] it was noted that the patient's rash seemed stable. He remained in atrial fibrillation. Amiodarone was given, Magnesium, otherwise, he was at no time hemodynamically unstable. The Gram stain of his sputum showed 3 to 4 gram negative rods, which eventually grew out Serratia. The patient was noted on postoperative day #5, [**2146-1-10**] to have a white count of 29.7, remained in atrial fibrillation with a blood pressure, which was relatively low at 86/50 nonsymptomatic. He was transferred to the Intensive Care Unit for pressor support, if required while being given Lopressor. The Department of Dermatology was called and they stated that we should discontinue any unnecessary medications and start topical creams and ointments as well as Zyrtec every night and topical steroids such as Lidex, which was done. On [**2146-1-11**] the patient remained on Ancef, Amiodarone, Lopressor and Heparin for anticoagulation. The patient was doing relatively well. The rest of his Intensive Care Unit stay was uneventful. He maintained his pressure without the requirement for Neomycin. He was started on Augmentin on [**2146-1-12**]. He was transferred to the back to the floor without incident. The Department of Infectious Disease was called that same day because the patient's white count had now gone to 32. Infectious Disease recommended blood cultures and urine cultures. They recommended us discontinuing Augmentin, which was done and they felt that the reaction was allergic to a medication he had received, which was consistent with the eosinophilia seen on the peripheral differential. This was done and a C.difficile culture was also sent because it was felt that the C. difficile could also cause white counts to be high. The C. difficile specimen returned negative. The patient's wound, throughout all these events, remained stable with no discharge. The patient was ambulating very well to level 5 in the hospital mainly because of his rash. It was noted that he had fluid on his foot and arms, which were noninfected looking and left alone for the time being on [**2146-1-14**]. Final discharge summary to follow. Another addendum will be inserted regarding the final disposition and the discharge medications. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 02-358 Dictated By:[**Name8 (MD) 16758**] MEDQUIST36 D: [**2146-1-14**] 13:18 T: [**2146-1-14**] 13:29 JOB#: [**Job Number 38473**] Name: [**Known lastname 6963**], [**Known firstname **] Unit No: [**Numeric Identifier 6964**] Admission Date: [**2146-1-4**] Discharge Date: [**2146-1-16**] Date of Birth: [**2076-12-7**] Sex: M Service: DISCHARGE SUMMARY ADDENDUM: Over the ensuing days the patient continued to do well. He was afebrile, white count had diminished. The patient was discharged home in stable condition to follow up with Dr. [**Last Name (STitle) 71**] within two weeks of discharge or as needed. DISCHARGE MEDICATIONS: 1. Aspirin 325 milligrams po q day. 2. Colace 100 milligrams po q day. 3. Lipitor 10 milligrams po q HS. 4. Zyrtec 10 milligrams po q HS. 5. Lopressor 50 milligrams po bid. 6. Lasix 10 milligrams po bid. 7. Potassium Chloride 20 milligrams po bid. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 2728**] Dictated By:[**Last Name (NamePattern1) 5280**] MEDQUIST36 D: [**2146-1-16**] 08:34 T: [**2146-1-17**] 11:45 JOB#: [**Job Number 6965**] Admission Date: [**2146-1-4**] Discharge Date: [**2146-1-18**] Date of Birth: [**2076-12-7**] Sex: M Service: ADDENDUM: The patient, on [**2146-1-14**], was doing well and Physical Therapy was involved. The patient was doing a Level IV. Infectious Disease and Immunology were following along. Allergy felt that the pitting in the skin was most likely related to the diuretics, and possibly other medications. They advised continuing with Zyrtec and Benadryl ointment to the itchy area over his skin, avoiding vancomycin, amiodarone and Toradol and penicillin. Nothing grew out positive. The patient was doing well and the rash was improving and the skin desquamation was going down. The patient remained with low-grade temperature and a white blood cell count was down to 12 by [**2146-1-17**]. The decision was made to discharge the patient on [**2146-11-17**] after his white count had decreased and he was afebrile and vital signs were stable, with only a low-grade temperature. DISCHARGE MEDICATIONS: 1. Potassium chloride 20 mEq twice a day for 15 days supply, but only meant to be taken when the patient is taking lasix 2. Lasix 20 mg by mouth twice a day for five days 3. Lidex ointment to the affected areas 4. Percocet one to two tablets by mouth every four to six hours as needed for pain 5. Lopressor 50 mg by mouth twice a day 6. Zyrtec 10 mg daily at bedtime, given 30 7. Lipitor 10 mg by mouth once daily, dispensed 30 The patient is to follow up with his primary care physician within three weeks, and is doing well upon discharge. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 02-358 Dictated By:[**Name8 (MD) 16758**] MEDQUIST36 D: [**2146-1-17**] 23:41 T: [**2146-1-18**] 00:09 JOB#: [**Job Number 32332**] Admission Date: [**2146-1-4**] Discharge Date: [**2146-1-19**] Date of Birth: [**2076-12-7**] Sex: M Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: This is a 60-year-old male with a past medical history significant for hypertension, coronary artery disease diagnosed in [**2142**], who had a cardiac catheterization done at that time which showed 3-vessel coronary artery disease. He was managed medically. He subsequently wanted a second opinion. He later had a positive stress and repeat cardiac catheterization which revealed 30% to 55% left main disease and 80% left anterior descending artery disease. The patient was then referred for coronary artery bypass grafting. ALLERGIES: The patient has an allergy to SULFA DRUGS. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission revealed the patient was neurologically intact. Cranial nerves II through XII were intact. The patient had no jugular venous distention. Pupils were equal, round, and reactive to light and accommodation. No bruits. Lungs were clear. Heart was regular in rate and rhythm, normal first heart sound and second heart sound. The abdomen soft and nontender, normal active bowel sounds. Extremities revealed the patient had good veins, 2+ distal pulses. HOSPITAL COURSE: The patient underwent coronary artery bypass graft on [**2146-1-5**] with left internal mammary artery to the diagonal, saphenous vein graft to the right coronary artery and right posterior descending artery sequential, and saphenous vein graft to the obtuse marginal. The patient arrived to the unit with ST elevations. An electrocardiogram was done as well as a transesophageal echocardiogram, and they felt that there was no wall motion abnormalities. The patient was on intravenous nitroglycerin which was turned off due to the patient's hypotension. The patient had frequent premature atrial contractions and rare premature ventricular contractions with a heart rate in the 110s, so the patient received some intravenous Lopressor times two with good affect to bring the heart rate down to the 90s, with a systolic blood pressure of 100 to 150s. A red/warm rash was noted over the back, trunk and thigh, and the patient complained of feeling claustrophobic. On postoperative day one, the patient's temperature maximum was 100.8, temperature current of 99.8, blood pressure 95/53, heart rate 101, in sinus tachycardia. The patient was satting at 99% on 4 liters nasal cannula. On physical examination, the patient's lungs were clear to auscultation bilaterally. Heart had a regular rate and rhythm. The abdomen was soft, nontender, and nondistended. Extremities were warm. Chest tube output total was 405. White blood cell count of 10.8, hematocrit of 26.9, platelet count of 129. Sodium 136, potassium 4.5, blood urea nitrogen 11, creatinine 0.8, glucose of 134. Magnesium of 2, and calcium of 1.14. The plan was to transfer the patient to the floor. There was no progression of the patient's rash. The skin was intact without breakdown. On postoperative day two, the patient's temperature was 99.5, heart rate 82, in normal sinus rhythm, blood pressure of 103/54, satting at 100% on 4 liters of nasal cannula. The patient was awake and alert. Lungs were clear to auscultation bilaterally. Wound incisions were clean, dry, and intact. Heart was regular in rate and rhythm. The abdomen was benign. Extremities were benign. Chest tube output was 98 on the last shift. White blood cell count was up at 13.3, hematocrit was down at 23.3, with platelets of 139. Sodium of 137, potassium of 4.6, blood urea nitrogen of 13, creatinine of 0.8, with a glucose of 131. Calcium was 1.15 with a magnesium of 1.5. The plan was to wean the Neo-Synephrine, to discontinue the chest tube, continue Lopressor. Question of transfusing because the patient has no transfusion history; will discuss with Dr. [**Last Name (STitle) 70**]. The plan was to transfer to the floor if off Neo-Synephrine. On postoperative day three, the patient's temperature maximum was 99.6, temperature current 98.3, heart rate 64, blood pressure 104/60, satting at 97% on 2 liters. The patient was in sinus rhythm. A few premature atrial contractions. On physical examination heart had a regular rate and rhythm. Lungs were clear to auscultation bilaterally. Chest tubes were in place. Wires were in place. Wounds were all right. Laboratories revealed white blood cell count of 7.3, hematocrit of 25.8, platelet count of 112. Sodium of 134, potassium of 4.5, blood urea nitrogen of 16, creatinine of 0.9, with a glucose of 95. The plan was to discontinue Foley and to replete electrolytes. The Cardiothoracic Service also noted the patient with a diffuse rash. No respiratory distress. No wheezing. Saturations were all right. Vital signs were stable. Chest tubes and wires were discontinued. The plan was to administer Benadryl, attributing the rash to the patient's antibiotics (to the patient's Vancomycin). On postoperative day four, temperature maximum of 101.4, temperature current of 99.4, heart rate 100, blood pressure 102/60, satting at 95% on 2 liters. The patient was in and out of atrial fibrillation with sinus rhythm and premature atrial contractions. Lopressor was given yesterday. Chest x-ray yesterday showed no consolidation, and no pneumonia. On physical examination the lungs were clear. Heart had a regular rhythm. The wounds had no discharge or erythema. Laboratories were pending. The plan was to start amiodarone. Gram stain showed 3 to 4+ gram-negative rods. They began Levaquin. At 12:30 p.m. the patient was found to be in atrial fibrillation. They started amiodarone. At 8:30 p.m. on [**1-9**], Cardiothoracic Surgery was called for a temperature of 101.4. Blood pressure was 84/50. The patient had received Lopressor in the morning, amiodarone, and Levaquin. The patient was transferred back to the unit alert and oriented times three with complaints of sweats. No shortness of breath, and no chest pain. Lungs were clear to auscultation bilaterally. Heart was tachycardic. The abdomen was soft. Hematocrit was 31. White blood cell count was 12. Potassium was 4.2. Calcium was 7.8, magnesium of 1.8. Blood pressure increased to 98/40 on its own, heart rate 110 but irregular. The plan was to decrease the Lopressor, and the patient was on Levaquin and to check culture. On postoperative day five, the patient's temperature maximum was 101.7, temperature current was 101, heart rate in the 100s, blood pressure 86/50. White blood cell count had increased to 20.7. Blood cultures were pending. On physical examination heart was irregularly irregular. Lungs were clear to auscultation bilaterally. Sternal wounds had no discharge, no click, and no erythema. Leg wounds had no discharge; however, there was some ecchymosis. The plan was to follow up with the culture and check x-ray, continue him on his amiodarone. Dermatology was asked to evaluate the patient for the patient's skin eruption. They recommended discontinuing any unnecessary medications, use topical Sarna p.r.n., antihistamines (preferably Zyrtec 10 mg p.o. q.6h.), and topical steroids (Lidex ointment b.i.d.). On postoperative day six, the patient was on Ancef, amiodarone, and heparin. The patient's temperature maximum was 102.2, temperature current was 100.5, heart rate 111, in sinus tachycardia, blood pressure 100/54, satting at 93% on nasal cannula. The patient was awake and alert. Lungs were clear to auscultation bilaterally. Heart had a regular rate and rhythm; however, tachycardic. The abdomen was benign. Extremities were benign. Skins was still with erythematous rash persisting. White blood cell count was up to 25, and hematocrit was down to 26.4. Sodium 131, potassium 4.4, blood urea nitrogen 21, creatinine 1.1, with a glucose of 117. Calcium of 1.06. The plan was to continue amiodarone, check the coagulations because of the heparin, continue Ancef. On postoperative day seven, the patient's temperature maximum was 100.8, temperature current 96.9, heart rate in sinus tachycardia at 102, blood pressure 98/44, satting at 93%. The patient was awake and alert, on heparin and Augmentin. The lungs were clear to auscultation bilaterally. Dressings were clean, dry, and intact. Heart had a regular rate and rhythm; however, tachycardic. The abdomen was benign. The lower extremities were benign. The patient's white blood cell count was up to 27.5, hematocrit was down to 25.9, platelets of 242. Sodium 134, potassium 4.1, blood urea nitrogen 21, creatinine 0.9, with a glucose of 89. The plan was to transfer the patient to the floor. Infectious Disease came by to see the patient on [**1-12**]. The patient with increased leukocytosis without localizing symptoms. They recommended following the complete blood count. Blood cultures through C-line and peripherally. Discontinue Augmentin if the patient develops diarrhea. They would also send stool for Clostridium difficile toxin assay and empirically start metronidazole. If there were any changes in the chest wound, they would image with CT and initiate empiric coverage from gram-negative rods and gram-positive cocci with levofloxacin. Infectious Disease came by and saw the patient again [**1-13**]. They noted the patient to have a diffuse erythematous rash but was thought likely secondary to drugs; now with persistent increased white blood cell count. The plan was as previously stated. Still concern for Clostridium difficile. The plan was also to discontinue Augmentin. The patient had no cough and no infiltrate on the chest x-ray, and it may be worsening Clostridium difficile. On postoperative day eight, the patient's temperature maximum was 99.6, temperature current was 99.4, heart rate 100, blood pressure of 100/43, satting at 95% on room air. The patient was transferred out of the unit with a white blood cell count of 32 yesterday. The patient was stable on the floor. The patient remained red and afebrile. His sternal wound was clean with no discharge and no click. The left leg was slightly erythematous with no infection. The plan was to discontinue Augmentin per Infectious Disease request and continue the current regimen. On postoperative day nine, the patient's temperature maximum was 99.8, temperature current was 99.6, heart rate of 104, blood pressure of 116/56, satting at 94% on room air. The rash was better. The patient was in regular rhythm at this time. Lungs were clear to auscultation bilaterally. Sternal wound with no discharge and no erythema. Leg wounds with no cellulitis. The plan was to increase Lopressor to 50 mg p.o. b.i.d. Infectious Disease came by and saw the patient again on [**1-14**]. They recommended to continue to monitor the patient off of antibiotics, check the Clostridium difficile two more times, monitor the bullous lesions. They did not think that antibiotics were needed at that point. Allergy and Immunology came by and saw the patient on [**1-14**]. They were asked to consult with the patient regarding severe dermatitis. They recommended to continue Zyrtec 10 mg p.o. q.d., plus Benadryl 25 mg to 50 mg p.o. q.6h. p.r.n., moisturizer to the face and dry skin, Lidex ointment b.i.d. to t.i.d. to the itchy areas, avoid vancomycin, amiodarone and Toradol for now. Try to eliminate as many medications as possible. Avoid penicillins unless absolutely necessary. Continue to pursue sources of infection, as the increased white blood cell count with increased neutrophils and bands were concerning. Infectious Disease came by and saw the patient on [**1-15**]. They assessed that the leukocytosis was still continuing to resolve without antimicrobial coverage. The wound appeared clean. No diarrhea, just Clostridium difficile. No active infectious process was seen. Follow white blood cell count off the antibiotics. On postoperative day 10, the patient was afebrile, with a heart rate of 89, blood pressure of 102/52, satting at 96%. The lungs were clear to auscultation bilaterally. Heart was regular in rate and rhythm. The abdomen was benign. Extremities were benign. The patient was doing well. Infectious Disease came by and saw the patient on [**1-16**]. They recommended to follow white blood cell count if the patient's spikes again. The patient needed a fever workup with blood cultures, urinalysis, urine culture, and chest x-ray, and continued to state that the patient did not need any antibiotics at this point. On postoperative day 11, the patient with premature atrial contractions this morning. Temperature maximum was 99.1, heart rate of 90, blood pressure of 109/65, satting at 99%. Heart was regular in rate and rhythm. Lungs were clear to auscultation bilaterally. The abdomen was benign. The rash was improving. On postoperative day 12, temperature maximum and temperature current were 100.9. White blood cell count of 12, hematocrit of 24.3, platelets of 491. Sodium of 129, potassium of 4.3, blood urea nitrogen of 13, creatinine of 1, glucose of 108. The patient's rhythm was slightly irregular. His skin was peeling on physical examination. The sternal wounds and leg wounds were all right with no discharge. Infectious Disease came by and saw the patient on [**1-17**]. They were informed that the patient continued to have temperatures all day yesterday. The lowest temperature was 100.3; however, examination was nonfocal. They agreed that the central line may be the source. They recommended checking blood cultures times two to rule out bacteremia and await catheter tip results. They recommended that if there is a line infection, if the line is already out, but depending on the organisms may need a short course of antibiotics. Allergy and Immunology also came by and saw the patient on [**1-17**], and they recommended discontinuing the antihistamine and topical steroids and use moisturizing lotion p.r.n. The patient may follow up as an outpatient for further advice regarding medical allergies and possible testing to penicillin. Infectious Disease came and saw the patient on [**1-18**]. The patient had a spike to 101.2 the night prior with no blood cultures drawn. Still nothing focal on the examination. Likely related to his central line. Awaiting the cultures on the central line tip, and the plan was to follow the cultures. If the patient re-spiked, they recommended further fever workup. On postoperative day 13, the patient's temperature maximum was 101.2, temperature current 99.8, heart rate 91, blood pressure of 117/68, satting at 100% on room air. Heart was regular. Lungs were more clear at the bilateral bases. The incisions were clean with no discharge. The patient's skin was still peeling from the rash. The plan was to follow up with the cultures and to check urinalysis. Infectious Disease came by and saw the patient on [**1-19**]. They stated that since the patient remained afebrile overnight, with a white blood cell count at 5.9, and blood cultures were negative, catheter tip was negative, the patient was not declaring an active infection at that time, they would sign off for now. On physical examination the patient was alert and oriented times three, moved all of his extremities, conversational. Respiratory wise he was clear to auscultation bilaterally. Heart was regular in rate and rhythm with first heart sound and second heart sound. No murmurs. His sternum was stable. The incision with Steri-Strips and was clean and dry. The abdomen was soft, nontender, and nondistended, with normal active bowel sounds. Extremities were warm and well perfused. No clubbing, cyanosis or edema. The patient was still with a generalized rash which was resolving; however, he was still with skin peeling, especially in the arms and groin. The patient's preoperative weight was 66.4 kg; discharge weight was 68 kg. Laboratories revealed white blood cell count of 5.9, hematocrit of 26.4, with a platelet count of 488. Sodium of 133, potassium of 4.5, blood urea nitrogen of 17, creatinine of 1, with a glucose of 101. DISCHARGE STATUS: The patient was discharged home. MEDICATIONS ON DISCHARGE: 1. Aspirin 325 mg p.o. q.d. 2. Lopressor 50 mg p.o. b.i.d. 3. Lipitor 10 mg p.o. q.d. 4. Colace 100 mg p.o. b.i.d. 5. Percocet one to two tablets p.o. q.4h. p.r.n. for pain. CONDITION AT DISCHARGE: The patient's condition on discharge was stable. DISCHARGE FOLLOWUP: The patient was to follow up with [**Hospital 409**] Clinic in two weeks. Follow up with Dr. [**Last Name (STitle) 70**] in four to six weeks. Follow up with Dermatology and the Allergy Service as needed. DISCHARGE DIAGNOSES: Coronary artery disease. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Doctor Last Name 182**] MEDQUIST36 D: [**2146-1-19**] 10:46 T: [**2146-1-20**] 15:12 JOB#: [**Job Number 38474**]

414,427,693,E930,V707,285,401

{'Coronary atherosclerosis of native coronary artery,Atrial fibrillation,Dermatitis due to drugs and medicines taken internally,Other specified antibiotics causing adverse effects in therapeutic use,Examination of participant in clinical trial,Anemia, unspecified,Unspecified essential hypertension'}

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 68-year-old male with substernal chest pain, status post cardiac catheterization two years prior. He has positive stress teat and cardiac catheterization at an outside hospital revealed a 50% to 55% stenosis of his left main and 80% of the LAD. The patient was transferred to the [**Hospital1 188**] for further management. MEDICAL HISTORY: 1. Hypertension. 2. Coronary artery disease. 3. Status post salivary gland removal in [**2121**]. MEDICATION ON ADMISSION: ALLERGIES: The patient is allergic to SULFA DRUGS. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: No cigarette smoking, no ethanol abuse. ### Response: {'Coronary atherosclerosis of native coronary artery,Atrial fibrillation,Dermatitis due to drugs and medicines taken internally,Other specified antibiotics causing adverse effects in therapeutic use,Examination of participant in clinical trial,Anemia, unspecified,Unspecified essential hypertension'}

CHIEF COMPLAINT: PRESENT ILLNESS: This is a 49 year-old woman with restrictive lung disease, diastolic heart failure, obstructive sleep apnea, requiring BiPAP and mental retardation who presented with mental status changes and increased lower extremity edema. She was found to be hypoxic at an O2 of 64% room air, unresponsive on arrival. The patient was also bradycardic on arrival and given Atropine and diuresis. The patient was also given BiPAP. Also in the Emergency Room the patient was found to be in acute renal failure and is immediately transferred to the Medical Intensive Care Unit. In the Intensive Care Unit the patient was given BiPAP and diuresed initially. The patient was hypercapnic initially. These levels were monitored with modest improvement on BiPAP. The patient was also thought to be in left heart failure, however, echocardiogram was performed, which showed evidence of right heart failure. The patient's creatinine and liver function tests were increased. Renal and abdominal ultrasound showed no abnormalities. These levels were monitored and trended toward normal. The patient's beta blocker was held in the Intensive Care Unit as she was bradycardic. The patient was also treated empirically for pneumonia with Ceftriaxone and Flagyl. The patient had mild improvement of mental status and was transferred to the Medical Floor on Azithromycin. MEDICAL HISTORY: 1. Restrictive lung disease FEV1 to FVC ratio 79, which is 104% predicted, decreased DLCO. 2. Obstructive sleep apnea on home BiPAP. 3. Pulmonary hypertension. 4. Diabetes hypertension. 5. Congestive heart failure with diastolic dysfunction. 6. Panhypopituitarism secondary to empty sella, low thyroid, adrenal insufficiency, diabetes insipidus. 7. Mental retardation. MEDICATION ON ADMISSION: ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: Smokes two packs per day. She lives with her daughter who assists her in her activities of daily living.

Congestive heart failure, unspecified,Other emphysema,Acute respiratory failure,Acute kidney failure, unspecified,Acidosis,Thrombocytopenia, unspecified,Panhypopituitarism,Hepatomegaly

CHF NOS,Emphysema NEC,Acute respiratry failure,Acute kidney failure NOS,Acidosis,Thrombocytopenia NOS,Panhypopituitarism,Hepatomegaly

Admission Date: [**2116-1-22**] Discharge Date: [**2116-1-26**] Date of Birth: [**2066-10-13**] Sex: F Service: [**Hospital1 **] HISTORY OF PRESENT ILLNESS: This is a 49 year-old woman with restrictive lung disease, diastolic heart failure, obstructive sleep apnea, requiring BiPAP and mental retardation who presented with mental status changes and increased lower extremity edema. She was found to be hypoxic at an O2 of 64% room air, unresponsive on arrival. The patient was also bradycardic on arrival and given Atropine and diuresis. The patient was also given BiPAP. Also in the Emergency Room the patient was found to be in acute renal failure and is immediately transferred to the Medical Intensive Care Unit. In the Intensive Care Unit the patient was given BiPAP and diuresed initially. The patient was hypercapnic initially. These levels were monitored with modest improvement on BiPAP. The patient was also thought to be in left heart failure, however, echocardiogram was performed, which showed evidence of right heart failure. The patient's creatinine and liver function tests were increased. Renal and abdominal ultrasound showed no abnormalities. These levels were monitored and trended toward normal. The patient's beta blocker was held in the Intensive Care Unit as she was bradycardic. The patient was also treated empirically for pneumonia with Ceftriaxone and Flagyl. The patient had mild improvement of mental status and was transferred to the Medical Floor on Azithromycin. PAST MEDICAL HISTORY: 1. Restrictive lung disease FEV1 to FVC ratio 79, which is 104% predicted, decreased DLCO. 2. Obstructive sleep apnea on home BiPAP. 3. Pulmonary hypertension. 4. Diabetes hypertension. 5. Congestive heart failure with diastolic dysfunction. 6. Panhypopituitarism secondary to empty sella, low thyroid, adrenal insufficiency, diabetes insipidus. 7. Mental retardation. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Atenolol 100 mg once a day. 2. Lasix 20 mg once a day. 3. Synthroid 50 mg once a day. 4. DDAVP 0.1 mg b.i.d. 5. Colace. 6. Aspirin 81 mg once a day. 7. Calcium carbonate 500 mg t.i.d. 8. Zantac 150 mg po b.i.d. 9. Combivent one to two puffs every four hours prn. SOCIAL HISTORY: Smokes two packs per day. She lives with her daughter who assists her in her activities of daily living. LABORATORIES ON TRANSFER: Hematocrit 30.3, platelets 105, AST 56, ALT 41, creatinine 1.6, INR 1.5, a.m. cortisol 5.1. HOSPITAL COURSE: 1. Mental status: The patient has known mental retardation. Vitamin B-12, folate, TSH, RPR was negative. The patient was managed conservatively on BiPAP and mental status improved during hospital course without further intervention. 2. Cardiac: The patient had elevated troponin and CK enzymes. This is partly related to her heart failure and renal failure. Enzymes were followed and trended down. She did not complain of chest pain and had no changes on electrocardiogram. The patient also had bradycardia. She was monitored on telemetry on the floor. Episodes of bradycardia into the 40s were noted particularly when the patient was asleep. The patient was symptomatic during these episodes. The patient's beta blocker Atenolol 100 mg once a day was held. Bradycardia was secondary to medications in the setting of acute renal failure. 3. Dyspnea: The patient has known pulmonary hypertension and component of chronic obstructive pulmonary disease. She was treated with chronic obstructive pulmonary disease flare with a Prednisone and Azithromycin course. In addition, the patient was given supportive care with nebulizers and MDIs of Combivent. The patient was given BiPAP at night with positive response. There is a question of aspiration pneumonia. Speech and swallow evaluation at bedside showed some difficulty swallowing. The patient was subsequently placed on thickened liquids for possibility of aspiration. 5. Anemia and elevated INR to 1.5. The patient was normocytic. During hospital course INR continued to improve as nutritional status improved. There was no evidence of hemolysis or blood loss. The possibility of a evaluation of bone marrow was considered, but deferred as an outpatient to be evaluated. 6. Renal failure resolved during hospital course with intravenous fluids. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: To home with VNA and home oxygen. DISCHARGE DIAGNOSES: 1. Obstructive sleep apnea. 2. Diabetes. 3. Pneumonia, possibly aspiration. 4. Acute renal failure. 5. Thrombocytopenia. 6. Hypertension. 7. Bradycardia secondary to medications. FOLLOW UP: 1. The patient is to follow up with her primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 110392**] [**Name (STitle) **]. 2. The patient was asked to follow up with pulmonologist and endocrinologist in the next one to two weeks. 3. The patient was asked to follow up with the cardiolgoist to evaluate for bradycardia and right heart failure. DR.[**Last Name (STitle) **],[**First Name3 (LF) 2467**] 12-746 Dictated By:[**Name8 (MD) 10402**] MEDQUIST36 D: [**2116-3-28**] 11:12 T: [**2116-3-30**] 08:30 JOB#: [**Job Number 110393**]

428,492,518,584,276,287,253,789

{'Congestive heart failure, unspecified,Other emphysema,Acute respiratory failure,Acute kidney failure, unspecified,Acidosis,Thrombocytopenia, unspecified,Panhypopituitarism,Hepatomegaly'}

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: This is a 49 year-old woman with restrictive lung disease, diastolic heart failure, obstructive sleep apnea, requiring BiPAP and mental retardation who presented with mental status changes and increased lower extremity edema. She was found to be hypoxic at an O2 of 64% room air, unresponsive on arrival. The patient was also bradycardic on arrival and given Atropine and diuresis. The patient was also given BiPAP. Also in the Emergency Room the patient was found to be in acute renal failure and is immediately transferred to the Medical Intensive Care Unit. In the Intensive Care Unit the patient was given BiPAP and diuresed initially. The patient was hypercapnic initially. These levels were monitored with modest improvement on BiPAP. The patient was also thought to be in left heart failure, however, echocardiogram was performed, which showed evidence of right heart failure. The patient's creatinine and liver function tests were increased. Renal and abdominal ultrasound showed no abnormalities. These levels were monitored and trended toward normal. The patient's beta blocker was held in the Intensive Care Unit as she was bradycardic. The patient was also treated empirically for pneumonia with Ceftriaxone and Flagyl. The patient had mild improvement of mental status and was transferred to the Medical Floor on Azithromycin. MEDICAL HISTORY: 1. Restrictive lung disease FEV1 to FVC ratio 79, which is 104% predicted, decreased DLCO. 2. Obstructive sleep apnea on home BiPAP. 3. Pulmonary hypertension. 4. Diabetes hypertension. 5. Congestive heart failure with diastolic dysfunction. 6. Panhypopituitarism secondary to empty sella, low thyroid, adrenal insufficiency, diabetes insipidus. 7. Mental retardation. MEDICATION ON ADMISSION: ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: Smokes two packs per day. She lives with her daughter who assists her in her activities of daily living. ### Response: {'Congestive heart failure, unspecified,Other emphysema,Acute respiratory failure,Acute kidney failure, unspecified,Acidosis,Thrombocytopenia, unspecified,Panhypopituitarism,Hepatomegaly'}

CHIEF COMPLAINT: Lethargy PRESENT ILLNESS: 46-year-old female with history of acute alcoholic hepatitis and biopsy-proven cirrhosis complicated by anemia, hepatic encephalopathy, fluid overload, and synthetic dysfunction was brought in by family concerned for lethargy x2 days. It appears that on [**6-17**] her diuretics and lactulose were discontinued for an elevated creatinine of 1.5. Today, pt was BIBA because family was concerned that she has been acting lethargic x 2 days. She does have a history of hepatic encephalopathy and her symptoms were consistent with prior presentations. Of note, her lactulose seems to have been discontinued recently in the setting of diarrhea and creatinine elevation out of concern for further dehydration. She was too lethargic to answer questions appropriately in the [**Last Name (LF) **], [**First Name3 (LF) **] EMS had complained of abdominal pain on the ride over. most of the history was obtained from family. MEDICAL HISTORY: 1. Recent diagnosis of alcoholic hepatitis and cirrhosis as above. 2. Hypertension. 3. Elevated BMI. 4. Cholecystectomy. 5. Anemia (likely thalassemia and anemia of chronic disease) 6. s/p Gastric bypass MEDICATION ON ADMISSION: . Information was obtained from . 1. FoLIC Acid 1 mg PO DAILY 2. Lactulose 15 mL PO QID 3. Lorazepam 0.5 mg PO BID:PRN anxiety 4. Metoprolol Succinate XL 100 mg PO DAILY 5. Omeprazole 20 mg PO DAILY 6. Potassium Chloride 10 mEq PO DAILY Duration: 24 Hours Hold for K > 4.5 7. Sertraline 50 mg PO Q4:PRN pain 8. Rifaximin 550 mg PO BID 9. Spironolactone 50 mg PO DAILY 10. traZODONE 200 mg PO HS:PRN insomnia 11. Thiamine 100 mg PO DAILY ALLERGIES: mold PHYSICAL EXAM: ADMISSION PHYSICAL EXAM FAMILY HISTORY: The patient's father had what was appraently alcoholic cirrhosis. No family history of heart disease, early MI. SOCIAL HISTORY: Lives with her mother in [**Name (NI) 5110**]. Alcohol excess with last sip of alcohol reportedly 5/[**2142**]. At most, drank 7+ alcoholic beverages a day for at least 10-plus years. Has a daughter, [**Name (NI) 20231**], who is 24 years old and is a good support system. Quit tobacco.

Hepatic encephalopathy,Toxic encephalopathy,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Unspecified protein-calorie malnutrition,Other ascites,Urinary tract infection, site not specified,Alcoholic cirrhosis of liver,Chronic kidney disease, unspecified,Other and unspecified alcohol dependence, unspecified,Thrombocytopenia, unspecified,Alpha thalassemia,Disorders of phosphorus metabolism,Late effect of intracranial injury without mention of skull fracture,Contusion of face, scalp, and neck except eye(s),Other cerebral degeneration,Unspecified paranoid state,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Anemia of other chronic disease,Esophageal reflux,Other acquired absence of organ,Bariatric surgery status,Personal history of tobacco use,History of physical abuse,Body Mass Index 34.0-34.9, adult,Accidental fall from bed,Accidents occurring in residential institution,Late effects of injury purposely inflicted by other person

Hepatic encephalopathy,Toxic encephalopathy,Acute kidney failure NOS,Hyposmolality,Protein-cal malnutr NOS,Ascites NEC,Urin tract infection NOS,Alcohol cirrhosis liver,Chronic kidney dis NOS,Alcoh dep NEC/NOS-unspec,Thrombocytopenia NOS,Alpha thalassemia,Dis phosphorus metabol,Lt eff intracranial inj,Contusion face/scalp/nck,Cereb degeneration NEC,Paranoid state NOS,Hy kid NOS w cr kid I-IV,Anemia-other chronic dis,Esophageal reflux,Acq absence of organ NEC,Bariatric surgery status,History of tobacco use,Hx of physical abuse,BMI 34.0-34.9,adult,Fall from bed,Accid in resident instit,Late effect assault

Admission Date: [**2143-6-25**] Discharge Date: [**2143-7-16**] Date of Birth: [**2096-9-20**] Sex: F Service: MEDICINE Allergies: mold Attending:[**First Name3 (LF) 4393**] Chief Complaint: Lethargy Major Surgical or Invasive Procedure: NONE History of Present Illness: 46-year-old female with history of acute alcoholic hepatitis and biopsy-proven cirrhosis complicated by anemia, hepatic encephalopathy, fluid overload, and synthetic dysfunction was brought in by family concerned for lethargy x2 days. It appears that on [**6-17**] her diuretics and lactulose were discontinued for an elevated creatinine of 1.5. Today, pt was BIBA because family was concerned that she has been acting lethargic x 2 days. She does have a history of hepatic encephalopathy and her symptoms were consistent with prior presentations. Of note, her lactulose seems to have been discontinued recently in the setting of diarrhea and creatinine elevation out of concern for further dehydration. She was too lethargic to answer questions appropriately in the [**Last Name (LF) **], [**First Name3 (LF) **] EMS had complained of abdominal pain on the ride over. most of the history was obtained from family. Pt has had many recnet hospitalizations recently at [**Hospital1 18**]: from [**Date range (1) 20228**] (liver failure) and then again [**Date range (3) 20229**] (s/p fall). Her last hospitalization [**Date range (1) 20230**] for worsening hepatic encephalopathy, which had improved since starting lactulose therapy. She was also on rifaximin, lasix 20mg daily and spironolactone 50mg daily Past Medical History: 1. Recent diagnosis of alcoholic hepatitis and cirrhosis as above. 2. Hypertension. 3. Elevated BMI. 4. Cholecystectomy. 5. Anemia (likely thalassemia and anemia of chronic disease) 6. s/p Gastric bypass Social History: Lives with her mother in [**Name (NI) 5110**]. Alcohol excess with last sip of alcohol reportedly 5/[**2142**]. At most, drank 7+ alcoholic beverages a day for at least 10-plus years. Has a daughter, [**Name (NI) 20231**], who is 24 years old and is a good support system. Quit tobacco. Family History: The patient's father had what was appraently alcoholic cirrhosis. No family history of heart disease, early MI. Physical Exam: ADMISSION PHYSICAL EXAM VS: 97.6 88/58 --> 94/72 71 12 100%RA GENERAL: Well appearing female in NAD. sleeping. Jaundiced HEENT: Sclera icteric. MMM. CARDIAC: RRR with II/VI systolic murmur LUNGS: CTA b/l with no wheezing, rales, or rhonchi - difficult to assess as pt somnolent and quite large ABDOMEN: Distended but Soft, tender to palpation in right upper and lower quadrants in particular. No clear shifting dullness or fluid wave but difficult to assess due to subcutaneous fat EXTREMITIES: 1+ edema b/l. Warm and well perfused, no clubbing or cyanosis. NEUROLOGY: asterixis - unable to assess as pt could not follow commands well enough DISCHARGE PHYSICAL EXAM VS: 98, 90s, 110-120s/60-70s, 20, 98-100% RA GENERAL: obese african american female, lying in bed, in NAD HEENT: Sclera slightly icteric. MMM. periorbital edema of R eye inferiorly CARDIAC: RRR with II/VI SEM LUNGS: CTAB with slight decreased BS at bases; no wheezing, rales, or rhonchi. Poor aeration ABDOMEN: Soft, nontender, nondistended, +BS EXTREMITIES: [**11-19**]+ pitting LE edema b/l. Warm and well perfused NEUROLOGY: no asterixis. A and O x3 Pertinent Results: [**2143-6-25**] 02:26AM BLOOD WBC-10.3 RBC-3.92* Hgb-9.7* Hct-32.3* MCV-83 MCH-24.8* MCHC-30.1* RDW-19.8* Plt Ct-180 [**2143-7-4**] 06:00AM BLOOD WBC-8.6 RBC-3.07* Hgb-7.5* Hct-24.9* MCV-81* MCH-24.5* MCHC-30.1* RDW-22.4* Plt Ct-107* [**2143-7-15**] 06:20AM BLOOD WBC-9.2 RBC-3.16* Hgb-8.1* Hct-26.6* MCV-84 MCH-25.7* MCHC-30.6* RDW-23.5* Plt Ct-186 [**2143-6-25**] 04:15AM BLOOD PT-19.7* PTT-41.8* INR(PT)-1.9* [**2143-7-3**] 07:28AM BLOOD PT-26.3* PTT-52.7* INR(PT)-2.5* [**2143-7-15**] 06:20AM BLOOD PT-20.4* INR(PT)-1.9* [**2143-6-25**] 02:26AM BLOOD Glucose-74 UreaN-30* Creat-3.4*# Na-122* K-GREATER TH Cl-104 HCO3-18* [**2143-6-28**] 04:09AM BLOOD Glucose-122* UreaN-29* Creat-4.1* Na-142 K-4.9 Cl-113* HCO3-18* AnGap-16 [**2143-7-15**] 06:20AM BLOOD Glucose-95 UreaN-24* Creat-2.2* Na-127* K-6.6* Cl-100 HCO3-15* AnGap-19 [**2143-7-15**] 01:50PM BLOOD Na-128* K-3.2* Cl-102 HCO3-16* AnGap-13 [**2143-6-25**] 02:26AM BLOOD ALT-54* AST-199* AlkPhos-228* TotBili-4.9* [**2143-7-5**] 05:00AM BLOOD ALT-23 AST-72* AlkPhos-120* TotBili-5.6* [**2143-7-15**] 06:20AM BLOOD ALT-29 AST-76* AlkPhos-121* TotBili-3.2* [**2143-6-25**] 04:15AM BLOOD Calcium-8.4 Phos-4.5 Mg-1.7 [**2143-7-6**] 06:20AM BLOOD Calcium-8.5 Phos-1.5* Mg-2.0 [**2143-7-15**] 06:20AM BLOOD Calcium-8.6 Phos-2.8 Mg-2.0 [**2143-7-10**] 11:38AM BLOOD VitB12-1372* Folate-GREATER TH [**2143-7-9**] 04:48AM BLOOD Hapto-10* [**2143-6-28**] 04:09AM BLOOD C3-47* C4-15 [**2143-6-25**] 02:33AM BLOOD Lactate-1.7 [**2143-6-25**] 12:23PM URINE Color-DkAmb Appear-Hazy Sp [**Last Name (un) **]-1.011 [**2143-6-30**] 12:34PM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG [**2143-6-30**] 12:34PM URINE RBC-180* WBC-33* Bacteri-NONE Yeast-NONE Epi-1 [**2143-6-30**] 12:34PM URINE CastHy-67* [**2143-6-25**] 12:23PM URINE Hours-RANDOM UreaN-409 Creat-211 Na-LESS THAN K-42 Cl-16 [**2143-7-3**] 10:00AM URINE Hours-RANDOM UreaN-620 Creat-212 Na-LESS THAN K-15 Cl-14 [**2143-7-10**] 03:00PM URINE Hours-RANDOM UreaN-524 Creat-92 Na-89 K-32 Cl-66 [**2143-6-25**] 12:23PM URINE Osmolal-335 [**2143-7-10**] 03:00PM URINE Osmolal-442 [**2143-6-30**] 12:33PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG [**2143-6-25**] 04:05PM ASCITES WBC-185* RBC-145* Polys-64* Lymphs-2* Monos-0 Mesothe-1* Macroph-33* [**2143-6-25**] 04:05PM ASCITES TotPro-1.6 Glucose-97 Creat-3.5 LD(LDH)-62 TotBili-1.1 Albumin-<1.0 Micro:GRAM POSITIVE COCCUS(COCCI). IN PAIRS AND CLUSTERS. GRAM POSITIVE RODS. CONSISTENT WITH CORYNEBACTERIUM OR PROPIONIBACTERIUM SPECIES. . Images: TTE [**2143-6-26**]: IMPRESSION: Mild aortic valve sclerosis. No pathologic flow or focal vegetations identified. Normal biventricular cavity sizes with preserved regional and global biventricular systolic function. Renal U/S: [**2143-6-25**]: IMPRESSION: Normal appearance of bilateral kidneys with normal Doppler evaluation of bilateral renal vessels. . EKG: [**2143-6-25**]: Sinus rhythm. Normal ECG. Compared to the previous tracing of [**2143-4-17**] no diagnostic interim change CT Head: [**2143-7-3**]: Wet Read: JBRe WED [**2143-7-3**] 5:44 AM No intracranial hemorrhage. No fracture. Large left parietal subgaleal EEG [**2143-7-1**]: IMPRESSION: This telemetry captured no pushbutton activations. There was possible muscle artifact, but the legible portions of the recording showed a slow background indicative of an encephalopathy. Systemic illness and medications are the most common causes. There were no clearly epileptiform features or electrographic seizures. Discharge Labs: [**2143-7-16**] 05:03AM BLOOD WBC-8.1 RBC-2.86* Hgb-7.5* Hct-24.1* MCV-84 MCH-26.2* MCHC-31.2 RDW-23.4* Plt Ct-162 [**2143-7-16**] 05:03AM BLOOD PT-21.7* INR(PT)-2.1* [**2143-7-16**] 05:03AM BLOOD Glucose-87 UreaN-23* Creat-2.0* Na-128* K-4.3 Cl-104 HCO3-16* AnGap-12 [**2143-7-16**] 05:03AM BLOOD ALT-26 AST-55* AlkPhos-113* TotBili-2.8* [**2143-7-16**] 05:03AM BLOOD Albumin-2.7* Calcium-8.2* Phos-2.9 Mg-1.9 Brief Hospital Course: MICU COURSE [**Date range (3) 20232**] 46 year old female with history of alcoholic cirrhosis and anemia presenting with hepatic encephalopathy, acute kidney injury, and worsening anemia. ACTIVE ISSUES: #Altered Mental Status: has had multiple admissions for encephalopathy. On admission to ICU had an Dobhoff tube placed for administration of lactulose. Received 30 cc's lactulose every two hours with mild improvement in mental status. Patient initially unresponsive to name, and would withdraw from pain with asterixis and clonus on the lower extremities and upgoing Babinski reflexes. After lactulose patient opening eyes and occasionally saying name, however cannot follow commands. Workup prior to ICU admission did not reveal portal vein thrombus, or evidence of blood stream infection or SBP. An LP was not performed given elevated INR. One blood culture from the emergency room did return positive with multiple organisms felt to be consistent with contamination. Patient received a 7-day course of Vancomycin and Ceftriaxone. Other contributions to her mental status may be from worsening renal failure causing encephalopathy. Of note, the patient has not had an EGD in the [**Hospital1 18**] system, however her stools have been guiac negative. Neurology was consulted and EEG was ordered. There was no signs of status epilepticus. CT scan was negative for an acute process and there was thought that there would be benefit to obtaining an MRI. While an MRI was not obtained due to patient agitation, she eventually recovered from her encephalopathy without a etiology being known. The leading thought that it was a toxic-metabolic insult caused by her not being able to clear a substance with her liver dysfunction and worsening kidney status. #Normocytic Anemia: Patient has a baseline hematocrit of about 27, possibly secondary to alpha thalasemia. Initially presented with HCT of 32, which decreased why she was an inpatient. She remained guaiac negative with no apparent source of bleeding. Hemoconcentration definitely played a role, but patient did need to be transfused on multiple occasions. Prior to discharge, her hematocrit stayed stable around 25. #Acute Kidney Injury: Patient had an acute on chronic rise in her creatinine. Creatinine was 3.4 on admission, it spiked to 4.1 and then came down to 2.0 with rehydration. Her creatinine had been increasing since before her Heme-onc appointment on [**6-17**], at which time it was 1.5 from a baseline of <1. #Decompensated Alcoholic Cirrhosis: Biopsy proven cirrhosis, being managed by Dr. [**Last Name (STitle) **]. INR 2.4, and the albumin was low on presentation. Not a candidate for transplant. Paracentesis was negative for SBP. Patient received increased dose of Thiamine acutely, but then transitioned to home dose of 100mg daily. She has not had an EGD and will require one as an outpatient. #Bacteremia: grew 1+ GPC in pairs and clusters and 1+ GPR c/w corynebacterium species. Likely contaminant as it is only in one bottle. However, given patients clinical status, she was treated with 7 days of Vancomycin and Ceftriaxone. #Delirium w/ Paranoia- Patient was recovering from her encephalopathy and over [**2052-7-6**] started having some nonsensical talk that evolved to be paranoid delirium. She spontaneously improved after two days. B12 and Folate were normal. Psychiatry was consulted and they noticed frontal release signs which they thought might be due to her known history of being abused. On discharge, patient was alert and oriented x 3 and very pleasant. She was agreeable to seeing outpatient psychiatry. She should get a psychiatrist via BEST 1-[**Telephone/Fax (1) 20233**] and [**Hospital1 1680**] Services 1-[**Telephone/Fax (1) **]. # Hx of Abuse: Patient with restraining order against ex-boyfriend, however, has still expressed desire to see him. Today, has said she would like to move on. Frontal release signs and atrophy likely a result of chronic trauma. The Center for Violence Prevention saw the patient while she was admitted. She is also willing to see a psychiatrist as an outpatient as listed above. She was put on a privacy alert while patient admitted, all male visitors should show ID at front desk #Hyper/hyponatremia: Pt presented with Na 122. With a combination of free water restriction and then later water replacement, her sodium fluctuated greatly. On discharge her sodium was 128 and she was asymptomatic. TRANSITIONAL ISSUES: - She should receive a follow up with a psychiatrist via BEST 1-[**Telephone/Fax (1) 20233**] and [**Hospital1 1680**] Services 1-[**Telephone/Fax (1) **] - Patient needs to have EGD completed as an outpatient. This has been scheduled with Dr. [**Last Name (STitle) 497**]. - Patient will be going to rehab for functional improvement - She will require labs to be drawn as an outpatient weekly (Chem7, CBC, LFTs) Medications on Admission: . Information was obtained from . 1. FoLIC Acid 1 mg PO DAILY 2. Lactulose 15 mL PO QID 3. Lorazepam 0.5 mg PO BID:PRN anxiety 4. Metoprolol Succinate XL 100 mg PO DAILY 5. Omeprazole 20 mg PO DAILY 6. Potassium Chloride 10 mEq PO DAILY Duration: 24 Hours Hold for K > 4.5 7. Sertraline 50 mg PO Q4:PRN pain 8. Rifaximin 550 mg PO BID 9. Spironolactone 50 mg PO DAILY 10. traZODONE 200 mg PO HS:PRN insomnia 11. Thiamine 100 mg PO DAILY Discharge Medications: 1. Lactulose 15 mL PO QID 2. FoLIC Acid 1 mg PO DAILY 3. Rifaximin 550 mg PO BID 4. Thiamine 100 mg PO DAILY 5. Ciprofloxacin HCl 250 mg PO/NG Q24H 6. Nicotine Patch 14 mg TD DAILY nicotene withdrawl 7. Omeprazole 20 mg PO DAILY 8. Sertraline 50 mg PO Q4:PRN pain Discharge Disposition: Extended Care Facility: [**Hospital6 2222**] - [**Location (un) 538**] Discharge Diagnosis: Primary Diagnosis: Encephalopathy, Not otherwise specified Secondary Diagnosis: Malnutrition Acute Kidney Injury Bacteremia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [**Known lastname 9480**], It was a pleasure taking care of you at the [**Hospital1 771**]. Your family brought you to the hospital because you had become increasingly tired and lethargic. CT Scan of your head repeatedly showed no acute process (nothing new) in your brain that was causing this condition. The neurologists were consulted (brain doctors) and they showed that you were NOT having a seizure either, but they were unsure of the reason this was happening. You were treated for infection, hepatic encephalopathy (confusion caused by your liver condition), blood electrolyte abnormalities and medication side effects, and eventually, you became less lethargic, despite us not knowing the exact reason that this happened. For one day during your admission, you were transferred to the Intensive Care Unit to ensure that you could be more closely monitored. You received blood while you were in the hospital to ensure that you had an adequate amount of blood for your condition. You also came in with an injury to your kidney that we thought was due to you being dehydrated. This improved as we gave you fluids. To help you get adequate nutrition while you were lethargic, we put a tube down your nose into your gut so we could feed you. Now that it is safe, we encourage you to continue feeding yourself. Physical therapy saw you and feels due to your current strength, it would be best for you to continue rehabilitation when you leave the hospital, and you can return here to get that done. You should follow up with the Liver Doctors, and you currently have an appointment for [**2143-7-23**] to see them. You should also make an appointment with your Primary Care Physician, [**Last Name (NamePattern4) **]. [**Name (NI) **] [**Name (NI) 20234**] [**Name (NI) **] to discuss this admission. Please follow up for an EGD on [**2143-7-30**]. The following changes were made to your medications: These medications were STARTED: Ciprofloxacin These medications were CHANGED: Lactulose These medications were STOPPED: Ativan Tramodol Trazodone Furosemide Metoprolol Followup Instructions: Name: [**Date Range **] [**Name (NI) 9329**] [**Name8 (MD) 9328**], MD Specialty: Primary Care Location: [**Hospital1 **] HOSPITAL - [**Hospital1 **] Address: [**Street Address(2) 9330**], [**Doctor First Name **] 2, [**Hospital1 **],[**Numeric Identifier 9331**] Phone: [**Telephone/Fax (1) 9332**] Please discuss with the staff at the facility a follow up appointment with your PCP when you are ready for discharge. Department: LIVER CENTER When: TUESDAY [**2143-7-23**] at 2:40 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 2422**] Building: LM [**Hospital Unit Name **] [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: ENDO SUITES When: TUESDAY [**2143-7-30**] at 11:00 AM Department: DIGESTIVE DISEASE CENTER When: TUESDAY [**2143-7-30**] at 11:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD [**Telephone/Fax (1) 463**] Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3202**] Campus: EAST Best Parking: Main Garage [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**] Completed by:[**2143-7-16**]

572,349,584,276,263,789,599,571,585,303,287,282,275,907,920,331,297,403,285,530,V457,V458,V158,V154,V853,E884,E849,E969

{'Hepatic encephalopathy,Toxic encephalopathy,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Unspecified protein-calorie malnutrition,Other ascites,Urinary tract infection, site not specified,Alcoholic cirrhosis of liver,Chronic kidney disease, unspecified,Other and unspecified alcohol dependence, unspecified,Thrombocytopenia, unspecified,Alpha thalassemia,Disorders of phosphorus metabolism,Late effect of intracranial injury without mention of skull fracture,Contusion of face, scalp, and neck except eye(s),Other cerebral degeneration,Unspecified paranoid state,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Anemia of other chronic disease,Esophageal reflux,Other acquired absence of organ,Bariatric surgery status,Personal history of tobacco use,History of physical abuse,Body Mass Index 34.0-34.9, adult,Accidental fall from bed,Accidents occurring in residential institution,Late effects of injury purposely inflicted by other person'}

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: Lethargy PRESENT ILLNESS: 46-year-old female with history of acute alcoholic hepatitis and biopsy-proven cirrhosis complicated by anemia, hepatic encephalopathy, fluid overload, and synthetic dysfunction was brought in by family concerned for lethargy x2 days. It appears that on [**6-17**] her diuretics and lactulose were discontinued for an elevated creatinine of 1.5. Today, pt was BIBA because family was concerned that she has been acting lethargic x 2 days. She does have a history of hepatic encephalopathy and her symptoms were consistent with prior presentations. Of note, her lactulose seems to have been discontinued recently in the setting of diarrhea and creatinine elevation out of concern for further dehydration. She was too lethargic to answer questions appropriately in the [**Last Name (LF) **], [**First Name3 (LF) **] EMS had complained of abdominal pain on the ride over. most of the history was obtained from family. MEDICAL HISTORY: 1. Recent diagnosis of alcoholic hepatitis and cirrhosis as above. 2. Hypertension. 3. Elevated BMI. 4. Cholecystectomy. 5. Anemia (likely thalassemia and anemia of chronic disease) 6. s/p Gastric bypass MEDICATION ON ADMISSION: . Information was obtained from . 1. FoLIC Acid 1 mg PO DAILY 2. Lactulose 15 mL PO QID 3. Lorazepam 0.5 mg PO BID:PRN anxiety 4. Metoprolol Succinate XL 100 mg PO DAILY 5. Omeprazole 20 mg PO DAILY 6. Potassium Chloride 10 mEq PO DAILY Duration: 24 Hours Hold for K > 4.5 7. Sertraline 50 mg PO Q4:PRN pain 8. Rifaximin 550 mg PO BID 9. Spironolactone 50 mg PO DAILY 10. traZODONE 200 mg PO HS:PRN insomnia 11. Thiamine 100 mg PO DAILY ALLERGIES: mold PHYSICAL EXAM: ADMISSION PHYSICAL EXAM FAMILY HISTORY: The patient's father had what was appraently alcoholic cirrhosis. No family history of heart disease, early MI. SOCIAL HISTORY: Lives with her mother in [**Name (NI) 5110**]. Alcohol excess with last sip of alcohol reportedly 5/[**2142**]. At most, drank 7+ alcoholic beverages a day for at least 10-plus years. Has a daughter, [**Name (NI) 20231**], who is 24 years old and is a good support system. Quit tobacco. ### Response: {'Hepatic encephalopathy,Toxic encephalopathy,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Unspecified protein-calorie malnutrition,Other ascites,Urinary tract infection, site not specified,Alcoholic cirrhosis of liver,Chronic kidney disease, unspecified,Other and unspecified alcohol dependence, unspecified,Thrombocytopenia, unspecified,Alpha thalassemia,Disorders of phosphorus metabolism,Late effect of intracranial injury without mention of skull fracture,Contusion of face, scalp, and neck except eye(s),Other cerebral degeneration,Unspecified paranoid state,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Anemia of other chronic disease,Esophageal reflux,Other acquired absence of organ,Bariatric surgery status,Personal history of tobacco use,History of physical abuse,Body Mass Index 34.0-34.9, adult,Accidental fall from bed,Accidents occurring in residential institution,Late effects of injury purposely inflicted by other person'}

CHIEF COMPLAINT: L knee pain PRESENT ILLNESS: (Per Orthopedic Admission Note) Mr. [**Known lastname **] previously had a total knee replacement performed in [**2174**] by Dr. [**Last Name (STitle) 26181**]. This was revised due to loosening in [**2184**] by Dr. [**Last Name (STitle) 82679**]. He required an allograft prosthetic reconstruction. At that point in time, the allograft fractured following a fall. In addition, the [**Doctor Last Name 3549**] taper between the tibial component and the tibial stem has become disengaged and has been disengaged for several years. Mr. [**Known lastname **] presents with chronic pain and requires a revision. As pt presented for elective surgery other review of systems unremarkable and feeling well. MEDICAL HISTORY: aortic stenosis coronary artery disease hypertension hyperlipidemia benign prostatic hyperplasia s/p resection of left acoustic neuroma s/p left tibial rodding s/p bilateral total knee replacements revision of left knee bilateral cataract surgery bilateral carpal tunnel release tonsillectomy/adenoidectomy excision of left upper extremity lipoma MEDICATION ON ADMISSION: Metoprolol 25 mg twice a day, simvastatin 40 mg once a day, terazosin 5 mg once a day, aspirin 81 mg once a day, - Held for OR potassium 20 mg once a day, furosemide 40 mg once a day, Zantac 150 mg twice a day. ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: On Admission: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Incision healing well with staples * Scant serosanguinous drainage * Thigh full but soft * No calf tenderness * 5/5 strength * SILT, NVI distally * Toes warm FAMILY HISTORY: brother with MI, RHD father suffered MI SOCIAL HISTORY: retired lives with wife tobacco: quit 40 yrs ago EtOH: 1 drink per month

Broken prosthetic joint implant,Metabolic encephalopathy,Acute posthemorrhagic anemia,Chronic diastolic heart failure,Other acute and subacute forms of ischemic heart disease, other,Knee joint replacement,Other iatrogenic hypotension,Unspecified essential hypertension,Coronary atherosclerosis of unspecified type of vessel, native or graft,Other and unspecified hyperlipidemia,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Aortocoronary bypass status,Heart valve replaced by other means,Personal history of tobacco use

Broke prosthtc jt implnt,Metabolic encephalopathy,Ac posthemorrhag anemia,Chr diastolic hrt fail,Ac ischemic hrt dis NEC,Joint replaced knee,Iatrogenc hypotnsion NEC,Hypertension NOS,Cor ath unsp vsl ntv/gft,Hyperlipidemia NEC/NOS,BPH w/o urinary obs/LUTS,Aortocoronary bypass,Heart valve replac NEC,History of tobacco use

Admission Date: [**2190-10-13**] Discharge Date: [**2190-10-19**] Date of Birth: [**2104-7-26**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Doctor First Name 3298**] Chief Complaint: L knee pain Major Surgical or Invasive Procedure: [**2190-10-13**]: s/p left total knee replacement revision - rotating hinge History of Present Illness: (Per Orthopedic Admission Note) Mr. [**Known lastname **] previously had a total knee replacement performed in [**2174**] by Dr. [**Last Name (STitle) 26181**]. This was revised due to loosening in [**2184**] by Dr. [**Last Name (STitle) 82679**]. He required an allograft prosthetic reconstruction. At that point in time, the allograft fractured following a fall. In addition, the [**Doctor Last Name 3549**] taper between the tibial component and the tibial stem has become disengaged and has been disengaged for several years. Mr. [**Known lastname **] presents with chronic pain and requires a revision. As pt presented for elective surgery other review of systems unremarkable and feeling well. Past Medical History: aortic stenosis coronary artery disease hypertension hyperlipidemia benign prostatic hyperplasia s/p resection of left acoustic neuroma s/p left tibial rodding s/p bilateral total knee replacements revision of left knee bilateral cataract surgery bilateral carpal tunnel release tonsillectomy/adenoidectomy excision of left upper extremity lipoma Social History: retired lives with wife tobacco: quit 40 yrs ago EtOH: 1 drink per month Family History: brother with MI, RHD father suffered MI Physical Exam: On Admission: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Incision healing well with staples * Scant serosanguinous drainage * Thigh full but soft * No calf tenderness * 5/5 strength * SILT, NVI distally * Toes warm On Discharge: VS: T 99.2, BP 102/56, P 71, RR 18, O2 95% on RA HEENT:OP clear w/o lesions CV: RRR, 3/6 systolic murmur Pulm: Clear to ausculatation bilaterally GI: Soft, NT, ND, Bowel sounds + Extrem: Left leg in immobilizer, dressing C/D/I Neuro: Alert and oriented to person, place, year (intermittently month) appropriate and pleasant with fluent speech Pertinent Results: ==================== LABORATORY RESULTS ==================== On Admission (from ICU) WBC-7.0# RBC-2.83*# Hgb-8.9*# Hct-25.2*# MCV-89 RDW-14.9 Plt Ct-104* PT-13.1 PTT-26.6 INR(PT)-1.1 Glucose-140* UreaN-16 Creat-0.9 Na-142 K-4.0 Cl-109* HCO3-24 On Discharge: WBC-4.7 RBC-3.34* Hgb-10.2* Hct-30.1* MCV-90 RDW-14.2 Plt Ct-183 Glucose-100 UreaN-25* Creat-0.8 Na-140 K-3.7 Cl-108 HCO3-27 Other Important Trends: [**2190-10-14**] 05:43AM CK(CPK)-1137* CK-MB-14* MB Indx-1.2 cTropnT-0.07* [**2190-10-14**] 09:26PM CK(CPK)-1576* CK-MB-34* MB Indx-2.2 cTropnT-0.55* [**2190-10-15**] 03:14AM CK(CPK)-1250* CK-MB-28* MB Indx-2.2 cTropnT-0.72* [**2190-10-15**] 11:23AM CK(CPK)-853* CK-MB-17* MB Indx-2.0 cTropnT-0.76* [**2190-10-15**] 06:58PM CK(CPK)-599* CK-MB-10 MB Indx-1.7 cTropnT-0.86* ============= MICROBIOLOGY ============= Joint Fluid [**2190-10-13**]: GRAM STAIN (Final [**2190-10-13**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2190-10-16**]): NO GROWTH. ACID FAST SMEAR (Final [**2190-10-14**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. Blood Cultures [**2190-10-14**] and [**2190-10-15**]: No growth to date Urine Culture [**2190-10-14**]: No growth ============== OTHER STUDIES ============== Knee Radiograph [**2190-10-13**]: IMPRESSION: Intact left total knee revision. No complications. ECG [**2190-10-14**]: Rapid regular tachycardia, rate 110. There is complete right bundle-branch block. Atrial activity is not visible on the current tracing. There is marked ST segment depression in leads V2-V6. Compared to the previous tracing of [**2188-3-25**] the complete left bundle-branch block and the ST segment depressions are new and consisetnt with acute ischemia. ECG [**2190-10-15**]: Sinus tachycardia. The P-R interval is prolonged. Left axis deviation. Right bundle-branch block with left anterior fascicular block. Compared to the previous tracing of [**2190-10-14**] the rate is slower and ST segment depression is no longer present. TTE [**2190-10-15**]: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with distal inferior hypokinesis. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and (top normal) transvalvular gradients. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([**11-29**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2188-3-24**], a aortic bioprosthesis is now seen. In addition very focal distal inferior hypokinesis is now seen. Head CT [**2190-10-15**]: Impression: 1. Bilateral periventricular hypodensities likely representing chronic ischemic changes. There is a right caudate infarct of undeterminate age. If anacute infarct is suspected, MRI is recommended for further evaluation. 2. Dense opacification of the left maxillary sinus with calcification may represent fungal infection. Unilateral Upper Extremity Ultrasound [**2190-10-16**]: IMPRESSION: No evidence of right upper extremity DVT. Studies Pending at Discharge: Blood Cultures from [**10-14**] and [**10-15**] remained negative at discharge but will be held for a full week each. Brief Hospital Course: This is an 86 yo M with CAD s/p CABG, BPH admitted following left total knee arthroplasty revision which was complicated by significant intra-operative and post-operative blood loss and hypotension. He was initially admitted to the Medical Intensive Care Unit and his hospital course was notable for acute blood loss anemia requiring 12 units pack red blood cells in total as well as cardiac biomarker elevation related to increased demand from anemia, hypotension, and tachycardia. #Revision of left knee arthroplasty/Intra- and Post-Operative Acute Blood Loss Anemia/Hypotension: Patient suffered 1.2L blood loss in the OR and had intraoperative hypotension. He was admitted to the Medical Intensive Care Unit where he was transfused to a hematocrit of >30 which required 12 units in total including in the OR. Following hemodynamic stabilization the patient was transferred to the medical floor where betablockers and diuretics were restarted. He was also started on prophylactic anticoagulation with no signs of active bleeding. #CAD s/p CABG/NSTEMI: Following surgery the patient developed an elevation in his cardiac biomarkers with elevation in TnT but without elevation in CK-MB index. It was felt this was reflective of potential fixed obstruction with increased cardiac demand from hypotension, anemia, tachycardia, and withholding of home beta-blockers. Cardiology was consulted who felt there was no further intervention required. An echocardiogram was obtained which showed only a focal distal inferior hypokinesis which was not felt to represent an acute coronary syndrome as detailed above. EF was preserved. Patient was continued on aspirin, betablocker, and statin when hemodynamically stable. #Chronic diastolic heart failure: Initially beta-blockade and diuretics were held, but these were restarted when the patient became hemodynamically stable and when the patient became mildly volume overloaded following stablization of bleeding. He was restarted on home diuretic therapy with furosemide 40 mg a day with good improvement. #Encephalopathy: Patient developed encephalopathy post-operatively felt to be due to a combination of hypotension, anesthesia, and narcotics for pain control. He failed a speech evaluation in this setting and was made NPO. His encephalopathy cleared prior to discharge and he was cleared by speech and swallow for a ground solid and nectar-thickened liquid diet. #Benign Prostatic Hypertrophy: Terazosin was held in setting of hypotension but restarted prior to discharge. Pt voided after removal of foley catheter without incident. #CODE: FULL #Disposition: Patient was discharged to rehab with Orthopedics and cardiology follow-up. Transitional Issues: -Pt was previously on no limitation of diet and will need further speech and swallow evaluation to be advanced back to full liquid diet without limitations. -Pt will continue physical therapy and knee kept in immobilizer until cleared by orthopedics. Medications on Admission: Metoprolol 25 mg twice a day, simvastatin 40 mg once a day, terazosin 5 mg once a day, aspirin 81 mg once a day, - Held for OR potassium 20 mg once a day, furosemide 40 mg once a day, Zantac 150 mg twice a day. Discharge Medications: 1. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) syringe Subcutaneous once a day for 4 weeks. 2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 6. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 7. atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 9. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 10. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 13. terazosin 1 mg Capsule Sig: Three (3) Capsule PO HS (at bedtime). 14. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at [**Hospital6 1109**] - [**Location (un) 1110**] Discharge Diagnosis: Primary Diagnoses: failed L total knee replacement Post-operative bleeding complicated by acute blood loss anemia Type 2 (demand) non-ST elevation myocardial infarction Secondary Diagnoses: Aortic stenosis 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: You were admitted to the hospital after your left total knee replacement revision. You had a significant amount of blood loss during surgery and required blood transfusions in the Intensive Care Unit. You were noted to have stress on your heart, but did not have a true heart attack. You also had a CT scan of your head which did not show any bleeding, but did show evidence of a possible old stroke. Therefore, it is important that you follow up with your primary care physician and cardiologist once you are discharged from rehab to see if you require any modifications to current medication regimen or if you require any additional testing. You also had a speech and swallowing evaluation prior to discharge to rehab which showed some difficulties with swallowing, likely due to weakness. You were put on thickened liquids and ground foods in order to help prevent aspiration of food into your lungs, which can cause respiratory problems. Please make sure to make follow up appointments with Orthopedics and cardiology. Your rehab will help make a follow up appointment with your PCP after discharge. In addition: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please keep your wounds clean. You may shower starting five (5) days after surgery, but no tub baths or swimming for at least four (4) weeks. No dressing is needed if wound continues to be non-draining. Stitches will be removed at your first f/u appt. 7. Please call your surgeon's office to schedule or confirm your follow-up appointment in 2 weeks. 8. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as celebrex, ibuprofen, advil, aleve, motrin, etc). 9. ANTICOAGULATION: Please continue your lovenox for four (4) weeks to help prevent deep vein thrombosis (blood clots). [**Male First Name (un) **] STOCKINGS x 6 WEEKS. 10. WOUND CARE: Please keep your incision clean and dry. It is okay to shower five days after surgery but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed at your follow up appt in two (2) weeks. 11. VNA (once at home): Home PT/OT, dressing changes as instructed, wound checks. 12. ACTIVITY: Weight bearing as tolerated on the operative extremity. Two crutches or walker at all times for 6 weeks. Mobilize. FULL EXTENSION AT ALL TIMES. NO ROM. KNEE IMMOBILIZER. No strenuous exercise or heavy lifting until follow up appointment. Followup Instructions: Department: ORTHOPEDICS When: THURSDAY [**2190-10-28**] at 1 PM With: [**First Name4 (NamePattern1) 6100**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Name: [**Last Name (LF) 7327**],[**First Name3 (LF) **] R. Specialty: INTERNAL MEDICINE Address: [**Location (un) 7330**], [**Location (un) **],[**Numeric Identifier 7331**] Phone: [**Telephone/Fax (1) 7328**] **Please discuss with the staff at the facility the need for a follow up appointment with your PCP when you are ready for discharge.** Name: [**Last Name (LF) **], [**First Name3 (LF) **] Specialty: CARDIOLOGY Location: THE HEART CENTER OF [**Hospital1 **] Address: [**First Name8 (NamePattern2) **] [**Location (un) **], [**Numeric Identifier 7398**] Phone: [**Telephone/Fax (1) 6256**] Appointment: WEDNESDAY [**11-17**] AT 10AM

996,348,285,428,411,V436,458,401,414,272,600,V458,V433,V158

{'Broken prosthetic joint implant,Metabolic encephalopathy,Acute posthemorrhagic anemia,Chronic diastolic heart failure,Other acute and subacute forms of ischemic heart disease, other,Knee joint replacement,Other iatrogenic hypotension,Unspecified essential hypertension,Coronary atherosclerosis of unspecified type of vessel, native or graft,Other and unspecified hyperlipidemia,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Aortocoronary bypass status,Heart valve replaced by other means,Personal history of tobacco use'}

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: L knee pain PRESENT ILLNESS: (Per Orthopedic Admission Note) Mr. [**Known lastname **] previously had a total knee replacement performed in [**2174**] by Dr. [**Last Name (STitle) 26181**]. This was revised due to loosening in [**2184**] by Dr. [**Last Name (STitle) 82679**]. He required an allograft prosthetic reconstruction. At that point in time, the allograft fractured following a fall. In addition, the [**Doctor Last Name 3549**] taper between the tibial component and the tibial stem has become disengaged and has been disengaged for several years. Mr. [**Known lastname **] presents with chronic pain and requires a revision. As pt presented for elective surgery other review of systems unremarkable and feeling well. MEDICAL HISTORY: aortic stenosis coronary artery disease hypertension hyperlipidemia benign prostatic hyperplasia s/p resection of left acoustic neuroma s/p left tibial rodding s/p bilateral total knee replacements revision of left knee bilateral cataract surgery bilateral carpal tunnel release tonsillectomy/adenoidectomy excision of left upper extremity lipoma MEDICATION ON ADMISSION: Metoprolol 25 mg twice a day, simvastatin 40 mg once a day, terazosin 5 mg once a day, aspirin 81 mg once a day, - Held for OR potassium 20 mg once a day, furosemide 40 mg once a day, Zantac 150 mg twice a day. ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: On Admission: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Incision healing well with staples * Scant serosanguinous drainage * Thigh full but soft * No calf tenderness * 5/5 strength * SILT, NVI distally * Toes warm FAMILY HISTORY: brother with MI, RHD father suffered MI SOCIAL HISTORY: retired lives with wife tobacco: quit 40 yrs ago EtOH: 1 drink per month ### Response: {'Broken prosthetic joint implant,Metabolic encephalopathy,Acute posthemorrhagic anemia,Chronic diastolic heart failure,Other acute and subacute forms of ischemic heart disease, other,Knee joint replacement,Other iatrogenic hypotension,Unspecified essential hypertension,Coronary atherosclerosis of unspecified type of vessel, native or graft,Other and unspecified hyperlipidemia,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Aortocoronary bypass status,Heart valve replaced by other means,Personal history of tobacco use'}

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is a 42-year-old female who was exercising on the treadmill and developed a severe headache. CT scan demonstrates 3 mm anterior communicating artery aneurysm. Angiogram confirmed the aneurysm, but it was unable to be safely coiled. The patient was planned for clipping and was admitted to the ICU for close neurologic observation. MEDICAL HISTORY: No past medical history. MEDICATION ON ADMISSION: ALLERGIES: PENICILLIN. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

Subarachnoid hemorrhage,Communicating hydrocephalus

Subarachnoid hemorrhage,Communicat hydrocephalus

Admission Date: [**2192-5-21**] Discharge Date: [**2192-6-13**] Date of Birth: [**2149-8-4**] Sex: F Service: NSU HISTORY OF PRESENT ILLNESS: The patient is a 42-year-old female who was exercising on the treadmill and developed a severe headache. CT scan demonstrates 3 mm anterior communicating artery aneurysm. Angiogram confirmed the aneurysm, but it was unable to be safely coiled. The patient was planned for clipping and was admitted to the ICU for close neurologic observation. ALLERGIES: PENICILLIN. PAST MEDICAL HISTORY: No past medical history. PAST SURGICAL HISTORY: No past surgical history. PHYSICAL EXAMINATION: On physical exam, temperature is 98.8 degrees, pulse 77, blood pressure 135/62, respiratory rate 20, oxygen saturation 100 percent. The patient had a drain placed. Her ICP was 11. The patient was sedated and intubated. Lungs were clear to auscultation. Cardiac: Regular rate and rhythm. Abdomen: Soft, nontender, and nondistended. Extremities: No clubbing, cyanosis, or edema. She had a Foley catheter in place. Her pulses were two plus in her lower extremities throughout bilaterally. She was on propofol. Neurologically, she was awake, alert, and oriented x3, following commands, moving all extremities with good strength. HOSPITAL COURSE: On [**2192-5-22**], the patient was taken to the OR and underwent right craniotomy for anterior communicating artery aneurysm clipping. There were no intraoperative complications. Postoperatively, the patient's vital signs were stable. She was afebrile. She was awake, alert, moving all extremities with good strength, following commands x4. Her EOMs were full. Her face was symmetric. Her tongue was midline. She had no drift. Her grasp was [**4-4**] in all muscle groups. Her temperature was 101 degrees, down to 99.4 degrees. She was extubated on postoperative day number one. On [**2192-5-24**], she had a repeat angiogram, which showed good clipping of the aneurysm and no evidence of vasospasm at that time. The patient postprocedure was awake, alert, and oriented x3. Pupils equal, round, and reactive to light. EOMs full with no drift. Spine was symmetric. Right groin had no hematoma, and she had good positive pedal pulses. Repeat head CT on [**2192-5-26**] showed no changes. On [**2192-5-30**], the patient remained neurologically intact, awake, alert, and oriented x3, moving all extremities with no drift. Strength was [**4-4**]. She was weaning from her steroids. She was continued on Dilantin 100 mg t.i.d., started on albumin 25 percent q.6 h. to keep her CVP 7 to 10. Her IV fluids were increased, and her blood pressure was kept to 150 to 170 range. On [**2192-6-2**], the patient's vent drain was raised to 20. She tolerated that without problems. On [**6-4**]//04, the drain was increased to 25, and the drain was clamped. The patient had lower extremities Dopplers done on [**2192-6-2**] that showed no evidence of DVT. She had a head CT on [**2192-5-31**] that showed no changes. On [**2192-6-5**], she had a repeat angiogram that showed no evidence of vasospasms. She remained in the ICU on triple H therapy; and on [**2192-6-5**], the vent drain was removed, and the patient tolerated that. The patient remained stable and was eventually transferred to the regular floor on [**2192-6-12**] in stable condition, awake, alert, and oriented x3, moving all extremities with good strength. No drift. EOMs full. Pupils equal, round, and reactive to light and then was discharged to home on [**2192-6-13**] in stable condition with follow up with Dr. [**Last Name (STitle) 1132**] in two weeks. DISCHARGE MEDICATIONS: 1. Midodrine 10 mg p.o. q.i.d. 2. Dilantin 150 mg p.o. t.i.d. 3. Colace 100 mg p.o. t.i.d. 4. Percocet 1 to 2 tablets p.o. q.4 h. p.r.n. 5. Lansoprazole 30 mg p.o. q.d. DISCHARGE CONDITION: The patient's condition was stable at the time of discharge. FOLLOW UP: She will follow up with Dr. [**Last Name (STitle) 1132**] in two weeks. [**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**] Dictated By:[**Last Name (NamePattern1) 6583**] MEDQUIST36 D: [**2192-6-13**] 10:47:30 T: [**2192-6-13**] 11:33:18 Job#: [**Job Number 106211**]

430,331

{'Subarachnoid hemorrhage,Communicating hydrocephalus'}

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 42-year-old female who was exercising on the treadmill and developed a severe headache. CT scan demonstrates 3 mm anterior communicating artery aneurysm. Angiogram confirmed the aneurysm, but it was unable to be safely coiled. The patient was planned for clipping and was admitted to the ICU for close neurologic observation. MEDICAL HISTORY: No past medical history. MEDICATION ON ADMISSION: ALLERGIES: PENICILLIN. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: ### Response: {'Subarachnoid hemorrhage,Communicating hydrocephalus'}

CHIEF COMPLAINT: Hypotension. PRESENT ILLNESS: Mrs. [**Known lastname **] is a 76-year-old right-handed woman with a history of metastatic melanoma (metastases to brain, stomach, subcutaneous tissues, and lung) who was originally admitted to the [**Hospital Unit Name 153**] with urosepsis and is now being transferred to the OMED service for further managment. MEDICAL HISTORY: 1. Mild hypertension. 2. Benign mitral regurgitation murmur with negative echocardiographic findings. 3. Osteoporosis. 4. Chronic benign hematuria that had been previously extensively MEDICATION ON ADMISSION: 1. Olmesartan 20 mg daily 2. Hydrochlorothiazide 12.5 mg PO DAILY 3. Prilosec OTC 20 mg PO once a day. 4. Benadryl 25 mg PO HS PRN 5. Levetiracetam 500 mg PO BID 6. Dexamethasone 4 mg PO Q12H ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: VITAL SIGNS: TEMPERATURE 96.5 F (Tmax 97.0 F and Tmin 95.9 F), blood pressure 119/51 (96-139/50-70), pulse 67 (60-99), respiratory rate 18, oxygen saturation 98% in room air. Her I/O: +3.5 L for LOS. GENERAL: Pleasant elderly female, NAD. HEENT: Minimal white patch in posterior OP, MMM. LUNGS: Chest clear to auscultation bilaterally. CARDIOVASCULAR: Regular w/ frequent ectopic beats. NL S1S2. No murmurs. ABDOMEN: Soft, NT, ND. Normoactive BS. No HSM. EXTREMITIES: No edema, with 2+ dorsalis pedis pulses bilaterally. FAMILY HISTORY: There is pneumonia and hypertension in her family. One of her sisters died of melanoma. Her mother is healthy at age [**Age over 90 **]. SOCIAL HISTORY: She lives with her daughter in [**Name (NI) 27256**], MA. Her children are quite supportive, and they take turn to drive her to [**Hospital1 18**] for radiation. She never smoked and denies any alcohol use. She was a very active woman doing daily walks, swims, etc.

Urinary tract infection, site not specified,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Mitral valve disorders,Secondary malignant neoplasm of lung,Secondary malignant neoplasm of brain and spinal cord,Other convulsions,Unspecified essential hypertension,Melanoma of skin, site unspecified

Urin tract infection NOS,Acute kidney failure NOS,Hyposmolality,Mitral valve disorder,Secondary malig neo lung,Sec mal neo brain/spine,Convulsions NEC,Hypertension NOS,Malig melanoma skin NOS

Admission Date: [**2146-2-2**] Discharge Date: [**2146-2-5**] Date of Birth: [**2069-9-1**] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 8850**] Chief Complaint: Hypotension. Major Surgical or Invasive Procedure: None. History of Present Illness: Mrs. [**Known lastname **] is a 76-year-old right-handed woman with a history of metastatic melanoma (metastases to brain, stomach, subcutaneous tissues, and lung) who was originally admitted to the [**Hospital Unit Name 153**] with urosepsis and is now being transferred to the OMED service for further managment. The patient was recently discharged from [**Hospital1 18**] on [**2146-1-27**] after an admission for seizures secondary to brain metastases. She was readmitted on [**2146-2-2**] for hypotension in the setting of UTI. She had been feeling a bit weak since discharge; went for her first episode of XRT [**2146-2-3**], then was noted to have a SBP in the 60's. ROS on admission: + loose stool x3, fatigue. Negative: F/C/NS, cough, N/V, abd pain, CP/SOB, LE edema, focal wakness/numbness/ paresthesias. In the ED, her vital signs were T 95.9, BP 92/54, HR 83. She was given 2L NS boluses, with improvement in BP to 115/50. She was also given Decadron 10 mg IV, ASA 325mg, and levofloxacin 500 mg IV. She was felt to need ICU care for overnight observation due to the hypotension. In the [**Hospital Unit Name 153**] the patient was treated with ciprofloxacin and IVF. Her ARF resolved with the administration of IVF. Stress dose steroids were discontinued and the patient was restarted on her home steroid regimen. Cardiac enzymes were checked given ST depressions on EKG (negative). She received XRT as scheduled on [**2146-2-3**]. After one night she remained normotensive and was called out to OMED. Past Medical History: 1. Mild hypertension. 2. Benign mitral regurgitation murmur with negative echocardiographic findings. 3. Osteoporosis. 4. Chronic benign hematuria that had been previously extensively investigated with negative findings. 5. Status post uncomplicated appendectomy [**2091**]. 6. Status post subtotal thyroidectomy in [**2103**] for benign nontoxic adenoma. 7. Status post fracture of her right ankle for which she underwent a surgical metal plate placed in [**2122**]. 8. metastatic melanoma; presented with episodes of slurred speech. Social History: She lives with her daughter in [**Name (NI) 27256**], MA. Her children are quite supportive, and they take turn to drive her to [**Hospital1 18**] for radiation. She never smoked and denies any alcohol use. She was a very active woman doing daily walks, swims, etc. Family History: There is pneumonia and hypertension in her family. One of her sisters died of melanoma. Her mother is healthy at age [**Age over 90 **]. Physical Exam: VITAL SIGNS: TEMPERATURE 96.5 F (Tmax 97.0 F and Tmin 95.9 F), blood pressure 119/51 (96-139/50-70), pulse 67 (60-99), respiratory rate 18, oxygen saturation 98% in room air. Her I/O: +3.5 L for LOS. GENERAL: Pleasant elderly female, NAD. HEENT: Minimal white patch in posterior OP, MMM. LUNGS: Chest clear to auscultation bilaterally. CARDIOVASCULAR: Regular w/ frequent ectopic beats. NL S1S2. No murmurs. ABDOMEN: Soft, NT, ND. Normoactive BS. No HSM. EXTREMITIES: No edema, with 2+ dorsalis pedis pulses bilaterally. NEUROLOGICAL EXAMINATION: Her Karnofsky Performance Score is 60. She is awake, alert, and oriented to person and place. There is no right-left confusion or finger agnosia. Calculation is intact. Her language is fluent with good comprehension, naming, and repetition. Her recent recall is fair. Cranial Nerve Examination: Her pupils are equal and reactive to light, 4 mm to 2 mm bilaterally. Extraocular movements are full. Visual fields are full to confrontation. Funduscopic examination reveals sharp disks margins bilaterally. Her face is symmetric. Facial sensation is intact bilaterally. Her hearing is intact bilaterally. Her tongue is midline. She has minimal slurring of her speech. Palate goes up in the midline. Sternocleidomastoids and upper trapezius are strong. Motor Examination: She does not have a drift. Her muscle strengths are [**3-26**] at all muscle groups. Her muscle tone is normal. Her reflexes are 2- and symmetric bilaterally. Her ankle jerks are absent. Her toes are down going. Sensory examination is intact to touch and proprioception. Coordination examination does not reveal appendicular or truncal ataxia. Pertinent Results: Initial labs: [**2146-2-2**] 04:30PM LACTATE-2.2* [**2146-2-2**] 04:15PM GLUCOSE-121* UREA N-71* CREAT-1.4* SODIUM-134 POTASSIUM-3.4 CHLORIDE-99 TOTAL CO2-23 ANION GAP-15 [**2146-2-2**] 02:32PM PT-11.5 PTT-22.1 INR(PT)-1.0 [**2146-2-2**] 02:32PM NEUTS-91.3* BANDS-0 LYMPHS-5.5* MONOS-2.4 EOS-0.2 BASOS-0.6 [**2146-2-2**] 02:32PM WBC-15.4* RBC-5.02 HGB-15.0 HCT-44.3 MCV-88 MCH-30.0 MCHC-34.0 RDW-13.3 [**2146-2-2**] 03:10PM URINE RBC-[**1-24**]* WBC-21-50* BACTERIA-MANY YEAST-NONE EPI-0-2 [**2146-2-2**] 03:10PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-SM [**2146-2-2**] 04:15PM CALCIUM-7.9* PHOSPHATE-3.7 MAGNESIUM-2.7* [**2146-2-2**] 04:15PM cTropnT-<0.01 [**2146-2-2**] 04:15PM CK(CPK)-22* [**2146-2-2**] 10:59PM CK-MB-3 cTropnT-<0.01 [**2146-2-2**] 10:59PM CK(CPK)-38 Discharge labs: [**2146-2-5**] 07:55AM BLOOD WBC-6.1 RBC-3.72* Hgb-11.0* Hct-33.0* MCV-89 MCH-29.5 MCHC-33.3 RDW-12.8 Plt Ct-129* [**2146-2-5**] 07:55AM BLOOD Plt Ct-129* [**2146-2-5**] 07:55AM BLOOD Glucose-88 UreaN-27* Creat-0.7 Na-134 K-4.1 Cl-104 HCO3-23 AnGap-11 [**2146-2-3**] 05:56AM BLOOD CK-MB-4 cTropnT-<0.01 [**2146-2-5**] 07:55AM BLOOD Calcium-8.0* Phos-2.0* Mg-2.0 Imaging: CXR:Multiple lung nodules consistent with metastatic disease. Emphysema. Micro: UCx: URINE CULTURE (Final [**2146-2-4**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Trimethoprim/Sulfa sensitivity testing confirmed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN--------- 1 S GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R 2 sets of blood cx NGTD Brief Hospital Course: A/P: This is a 76-year-old right-handed woman with past medical history significant for metastatic melanoma admitted for hypotension in setting of UTI and taking twice dose of HCTZ. (1) UROSEPSIS: Patient initially went to ICU because of hypotension. Blood pressure responded well to fluids and patient was called out of the ICU the next day. In addition, she was found to have E. Coli UTI which was sensitive to ciprofloxacin. Blood cultures are negative thus far. She was discharged on 14 day course of ciprofloxacin. She was afebrile and is hemodynamically stable on discharge. Patient's blood pressure medications were held. (2) ARF: Likely pre-renal in the setting of inadequate hydration in the setting of UTI. Resolved with IVFs. (3) HTN: Her blood pressure medications were held given hypotension and will hold on discharge as well given that patient is not eating and drinking as well and may be prone to dehydration. Will have VNA check BP and if elevated at home, should call Dr. [**Last Name (STitle) 724**] to restart. (4) METASTATIC MELANOMA: No chemotherapy at present. Tentative plan to enrolling her in the E2603 clinical trial with carboplatin, paclitaxel with and without sorafenib, following XRT of her brain mets. She will have 2 more sessions of XRT next week. (5) HISTORY OF SEIZURES: No episodes since last admission. We continued Keppra and dexamethasone. Dexamethasone should be tapered by radiation oncology. (6) ST DEPRESSIONS: patient had st depressions in setting of hypotension likely related to demand ischemia. Patient ruled out with 3 sets of negative enzymes. She was started on aspirin and this was continued on discharge. Medications on Admission: 1. Olmesartan 20 mg daily 2. Hydrochlorothiazide 12.5 mg PO DAILY 3. Prilosec OTC 20 mg PO once a day. 4. Benadryl 25 mg PO HS PRN 5. Levetiracetam 500 mg PO BID 6. Dexamethasone 4 mg PO Q12H Discharge Medications: 1. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*60 Tablet(s)* Refills:*0* 2. Senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*60 Tablet(s)* Refills:*0* 3. Aspirin 325 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:*2* 4. Nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO QID (4 times a day) as needed for thrush. Disp:*qs qs* Refills:*2* 5. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 11 days. Disp:*22 Tablet(s)* Refills:*0* 7. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*0* 8. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 9. Benadryl 25 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: Caregroup VNA Discharge Diagnosis: UTI Hypotension Melanoma Discharge Condition: She was discharged with stable hemodynamics and without fever. Discharge Instructions: You were admitted with a urinary tract infection and low blood pressure. You were given antibiotics and IV fluids and did very well. Please take all medications as directed. You should not take any of your blood pressure medication on discharge. Please follow-up with all outpatient appointments. Please return to the ED or call your doctor if you experience any fever> 100.5, chest pain, difficulty breathing, abdominal pain, vomiting or any other concerning symptoms. Followup Instructions: You have the following appointments. Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2146-2-28**] 10:00 Provider: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2146-2-28**] 11:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5387**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2146-2-28**] 1:30 You also have 2 more sessions of radiation on Monday [**2-7**] and Tuesday [**2-8**] at 7:30 am.

599,584,276,424,197,198,780,401,172

{'Urinary tract infection, site not specified,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Mitral valve disorders,Secondary malignant neoplasm of lung,Secondary malignant neoplasm of brain and spinal cord,Other convulsions,Unspecified essential hypertension,Melanoma of skin, site 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: Hypotension. PRESENT ILLNESS: Mrs. [**Known lastname **] is a 76-year-old right-handed woman with a history of metastatic melanoma (metastases to brain, stomach, subcutaneous tissues, and lung) who was originally admitted to the [**Hospital Unit Name 153**] with urosepsis and is now being transferred to the OMED service for further managment. MEDICAL HISTORY: 1. Mild hypertension. 2. Benign mitral regurgitation murmur with negative echocardiographic findings. 3. Osteoporosis. 4. Chronic benign hematuria that had been previously extensively MEDICATION ON ADMISSION: 1. Olmesartan 20 mg daily 2. Hydrochlorothiazide 12.5 mg PO DAILY 3. Prilosec OTC 20 mg PO once a day. 4. Benadryl 25 mg PO HS PRN 5. Levetiracetam 500 mg PO BID 6. Dexamethasone 4 mg PO Q12H ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: VITAL SIGNS: TEMPERATURE 96.5 F (Tmax 97.0 F and Tmin 95.9 F), blood pressure 119/51 (96-139/50-70), pulse 67 (60-99), respiratory rate 18, oxygen saturation 98% in room air. Her I/O: +3.5 L for LOS. GENERAL: Pleasant elderly female, NAD. HEENT: Minimal white patch in posterior OP, MMM. LUNGS: Chest clear to auscultation bilaterally. CARDIOVASCULAR: Regular w/ frequent ectopic beats. NL S1S2. No murmurs. ABDOMEN: Soft, NT, ND. Normoactive BS. No HSM. EXTREMITIES: No edema, with 2+ dorsalis pedis pulses bilaterally. FAMILY HISTORY: There is pneumonia and hypertension in her family. One of her sisters died of melanoma. Her mother is healthy at age [**Age over 90 **]. SOCIAL HISTORY: She lives with her daughter in [**Name (NI) 27256**], MA. Her children are quite supportive, and they take turn to drive her to [**Hospital1 18**] for radiation. She never smoked and denies any alcohol use. She was a very active woman doing daily walks, swims, etc. ### Response: {'Urinary tract infection, site not specified,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Mitral valve disorders,Secondary malignant neoplasm of lung,Secondary malignant neoplasm of brain and spinal cord,Other convulsions,Unspecified essential hypertension,Melanoma of skin, site unspecified'}

CHIEF COMPLAINT: GI bleed PRESENT ILLNESS: Pt is a 64 yo F who presents with 4 days of lightheadedness and orthostatic symptoms. Reports feelings of being weak with exertional dyspnea. No abd pain. Pt had 1 episode of dark stool yesterday. Otherwise constipation. Also complain of low back pain and urinary incontinence. Pt reports nausea, vomiting (dark brown). On coumadin for afib without recent changes. Reports her level is always around 2.2 MEDICAL HISTORY: -A fib (dxed and on coumadin since [**12-24**]) s/p outpt DCCV [**2118-3-10**], back in atrial fib -Endometriosis and h/o PID s/p supracervical hysterectomy and BSO [**2104**] -tachycardia-induced cardiomyopathy (EF>55%) -s/p appy [**2104**] MEDICATION ON ADMISSION: Atenolol 50 daily Dofetilide 500 [**Hospital1 **] Aldactone 25 [**Hospital1 **] Simvastatin 10mg daily Warfarin 9mg daily Glucosamine Chondroitin ALLERGIES: Iodine; Iodine Containing PHYSICAL EXAM: Admission exam: Vitals: 37.1 128/83 114 13 100% Gen: Mildly sick appearing. Mild distress. Comfortable. HEENT: NCAT. +pallor. MMM Neck: No LAD. Supple Pulm: CTA bilat. no w/r/r Cor: S1S2 irreg irreg. No murmurs Abd: Soft obese. ND. Mild epigastric TTP Ext: No edema, no petechia Neuro: CN II-XII intact, symmetric. Motor [**4-22**], sensory [**4-22**]. FAMILY HISTORY: Father- died of AAA rupture Mother - died age [**Age over 90 **], had A fib, SSS, s/p pacer. Sister - murmur and palpitations SOCIAL HISTORY: She is a nurse. She works at long-term care facility in [**Location 9104**]. She is not married and has no children. She denies smoking and has occasional alcohol use (has [**12-20**] glasses of wine with dinner qHS). No IVDA.

Other specified gastritis, with hemorrhage,Other primary cardiomyopathies,Atrial fibrillation,Hypopotassemia,Long-term (current) use of anticoagulants,Abnormal coagulation profile,Anticoagulants causing adverse effects in therapeutic use,Iron deficiency anemia secondary to blood loss (chronic)

Oth spf gastrt w hmrhg,Prim cardiomyopathy NEC,Atrial fibrillation,Hypopotassemia,Long-term use anticoagul,Abnrml coagultion prfile,Adv eff anticoagulants,Chr blood loss anemia

Admission Date: [**2121-3-20**] Discharge Date: [**2121-3-24**] Date of Birth: [**2056-8-16**] Sex: F Service: MEDICINE Allergies: Iodine; Iodine Containing Attending:[**First Name3 (LF) 2186**] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: Esophagogastroduodenoscopy with epinephrine injection and endoclipping. History of Present Illness: Pt is a 64 yo F who presents with 4 days of lightheadedness and orthostatic symptoms. Reports feelings of being weak with exertional dyspnea. No abd pain. Pt had 1 episode of dark stool yesterday. Otherwise constipation. Also complain of low back pain and urinary incontinence. Pt reports nausea, vomiting (dark brown). On coumadin for afib without recent changes. Reports her level is always around 2.2 In ED vitals 135/60, 138, 20, 100%RA, PAF. Exam with pallor and mild abd tenderness, guaiac positive. NG lavage with BRB, cleared with 250cc. Labs significant for INR 8.5 and HCT 21. Pt received protonix, zofran, 10 mg vitamin K IV, 2u FFP and 4L NS. Past Medical History: -A fib (dxed and on coumadin since [**12-24**]) s/p outpt DCCV [**2118-3-10**], back in atrial fib -Endometriosis and h/o PID s/p supracervical hysterectomy and BSO [**2104**] -tachycardia-induced cardiomyopathy (EF>55%) -s/p appy [**2104**] Social History: She is a nurse. She works at long-term care facility in [**Location 9104**]. She is not married and has no children. She denies smoking and has occasional alcohol use (has [**12-20**] glasses of wine with dinner qHS). No IVDA. Family History: Father- died of AAA rupture Mother - died age [**Age over 90 **], had A fib, SSS, s/p pacer. Sister - murmur and palpitations Physical Exam: Admission exam: Vitals: 37.1 128/83 114 13 100% Gen: Mildly sick appearing. Mild distress. Comfortable. HEENT: NCAT. +pallor. MMM Neck: No LAD. Supple Pulm: CTA bilat. no w/r/r Cor: S1S2 irreg irreg. No murmurs Abd: Soft obese. ND. Mild epigastric TTP Ext: No edema, no petechia Neuro: CN II-XII intact, symmetric. Motor [**4-22**], sensory [**4-22**]. Pertinent Results: [**2121-3-20**] 08:00PM BLOOD WBC-15.7*# RBC-2.22*# Hgb-6.9*# Hct-20.6*# MCV-93 MCH-31.1 MCHC-33.5 RDW-14.4 Plt Ct-312 [**2121-3-20**] 11:44PM BLOOD WBC-13.6* RBC-1.70* Hgb-5.3* Hct-15.6* MCV-92 MCH-31.3 MCHC-34.0 RDW-14.8 Plt Ct-253 [**2121-3-21**] 02:48AM BLOOD WBC-12.4* RBC-2.64*# Hgb-8.3*# Hct-23.1*# MCV-88 MCH-31.6 MCHC-36.1* RDW-14.8 Plt Ct-190 [**2121-3-22**] 09:30AM BLOOD Hct-29.1* [**2121-3-24**] 05:40AM BLOOD WBC-7.0 RBC-3.09* Hgb-9.4* Hct-27.8* MCV-90 MCH-30.5 MCHC-33.9 RDW-16.6* Plt Ct-253 [**2121-3-20**] 08:00PM BLOOD PT-69.5* PTT-32.2 INR(PT)-8.5* [**2121-3-23**] 05:20AM BLOOD PT-14.0* PTT-25.0 INR(PT)-1.2* [**2121-3-20**] 08:00PM BLOOD Glucose-202* UreaN-56* Creat-0.9 Na-137 K-4.0 Cl-105 HCO3-17* AnGap-19 [**2121-3-24**] 05:40AM BLOOD Glucose-101 UreaN-19 Creat-0.8 Na-141 K-4.2 Cl-105 HCO3-27 AnGap-13 [**2121-3-23**] 05:20AM BLOOD ALT-18 AST-23 [**2121-3-20**] 08:00PM BLOOD CK(CPK)-66 [**2121-3-20**] 08:00PM BLOOD cTropnT-<0.01 [**2121-3-20**] 08:09PM BLOOD Lactate-4.3* [**2121-3-20**] 11:44PM BLOOD Lactate-1.6 HELICOBACTER PYLORI ANTIBODY TEST (Final [**2121-3-21**]): NEGATIVE BY EIA. Reports: CXR ([**3-20**]): No acute pulmonary process. EGD ([**3-21**]): Multiple erosions of the mucosa in the antrum and stomach body were noted. One erosion showed stigmata of recent bleeding with a visible vessel but no active bleeding. 3 cc.of epinephrine 1/[**Numeric Identifier 961**] was injected with successful hemostasis. One endoclip was successfully applied to the stomach antrum for the purpose of hemostasis. Brief Hospital Course: 1. GI bleed: Found to have UGIB per NGT lavage with hematocrit of 20.6. She received 4 units pRBCs in the MICU upon admission, along with total 4 units FFP and 10mg vitamin K for INR 8.5. Repeat INR was 2, and an EGD was performed by GI significant for an erosion in the antrum and stomach body which was injected and clipped (see above report). She received 2 more units of pRBCs and her hematocrit subsequently remained stable at approximately 28. She was also treated with [**Hospital1 **] PPI IV, changed to PO for a four week course on discharge. H pylori serologies were sent and negative. Her warfarin and spironolactone were held until the day of discharge, at which time she was deemed stable enough for these to be restarted. 2. Afib: Typically patient is in sinus rhythm, but she had been holding dofetilide prior to admission due to not feeling well. She presented in afib with an INR of 8.5, reversed as discussed above. She was started on metoprolol for rate control and her dofetilide was restarted. She converted to sinus rhythm during her hospitalization, so the metoprolol was changed to her home atenolol. Warfarin was restarted prior to discharge as her INR had normalized and her hematocrit was stable. 3. Urinary incontinence: Patient had a normal neurological exam throughout her admission, so neuroimaging was not pursued. Although she had noted urinary incontinence prior to admission, this was not present during her admission. Furthermore, she had no confusion, saddle anesthesia or bowel incontinence. 4. Fall risk evaluation: Patient noted multiple falls prior to her admission in the setting of profound anemia, the most likely cause. Ecchymosis and tenderness was noted over her left shoulder, which improved with scheduled tylenol and heat packs. She exhibited no gait unsteadiness during this admission, and physical therapy determined her to be safe for discharge home. Medications on Admission: Atenolol 50 daily Dofetilide 500 [**Hospital1 **] Aldactone 25 [**Hospital1 **] Simvastatin 10mg daily Warfarin 9mg daily Glucosamine Chondroitin Discharge Medications: 1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Dofetilide 500 mcg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 3. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*1* 6. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day: You will adjust the dose depending on the INR results of your [**3-27**] appointment. Disp:*30 Tablet(s)* Refills:*1* Discharge Disposition: Home Discharge Diagnosis: Primary: Bleeding gastric erosions Supratherapeutic INR Atrial fibrillaiton Discharge Condition: Stable. Discharge Instructions: You were admitted to [**Hospital1 18**] with lightheadedness and found to have anemia from bleeding erosions in your stomach that was treated through endoscopy (scope with a camera that looks in the intestines). Your INR was high and this was reversed with medications and plasma transfusion. You also required several blood transfusions until your blood count stabilized. You were noted to be in atrial fibrillation, probably from not taking the dofetilide, but you returned to a regular rhythm before discharge. Please take all medications as prescribed and go to all follow up appointments. The following medication changes were made: - Started pantoprazole, an acid-blocker, due to your stomach bleed. You will take this for 4 weeks. - Lowered your warfarin dose to 3mg daily. You will have your INR checked on [**3-27**] and may need to adjust this dose depending on the results. If you experience lightheadedness, dizziness, bloody stools, vomiting, abdominal pain, diarrhea, abnormal bleeding, or any other concerning symptoms, please seek medical attention or come to the ER immediately. Followup Instructions: Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on Thursday [**3-27**] at 1:50 pm. You will need to have a blood draw to recheck your hematocrit and INR. If after completing the 4 weeks of pantoprazole you have any symptoms of stomach discomfort or other digestive concerns, please contact Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 349**], gastroenterology, for an appointment: [**Telephone/Fax (1) 463**]. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2121-4-29**] 4:20 Completed by:[**2121-3-25**]

535,425,427,276,V586,790,E934,280

{'Other specified gastritis, with hemorrhage,Other primary cardiomyopathies,Atrial fibrillation,Hypopotassemia,Long-term (current) use of anticoagulants,Abnormal coagulation profile,Anticoagulants causing adverse effects in therapeutic use,Iron deficiency anemia secondary to blood loss (chronic)'}

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: GI bleed PRESENT ILLNESS: Pt is a 64 yo F who presents with 4 days of lightheadedness and orthostatic symptoms. Reports feelings of being weak with exertional dyspnea. No abd pain. Pt had 1 episode of dark stool yesterday. Otherwise constipation. Also complain of low back pain and urinary incontinence. Pt reports nausea, vomiting (dark brown). On coumadin for afib without recent changes. Reports her level is always around 2.2 MEDICAL HISTORY: -A fib (dxed and on coumadin since [**12-24**]) s/p outpt DCCV [**2118-3-10**], back in atrial fib -Endometriosis and h/o PID s/p supracervical hysterectomy and BSO [**2104**] -tachycardia-induced cardiomyopathy (EF>55%) -s/p appy [**2104**] MEDICATION ON ADMISSION: Atenolol 50 daily Dofetilide 500 [**Hospital1 **] Aldactone 25 [**Hospital1 **] Simvastatin 10mg daily Warfarin 9mg daily Glucosamine Chondroitin ALLERGIES: Iodine; Iodine Containing PHYSICAL EXAM: Admission exam: Vitals: 37.1 128/83 114 13 100% Gen: Mildly sick appearing. Mild distress. Comfortable. HEENT: NCAT. +pallor. MMM Neck: No LAD. Supple Pulm: CTA bilat. no w/r/r Cor: S1S2 irreg irreg. No murmurs Abd: Soft obese. ND. Mild epigastric TTP Ext: No edema, no petechia Neuro: CN II-XII intact, symmetric. Motor [**4-22**], sensory [**4-22**]. FAMILY HISTORY: Father- died of AAA rupture Mother - died age [**Age over 90 **], had A fib, SSS, s/p pacer. Sister - murmur and palpitations SOCIAL HISTORY: She is a nurse. She works at long-term care facility in [**Location 9104**]. She is not married and has no children. She denies smoking and has occasional alcohol use (has [**12-20**] glasses of wine with dinner qHS). No IVDA. ### Response: {'Other specified gastritis, with hemorrhage,Other primary cardiomyopathies,Atrial fibrillation,Hypopotassemia,Long-term (current) use of anticoagulants,Abnormal coagulation profile,Anticoagulants causing adverse effects in therapeutic use,Iron deficiency anemia secondary to blood loss (chronic)'}

CHIEF COMPLAINT: weakness in legs PRESENT ILLNESS: HPI: 78yM with no PMH who had sudden onset back pain yesterday afternoon resulting in a progressively worsening and ascending paralysis and anesthesia. At 3pm, the patient noted the onset of his back pain. By 9pm, the patient developed BLE weakness and numbness. He was brought to OSH and transfered to [**Hospital1 18**] ED. Upon arrival, the patient had decreased sensation below T12 and [**3-17**] BLE strength and decreased rectal tone. MRI showed a T5/6 intradural mass. Exam worsened recently with 0/5 BLE motor tone and paresthesia below T8. Also of note, the patient developed chest pain in the ED. ECG was WNL and the first set of enzymes were negative. The patient was just given 10 IV decadron. MEDICAL HISTORY: none MEDICATION ON ADMISSION: Medications prior to admission: None ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: PHYSICAL EXAM: O: T: 97.8 BP: 120/70 HR: 101 R: 18 O2Sats: 97% RA Gen: WD/WN, Uncomfortable, complaining of chest pain HEENT: Pupils: 3-->2 MM PERRL EOMs Full Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, distended (baseline) Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Motor: D B T FE FF IP Q AT [**Last Name (un) 938**] G R 5 5 5 5 5 0 0 0 0 0 L 5 5 5 5 5 0 0 0 0 0 Unable to sit up and flex abdominal muscles FAMILY HISTORY: nc SOCIAL HISTORY: non smoker married supportive family

Malignant neoplasm of spinal cord,Myelopathy in other diseases classified elsewhere,Paraplegia

Mal neo spinal cord,Myelopathy in oth dis,Paraplegia NOS

Admission Date: [**2189-1-8**] Discharge Date: [**2189-1-14**] Date of Birth: [**2110-12-14**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2724**] Chief Complaint: weakness in legs Major Surgical or Invasive Procedure: Thoracic laminectomies with resection intradural mass IVCF placement History of Present Illness: HPI: 78yM with no PMH who had sudden onset back pain yesterday afternoon resulting in a progressively worsening and ascending paralysis and anesthesia. At 3pm, the patient noted the onset of his back pain. By 9pm, the patient developed BLE weakness and numbness. He was brought to OSH and transfered to [**Hospital1 18**] ED. Upon arrival, the patient had decreased sensation below T12 and [**3-17**] BLE strength and decreased rectal tone. MRI showed a T5/6 intradural mass. Exam worsened recently with 0/5 BLE motor tone and paresthesia below T8. Also of note, the patient developed chest pain in the ED. ECG was WNL and the first set of enzymes were negative. The patient was just given 10 IV decadron. Past Medical History: none Social History: non smoker married supportive family Family History: nc Physical Exam: PHYSICAL EXAM: O: T: 97.8 BP: 120/70 HR: 101 R: 18 O2Sats: 97% RA Gen: WD/WN, Uncomfortable, complaining of chest pain HEENT: Pupils: 3-->2 MM PERRL EOMs Full Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, distended (baseline) Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Motor: D B T FE FF IP Q AT [**Last Name (un) 938**] G R 5 5 5 5 5 0 0 0 0 0 L 5 5 5 5 5 0 0 0 0 0 Unable to sit up and flex abdominal muscles Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally in the upper extremities; Below T5/6 the patient is without sensation to light touch or nociception. The patient is sensate to deep palpation in the abdomen but not to deep palpation below his abdomen. Reflexes: B T Br Pa Ac Right 1 1 1 0 0 Left 1 1 1 0 0 Propioception absent in BLE; normal in BUE Toes downgoing bilaterally No clonus Normal tone on passive movement of lower extrimities Rectal exam - no rectal tone ON DISCHARGE HIS EXAM IS +++++++++++++++++++++++++++++++++++++ Pertinent Results: [**2189-1-8**] 10:00AM WBC-8.8 RBC-4.12* HGB-12.9* HCT-37.1* MCV-90 MCH-31.2 MCHC-34.7 RDW-14.8 [**2189-1-8**] 10:00AM NEUTS-79.1* LYMPHS-16.6* MONOS-4.0 EOS-0.2 BASOS-0.1 [**2189-1-8**] 10:00AM PLT COUNT-224 [**2189-1-8**] 10:00AM PT-12.8 PTT-19.3* INR(PT)-1.1 [**2189-1-8**] 10:00AM GLUCOSE-155* UREA N-26* CREAT-0.7 SODIUM-138 POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-27 ANION GAP-13 MRI: Severe mid thoracic cord compression at the T5-T6 level by intradural extramedullary mass, with mild adjacent cord edema. RADIOLOGY Final Report [**Numeric Identifier 3174**] INTERUP IVC [**2189-1-12**] 7:52 AM Reason: Please place IVC filter for PE prophylaxis Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 78 year old man with paraplegia after cord hemorrhage (T5) REASON FOR THIS EXAMINATION: Please place IVC filter for PE prophylaxis INDICATION: 78-year-old man with a thoracic cord tumor, status post resection, complicated by hemorrhage. Please place IVC filter for PE prophylaxis. RADIOLOGISTS: Drs. [**First Name (STitle) 4685**] [**Name (STitle) 4686**] and [**Name5 (PTitle) **] [**Doctor Last Name **]. Dr. [**Last Name (STitle) 4686**], the attending radiologist, was present and supervising throughout the procedure. TECHNIQUE/FINDINGS: The risks and benefits were discussed with the patient's son, and written informed consent was obtained. A preprocedure timeout was performed. The right groin was prepped and draped in standard sterile fashion. Ultrasound was used to identify and confirm patency of the right common femoral vein. Under ultrasonographic guidance and after the administration of 5 cc of 1% lidocaine, a 19-gauge needle was advanced into the right common femoral vein, and a 0.035 [**Last Name (un) 7648**] wire was advanced into the distal IVC, through which an Omniflush catheter was advanced into the contralateral external iliac vein. A venogram was performed demonstrating a single patent inferior vena cava, with no evidence of thrombosis. The renal veins were identified at the level of L1. Based on this diagnostic findings, it was determined that the placement of an IVC filter would be indicated. An OptEase filter was placed below the level of the renal veins. The vascular sheath was removed, and manual compression was held for 10 minutes to achieve hemostasis. A final fluoroscopic image was obtained to confirm filter placement. The patient tolerated the procedure well with no immediate complications. IMPRESSION: Successful placement of an OptEase filter in the infrarenal inferior vena cava. This may be retrieved within 14 days of placement if indicated, or left in permanently. Cardiology Report ECG Study Date of [**2189-1-8**] 9:46:56 AM Artifact is present. Sinus rhythm. Left axis deviation. Right bundle-branch block with left anterior fascicular block. There are small R waves in the inferior leads consistent with possible prior inferior myocardial infarction. No previous tracing available for comparison. Read by: [**Last Name (LF) 2194**],[**First Name3 (LF) **] H. Intervals Axes Rate PR QRS QT/QTc P QRS T 87 156 142 410/457 63 -42 5 Brief Hospital Course: Pt was brought to the OR from the ER where under general anesthesia he underwent thoracic laminectomy T4-7 with resection of intradural extramedullary mass. He tolerated this procedure well , was extubated and transferred to the ICU for close neurologic monitoring. Post op his LE motor remained 0/5. He had sensory level at T6. His SBP was maintained > 100 for cord perfusion. He was on decadron and tapered. His dresssing was clean and dry and was removed post op day 2 and incision was well healing with staples.He had IVC filter placed prophylactically. He weas seen by PT and PT as well as social work for his acute change in physical exam. He is incontinent of stool at times. He has a foley catheter in place. Post-operatively, some of the sensation in his lower extremeities has returned, howver his mobility and propriception have not. He is stable medically at the time of discharge. Medications on Admission: Medications prior to admission: None Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever. 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 5. Multivitamins Tablet, Chewable Sig: One (1) Cap PO DAILY (Daily). 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED): while on steroids. 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 9. Sodium Phosphates Solution Sig: Forty Five (45) ML PO BID (2 times a day) as needed. 10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 11. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 12. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO every eight (8) hours for 2 days: [**2189-1-14**] and [**1-15**]. 13. Dexamethasone 1 mg Tablet Sig: One (1) Tablet PO three times a day for 2 days: [**1-16**] and [**1-17**]. 14. Dexamethasone 1 mg Tablet Sig: One (1) Tablet PO twice a day: start [**1-18**] and continue. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Intradural Extramedullary mass T5-6 cord compression Discharge Condition: NEUROLOGICALLY SLIGHTLY IMPROVED FROM ADMISSION H&P Discharge Instructions: DISCHARGE INSTRUCTIONS FOR SPINE CASES ?????? Do not smoke ?????? Keep wound clean / No tub baths or pools for two weeks from your date of surgery ?????? No pulling up, lifting> 10 lbs., excessive bending or twisting ?????? Have a family member check your incision daily for signs of infection ?????? Take pain medication as instructed; you may find it best if taken in the a.m. when you wake for morning stiffness and before bed for sleeping discomfort ?????? Do not take any anti-inflammatory medications such as Motrin, Advil, aspirin, Ibuprofen etc. unless directed by your doctor ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? Pain that is continually increasing or not relieved by pain medicine ?????? Any weakness, numbness, tingling in your extremities ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F ?????? Any change in your bowel or bladder habits Followup Instructions: YOUR STAPLES SHOULD BE REMOVED ON [**2189-1-21**] PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.[**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS. YOU WILL NOT NEED XRAYS PRIOR TO YOUR APPOINMENT Completed by:[**2189-1-14**]

192,336,344

{'Malignant neoplasm of spinal cord,Myelopathy in other diseases classified elsewhere,Paraplegia'}

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: weakness in legs PRESENT ILLNESS: HPI: 78yM with no PMH who had sudden onset back pain yesterday afternoon resulting in a progressively worsening and ascending paralysis and anesthesia. At 3pm, the patient noted the onset of his back pain. By 9pm, the patient developed BLE weakness and numbness. He was brought to OSH and transfered to [**Hospital1 18**] ED. Upon arrival, the patient had decreased sensation below T12 and [**3-17**] BLE strength and decreased rectal tone. MRI showed a T5/6 intradural mass. Exam worsened recently with 0/5 BLE motor tone and paresthesia below T8. Also of note, the patient developed chest pain in the ED. ECG was WNL and the first set of enzymes were negative. The patient was just given 10 IV decadron. MEDICAL HISTORY: none MEDICATION ON ADMISSION: Medications prior to admission: None ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: PHYSICAL EXAM: O: T: 97.8 BP: 120/70 HR: 101 R: 18 O2Sats: 97% RA Gen: WD/WN, Uncomfortable, complaining of chest pain HEENT: Pupils: 3-->2 MM PERRL EOMs Full Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, distended (baseline) Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Motor: D B T FE FF IP Q AT [**Last Name (un) 938**] G R 5 5 5 5 5 0 0 0 0 0 L 5 5 5 5 5 0 0 0 0 0 Unable to sit up and flex abdominal muscles FAMILY HISTORY: nc SOCIAL HISTORY: non smoker married supportive family ### Response: {'Malignant neoplasm of spinal cord,Myelopathy in other diseases classified elsewhere,Paraplegia'}

CHIEF COMPLAINT: Difficulty Breathing PRESENT ILLNESS: 59M with +tobacco history, previous visits to ED for COPD exacerbations (per ED report), s/p CVA x2, psychotic d/o who presents with difficulty breathing x1day. No chest pain, no cough. Not using albuterol inhalers at home as directed, but did endorse relief of sx when used inhaler. Continues to smoke, though at much reduced quantity (few cig per day). No known sick contacts, but attends adult day care. No recent long car rides, flights, travel. Did not check temperature at home, and has not felt feverish. Received flu shot 3-4 months ago from daycare program. . In the ED, vitals were T101.6 HR 116 136/70 20 98% 2L NC. Then 102.6 107 172/106 24 98% 15L NRB . Pt received nebs x 2 and had improvement in breathing. Attempted peak flow, but pt couldn't quite understand. Given Levofloxaxin 750mg x1 and prednisone 60mg x1. Also given Tylenol for fever. EKG showed sinus tachy without signs of ischemia. At time of transfer, pt was satting 98% on 2L NC. . Of note, pt was admitted 3 weeks ago for cellulitic black eschar on lateral aspect of left foot. Had followed up with podiatry as an outpatient, and Dr. [**Last Name (STitle) **] felt lesion was healing well on [**2183-1-29**]. . On the floor, pt states he is "very well, thank you." Denying F/C, N/V, change in urinary habits, CP, DOE, SOB (current), rhinorrhea, cough, hemoptysis or other phlegm, orthopnea. MEDICAL HISTORY: * Status post two cerebrovascular accidents complicated by L hemiplegia ([**2174**]) * Hypertension * Coronary Artery Disease * Hypercholesterolemia * Psychotic disorder NOS, mental baseline per family is child-like * Anxiety disorder MEDICATION ON ADMISSION: 1. atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day. 2. dipyridamole-aspirin 200-25 mg Cap, Multiphasic Release 12 hr ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: PHYSICAL EXAMINATION AT ADMISSION: VS: 100.8, 114/74, 110, 20@98%(RA) Gen: NAD. Mood and affect slightly childish and difficulty attending to questions. Pleasant and cooperative. Resting in bed. HEENT: NCAT. Acne. R pupil appeared to be [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **], but both eyes difficult to examine. EOM appeared to be intact. Anicteric sclera. MMM, OP clear. Dentures in place. Neck: Supple. JVP not elevated. No carotid bruits noted. CV: Slight tachycardia. Normal S1, S2. No murmur, rubs, or gallops. Chest: Respiration unlabored, no accessory muscle use. CTAB. Poor air movement bilaterally, but no wheezing appreciated. Abd: BS present. Soft, NT, ND. No HSM detected. Ext: WWP, no cyanosis or clubbing. No edema. Distal pulses radial 2+, DP/PT unappreciated; No asymmetry in color or size of LE, no pain in palpation of gastrocnemius. Skin: L lateral foot with healing eschar, no surrounding erythema. No rashes, ecchymoses noted. Neuro/Psych: CNs II-XII intact as best as can appreciate with level of cooperation. 5/5 strength in right U/L extremities. [**3-18**] on LUE, hamstring; [**12-18**] in dorsiflexion; L foot kept in plantar flexion. DTRs 2+ BL (biceps, patellar); clonus noted in L ankle with + Babinski. Sensation intact to LT, temperature. Cerebellum not formally tested, but pt able to initiate complex movements (e.g. crossing legs) bilaterally. WC bound at baseline. FAMILY HISTORY: One relative with CVA, niece with pulmonary fibrosis, brother with DM2. [**Name2 (NI) **] known cancer or MI in family. SOCIAL HISTORY: Patient immigrated to [**State 760**], then [**Location (un) 86**] from [**Male First Name (un) 1056**] in his mid teens. Formerly worked as a teacher's aid, performing dancing and comedy on the side. Requires constant care and supervision from adult daycare, niece, sister, and other family since his stroke and hemiparesis. He is wheelchair bound. Smoked for ~40 years, before CVA 4PPD, now 1/2PPD. Denies EtOH, other drugs

Influenza with pneumonia,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Chronic obstructive asthma with (acute) exacerbation,Coronary atherosclerosis of native coronary artery,Pure hypercholesterolemia,Anxiety state, unspecified,Tobacco use disorder,Pressure ulcer, other site,Other specified cardiac dysrhythmias,Dehydration,Unspecified psychosis,Benign essential hypertension,Viral pneumonia, unspecified

Influenza with pneumonia,Late ef-hemplga side NOS,Ch obst asth w (ac) exac,Crnry athrscl natve vssl,Pure hypercholesterolem,Anxiety state NOS,Tobacco use disorder,Pressure ulcer, site NEC,Cardiac dysrhythmias NEC,Dehydration,Psychosis NOS,Benign hypertension,Viral pneumonia NOS

Admission Date: [**2183-2-3**] Discharge Date: [**2183-2-10**] Date of Birth: [**2123-7-2**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1990**] Chief Complaint: Difficulty Breathing Major Surgical or Invasive Procedure: None History of Present Illness: 59M with +tobacco history, previous visits to ED for COPD exacerbations (per ED report), s/p CVA x2, psychotic d/o who presents with difficulty breathing x1day. No chest pain, no cough. Not using albuterol inhalers at home as directed, but did endorse relief of sx when used inhaler. Continues to smoke, though at much reduced quantity (few cig per day). No known sick contacts, but attends adult day care. No recent long car rides, flights, travel. Did not check temperature at home, and has not felt feverish. Received flu shot 3-4 months ago from daycare program. . In the ED, vitals were T101.6 HR 116 136/70 20 98% 2L NC. Then 102.6 107 172/106 24 98% 15L NRB . Pt received nebs x 2 and had improvement in breathing. Attempted peak flow, but pt couldn't quite understand. Given Levofloxaxin 750mg x1 and prednisone 60mg x1. Also given Tylenol for fever. EKG showed sinus tachy without signs of ischemia. At time of transfer, pt was satting 98% on 2L NC. . Of note, pt was admitted 3 weeks ago for cellulitic black eschar on lateral aspect of left foot. Had followed up with podiatry as an outpatient, and Dr. [**Last Name (STitle) **] felt lesion was healing well on [**2183-1-29**]. . On the floor, pt states he is "very well, thank you." Denying F/C, N/V, change in urinary habits, CP, DOE, SOB (current), rhinorrhea, cough, hemoptysis or other phlegm, orthopnea. Past Medical History: * Status post two cerebrovascular accidents complicated by L hemiplegia ([**2174**]) * Hypertension * Coronary Artery Disease * Hypercholesterolemia * Psychotic disorder NOS, mental baseline per family is child-like * Anxiety disorder Social History: Patient immigrated to [**State 760**], then [**Location (un) 86**] from [**Male First Name (un) 1056**] in his mid teens. Formerly worked as a teacher's aid, performing dancing and comedy on the side. Requires constant care and supervision from adult daycare, niece, sister, and other family since his stroke and hemiparesis. He is wheelchair bound. Smoked for ~40 years, before CVA 4PPD, now 1/2PPD. Denies EtOH, other drugs Family History: One relative with CVA, niece with pulmonary fibrosis, brother with DM2. [**Name2 (NI) **] known cancer or MI in family. Physical Exam: PHYSICAL EXAMINATION AT ADMISSION: VS: 100.8, 114/74, 110, 20@98%(RA) Gen: NAD. Mood and affect slightly childish and difficulty attending to questions. Pleasant and cooperative. Resting in bed. HEENT: NCAT. Acne. R pupil appeared to be [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **], but both eyes difficult to examine. EOM appeared to be intact. Anicteric sclera. MMM, OP clear. Dentures in place. Neck: Supple. JVP not elevated. No carotid bruits noted. CV: Slight tachycardia. Normal S1, S2. No murmur, rubs, or gallops. Chest: Respiration unlabored, no accessory muscle use. CTAB. Poor air movement bilaterally, but no wheezing appreciated. Abd: BS present. Soft, NT, ND. No HSM detected. Ext: WWP, no cyanosis or clubbing. No edema. Distal pulses radial 2+, DP/PT unappreciated; No asymmetry in color or size of LE, no pain in palpation of gastrocnemius. Skin: L lateral foot with healing eschar, no surrounding erythema. No rashes, ecchymoses noted. Neuro/Psych: CNs II-XII intact as best as can appreciate with level of cooperation. 5/5 strength in right U/L extremities. [**3-18**] on LUE, hamstring; [**12-18**] in dorsiflexion; L foot kept in plantar flexion. DTRs 2+ BL (biceps, patellar); clonus noted in L ankle with + Babinski. Sensation intact to LT, temperature. Cerebellum not formally tested, but pt able to initiate complex movements (e.g. crossing legs) bilaterally. WC bound at baseline. PHYSICAL EXAMINATION AT DISCHARGE: VS: Tm 98.3 Tc 97.8, HR 84(84-140) 110/70(110-148/70-88) 20 96RA GEN: NAD, lying on left side hunched over in bed HEENT: NC/AT,Mild nasal congestion. CV: RRR, nl s1 and s2, no m/r/g appreciated PULM: Left lung decreased breath sounds on (dependent), Breathing unlabored. ABD: soft, protuberant, non-tender, +BS EXT: wwp, radial pulses palpated, pedal pulses not palpable SKIN: left eschar wrapped in kerlix NEURO: arousable, stable left hemiplegia with clonus of the left foot Pertinent Results: IMAGING: [**2183-2-3**] CXR: Cardiac, mediastinal and hilar contours are normal. There is no pleural effusion or pneumothorax. There is no focal consolidation. No acute intrathoracic abnormality . [**2183-2-5**], CXR: Previous chest radiographs documented hyperinflation likely due to emphysema or small airways obstruction. Today's study shows normal lung volumes, although there is distortion of the pulmonary vascular branching in the upper lobes suggesting emphysema. Most significant is interstitial abnormality at both lung bases, chronicity indeterminate, that could be acute viral pneumonia or chronic interstitial disease such as non-specific interstitial pneumonitis. Of note, the heart is not enlarged. There is no pulmonary vascular or mediastinal venous engorgement and no pleural effusion. . **FINAL REPORT [**2183-2-5**]** DIRECT INFLUENZA A ANTIGEN TEST (Final [**2183-2-5**]): POSITIVE FOR INFLUENZA A VIRAL ANTIGEN. REPORTED BY PHONE TO [**First Name8 (NamePattern2) 4224**] [**Last Name (NamePattern1) **] [**2183-2-5**] 10:40AM. DIRECT INFLUENZA B ANTIGEN TEST (Final [**2183-2-5**]): Negative for Influenza B. . -Legionella negative. -Urine and blood cx NEGATIVE ################################################################ Labs: [**2183-2-3**] 01:35PM BLOOD WBC-6.6 RBC-4.17* Hgb-13.9* Hct-40.5 MCV-97 MCH-33.3* MCHC-34.4 RDW-13.1 Plt Ct-154 [**2183-2-5**] 11:07AM BLOOD WBC-7.3 RBC-4.19* Hgb-13.7* Hct-40.6 MCV-97 MCH-32.7* MCHC-33.8 RDW-13.2 Plt Ct-147* [**2183-2-10**] 05:50AM BLOOD WBC-7.6 RBC-4.10* Hgb-13.3* Hct-39.6* MCV-97 MCH-32.5* MCHC-33.7 RDW-12.9 Plt Ct-225 . [**2183-2-5**] 12:45PM BLOOD PT-12.7 PTT-26.1 INR(PT)-1.1 , [**2183-2-3**] 01:35PM BLOOD Glucose-97 UreaN-13 Creat-1.0 Na-134 K-4.7 Cl-99 HCO3-26 AnGap-14 [**2183-2-7**] 05:35AM BLOOD Glucose-143* UreaN-25* Creat-1.0 Na-136 K-3.8 Cl-99 HCO3-28 AnGap-13 [**2183-2-9**] 06:20AM BLOOD Glucose-88 UreaN-24* Creat-0.9 Na-142 K-3.7 Cl-107 HCO3-27 AnGap-12 [**2183-2-10**] 05:50AM BLOOD Glucose-91 UreaN-33* Creat-1.1 Na-139 K-3.9 Cl-106 HCO3-28 AnGap-9 . [**2183-2-6**] 06:38AM BLOOD Calcium-9.4 Phos-3.9 Mg-2.3 [**2183-2-9**] 06:20AM BLOOD Calcium-9.2 Phos-3.3 Mg-2.0 . [**2183-2-3**] 02:53PM BLOOD Lactate-1.1 [**2183-2-5**] 12:50PM BLOOD Lactate-1.0 Brief Hospital Course: Mr. [**Known lastname 68250**] is a 59 year old man with a history of left sided hemiplegia secondary to CVA x2, HTN, significant tobacco use and emphysema (COPD per ED report) who presented with difficulty breathing. At presentation to the ED, he was additionally found to be tachycardic and febrile. # Dyspnea: The acute onset of shortness of breath is likely due to underlying COPD exacerbated by influenza infection, possibly with bacterial superinfection and worsened by anxiety. At presentation, there was minimal concern for PE given the lack of risk factors; however, the patient has limited mobility at baseline and was tachycardic at presentations. Consistent with a COPD exacerbation, wheezes were noted at presentation, and again during periods of shortness of breath. He was started on steroids, azithromycin, and standing nebulizers. The patient had received a flu vaccine this year, but DFA for influenza was sent given his poor respiratory status and fever, and returned positive on HD2. The morning of hospital day 2, Mr. [**Known lastname 68250**] began suffering from worsening respiratory distress, and required transfer to the intensive care unit for closer observation. Oseltamivir was given for influenza, as were antibiotics for concern for a secondary bacterial infection causing pneumonia. With BiPAP and neb treatment, he improved, and the following day returned to the floor. He never required intubation. A chest radiograph revealed emphysema and bibasilar interstitial infiltrates concerning for viral pneumonia or a chronic interstitial disease. Given that his decompensation occurred after being admitted for >36 hours, suspicion for bacterial superinfection was sufficiently high to initiate treatment for common causes of community acquired pneumonia. Of note, patient's respiratory status also decompensated with increased anxiety, and anxiety was managed using outpatient regimen of Ativan TID PRN. # Sinus Tachycardia: The patient was tachycardic in the ED and on the floor. This was most likely due his response to infection, but use of albuterol and dehydration likely contributed. The tachycardia could have also been related to rebound tachycardia from holding atenolol. The tachycardia improved in conjunction with improvement in his shortness of breath and restarting his atenolol at half dose - 50mg PO daily. # Left Lateral Foot Eschar: The pressure ulcer, which resulted in a recent hospital admission, likely is due to the patient's proclivity towards lying and sleeping on his left lateral side in combination with left hemiplegia. Per the podiatry recommendations, Silvadene was applied with daily dressing changes, and a waffle boot was placed on the left foot as tolerated to avoid injury from continued pressure. He will have daily dressing changes and follow up with podiatry. # Hypertension: The patient was continued on home enalapril and hydrochlorothiazide. Home atenolol was held briefly after the ICU transfer for concern that it would exacerbate poor respiratory function. Atenolol was restarted and his BP was stable at the time of discharge. # Anxiety/Psychosis NOS: Home medications were continued, which include fluoxetine, olanzapine, trazodone and lorazepam. Trazodone and lorazepam were held briefly after the ICU transfer for concern that they would exacerbate poor respiratory function. Lorazepam was restarted and trazadone was held to be restarted by his PCP. # Hyperlipidemia: Home simvastatin was continued. # s/p Cerebrovascular Accident with residual left-sided hemiplegia: Continued home dipyridamole-aspirin and tizanidine. Tizanidine was held during and briefly after the ICU transfer for concern that the sedating effects would exacerbate respiratory distress. Pt respiratory status is stable, and Tizanidine was restarted at the time of discharge and for him to be followed by his PCP and nurse practitioner. # Code: confirmed full Medications on Admission: 1. atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day. 2. dipyridamole-aspirin 200-25 mg Cap, Multiphasic Release 12 hr Sig: One (1) Cap PO BID (2 times a day). 3. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. olanzapine 5 mg Tablet Sig: One (1) Tablet PO at bedtime. 7. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia --> Per pharmacy, filled [**1-23**] at 1/2 tab q6 hours 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 11. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours). --> not taking, finished course 12. enalapril maleate 20 mg Tablet Sig: One (1) Tablet PO once a day. 13. lorazepam 1 mg Tablet Sig: One (1) Tablet PO once a day as needed for anxiety. 14. calcium and vit D Sig: continue home regimen twice a day. 15. Tizanadine 4mg PO BID 16. Silvadene cream TP to Left foot qday --> pt's niece reports occasional inhaler use, but pharmacy hasn't had Rx filled since [**2181-12-14**] Discharge Medications: 1. silver sulfadiazine 1 % Cream Sig: One (1) Appl Topical DAILY (Daily). 2. dipyridamole-aspirin 200-25 mg Cap, ER Multiphase 12 hr Sig: One (1) Cap PO BID (2 times a day). 3. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 7. calcium carbonate Oral 8. cholecalciferol (vitamin D3) Oral 9. enalapril maleate 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 11. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)). 12. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. lorazepam 1 mg Tablet Sig: One (1) Tablet PO NOON (At Noon) as needed for agitation, anxiety. 15. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:*1 inhaler* Refills:*0* 16. Aggrenox 200-25 mg Cap, ER Multiphase 12 hr Sig: One (1) Cap, ER Multiphase 12 hr PO twice a day. 17. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO every eight (8) hours for 1 days. Disp:*3 Tablet(s)* Refills:*0* 18. prednisone 10 mg Tablet Sig: Three (3) Tablet PO taper for 8 days: 30mg (3 tabs)through [**2-11**]; On [**2-12**] take 20mg (2tabs) through [**2-14**]; on [**2-15**] take 10mg through [**2-17**] . Disp:*12 Tablet(s)* Refills:*0* 19. tizanidine 4 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home With Service Facility: guardian healthcare Discharge Diagnosis: Principle: -Dyspnea, multifactorial . Secondary: -Emphysema -Influenza A -Anxiety -Left lateral foot ulcer -Hypertension -Hyperlipidemia -Cerebrovascular Accident -Psychosis NOS Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [**Known lastname 68250**], It was a pleasure taking care of you at the [**Hospital1 18**]. You came to the emergency department with difficulty breathing and a fever. You were admitted to the hospital and were treated with inhaled medications to improve your breathing. We then discovered that you had the flu (influenza). Your respiratory infection was treated with Oseltamivir and several antibiotics for a bacterial infection of your lungs (in addition to the flu). You are now doing much better and are ready for discharge to home. Please continue your home medications as directed. The following additional medications were prescribed: - START Augmentin 500 mg every 8 hours, for 1 day end [**2183-2-11**] - START Prednisone, and taper your dose as follows:30mg through [**2-11**]; then 20mg through [**2-14**]; then 10mg through [**2-17**] - START using an inhaler to help your breathing - DECREASE your dose of atenolol to 50mg daily Please call your primary care doctor if your symptoms return. Dial 911 if it is an emergency. Followup Instructions: Your nurse will visit you at home after your discharge from the hospital. Department: PODIATRY When: THURSDAY [**2183-2-27**] at 2:20 PM With: [**First Name11 (Name Pattern1) 5445**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5446**], DPM [**Telephone/Fax (1) 543**] Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage

487,438,493,414,272,300,305,707,427,276,298,401,480

{'Influenza with pneumonia,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Chronic obstructive asthma with (acute) exacerbation,Coronary atherosclerosis of native coronary artery,Pure hypercholesterolemia,Anxiety state, unspecified,Tobacco use disorder,Pressure ulcer, other site,Other specified cardiac dysrhythmias,Dehydration,Unspecified psychosis,Benign essential hypertension,Viral pneumonia, 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: Difficulty Breathing PRESENT ILLNESS: 59M with +tobacco history, previous visits to ED for COPD exacerbations (per ED report), s/p CVA x2, psychotic d/o who presents with difficulty breathing x1day. No chest pain, no cough. Not using albuterol inhalers at home as directed, but did endorse relief of sx when used inhaler. Continues to smoke, though at much reduced quantity (few cig per day). No known sick contacts, but attends adult day care. No recent long car rides, flights, travel. Did not check temperature at home, and has not felt feverish. Received flu shot 3-4 months ago from daycare program. . In the ED, vitals were T101.6 HR 116 136/70 20 98% 2L NC. Then 102.6 107 172/106 24 98% 15L NRB . Pt received nebs x 2 and had improvement in breathing. Attempted peak flow, but pt couldn't quite understand. Given Levofloxaxin 750mg x1 and prednisone 60mg x1. Also given Tylenol for fever. EKG showed sinus tachy without signs of ischemia. At time of transfer, pt was satting 98% on 2L NC. . Of note, pt was admitted 3 weeks ago for cellulitic black eschar on lateral aspect of left foot. Had followed up with podiatry as an outpatient, and Dr. [**Last Name (STitle) **] felt lesion was healing well on [**2183-1-29**]. . On the floor, pt states he is "very well, thank you." Denying F/C, N/V, change in urinary habits, CP, DOE, SOB (current), rhinorrhea, cough, hemoptysis or other phlegm, orthopnea. MEDICAL HISTORY: * Status post two cerebrovascular accidents complicated by L hemiplegia ([**2174**]) * Hypertension * Coronary Artery Disease * Hypercholesterolemia * Psychotic disorder NOS, mental baseline per family is child-like * Anxiety disorder MEDICATION ON ADMISSION: 1. atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day. 2. dipyridamole-aspirin 200-25 mg Cap, Multiphasic Release 12 hr ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: PHYSICAL EXAMINATION AT ADMISSION: VS: 100.8, 114/74, 110, 20@98%(RA) Gen: NAD. Mood and affect slightly childish and difficulty attending to questions. Pleasant and cooperative. Resting in bed. HEENT: NCAT. Acne. R pupil appeared to be [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **], but both eyes difficult to examine. EOM appeared to be intact. Anicteric sclera. MMM, OP clear. Dentures in place. Neck: Supple. JVP not elevated. No carotid bruits noted. CV: Slight tachycardia. Normal S1, S2. No murmur, rubs, or gallops. Chest: Respiration unlabored, no accessory muscle use. CTAB. Poor air movement bilaterally, but no wheezing appreciated. Abd: BS present. Soft, NT, ND. No HSM detected. Ext: WWP, no cyanosis or clubbing. No edema. Distal pulses radial 2+, DP/PT unappreciated; No asymmetry in color or size of LE, no pain in palpation of gastrocnemius. Skin: L lateral foot with healing eschar, no surrounding erythema. No rashes, ecchymoses noted. Neuro/Psych: CNs II-XII intact as best as can appreciate with level of cooperation. 5/5 strength in right U/L extremities. [**3-18**] on LUE, hamstring; [**12-18**] in dorsiflexion; L foot kept in plantar flexion. DTRs 2+ BL (biceps, patellar); clonus noted in L ankle with + Babinski. Sensation intact to LT, temperature. Cerebellum not formally tested, but pt able to initiate complex movements (e.g. crossing legs) bilaterally. WC bound at baseline. FAMILY HISTORY: One relative with CVA, niece with pulmonary fibrosis, brother with DM2. [**Name2 (NI) **] known cancer or MI in family. SOCIAL HISTORY: Patient immigrated to [**State 760**], then [**Location (un) 86**] from [**Male First Name (un) 1056**] in his mid teens. Formerly worked as a teacher's aid, performing dancing and comedy on the side. Requires constant care and supervision from adult daycare, niece, sister, and other family since his stroke and hemiparesis. He is wheelchair bound. Smoked for ~40 years, before CVA 4PPD, now 1/2PPD. Denies EtOH, other drugs ### Response: {'Influenza with pneumonia,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Chronic obstructive asthma with (acute) exacerbation,Coronary atherosclerosis of native coronary artery,Pure hypercholesterolemia,Anxiety state, unspecified,Tobacco use disorder,Pressure ulcer, other site,Other specified cardiac dysrhythmias,Dehydration,Unspecified psychosis,Benign essential hypertension,Viral pneumonia, unspecified'}

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is an 83 year-old white male with a history of large left sided lung mass who recently had a biopsy who presented with mental status changes and vomiting followed by hypoxemia. He had a biopsy of his lung mass on [**2115-1-18**]. On the day prior to admission the patient complained of pain at his biopsy site, which is controlled with Percocet. On the morning of admission he developed a fever to 101.7 degrees Fahrenheit rectally. His O2 sats were 90% on 2.5 liters nasal cannula. A chest x-ray revealed left upper lobe and right lower lobe infiltrates and the patient was started on Levofloxacin for presumed pneumonia. Later that day he gradually became more lethargic and required more pain medication. After the one episode of vomiting the patient's O2 sats fell to the 80s on 2.5 liters per minute nasal cannula and he was 92% on 8 liters of nasal cannula. He was then transferred to the [**Hospital1 1444**] for further management. On arrival the patient required 100% nonrebreather face mask to keep his O2 sats in the high to mid 90s. A chest x-ray revealed left lower lobe collapse and consolidation with an additional infiltrate around the mass and a moderate sized left pleural effusion. He was given a dose of Levofloxacin and Flagyl in the Emergency Department. Arterial blood gas on a nonrebreather mask revealed pH at 7.2 on oxygen, CO2 of 80 and oxygen of 125. A trial of BIPAP was attempted, however, the patient could not tolerate the mask. He was then placed back on a nonrebreather with almost identical arterial blood gas of 7.20, 79, and 125. The MICU team was then called to evaluate the patient. MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease on 2 liters nasal cannula at home. Pulmonary function tests in [**2107**] showed an FEV of 0.62, FVC of 1.3 and FEV/FVC of 45%. 2. Peripheral vascular disease status post right femoral popliteal bypass graft. 3. Coronary artery disease status post percutaneous transluminal coronary angioplasty and myocardial infarction. 4. Hypertension. 5. Type 2 diabetes. 6. Benign prostatic hypertrophy status post transurethral resection of the prostate. 7. Depression. 8. Essential tremor. 9. Bladder cancer. 10. Benign positional vertigo. 11. Lung cancer metastatic to the liver. Recent biopsy performed with biopsy results pending. MEDICATION ON ADMISSION: Heparin, Tylenol #3, aspirin, Lactulose, Fluoxetine, Isosorbide mononitrate, Imdur, Lisinopril, Fluticasone, Atrovent, Albuterol, Senna and Colace. ALLERGIES: Sulfa rash. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Unspecified pleural effusion,Obstructive chronic bronchitis with (acute) exacerbation,Malignant neoplasm of other parts of bronchus or lung,Malignant neoplasm of liver, secondary,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Old myocardial infarction

Food/vomit pneumonitis,Acute respiratry failure,Pleural effusion NOS,Obs chr bronc w(ac) exac,Mal neo bronch/lung NEC,Second malig neo liver,DMII wo cmp nt st uncntr,Hypertension NOS,Old myocardial infarct

Admission Date: [**2115-1-21**] Discharge Date: [**2115-1-23**] Service: MEDICAL ICU/[**Hospital1 212**] HISTORY OF PRESENT ILLNESS: The patient is an 83 year-old white male with a history of large left sided lung mass who recently had a biopsy who presented with mental status changes and vomiting followed by hypoxemia. He had a biopsy of his lung mass on [**2115-1-18**]. On the day prior to admission the patient complained of pain at his biopsy site, which is controlled with Percocet. On the morning of admission he developed a fever to 101.7 degrees Fahrenheit rectally. His O2 sats were 90% on 2.5 liters nasal cannula. A chest x-ray revealed left upper lobe and right lower lobe infiltrates and the patient was started on Levofloxacin for presumed pneumonia. Later that day he gradually became more lethargic and required more pain medication. After the one episode of vomiting the patient's O2 sats fell to the 80s on 2.5 liters per minute nasal cannula and he was 92% on 8 liters of nasal cannula. He was then transferred to the [**Hospital1 1444**] for further management. On arrival the patient required 100% nonrebreather face mask to keep his O2 sats in the high to mid 90s. A chest x-ray revealed left lower lobe collapse and consolidation with an additional infiltrate around the mass and a moderate sized left pleural effusion. He was given a dose of Levofloxacin and Flagyl in the Emergency Department. Arterial blood gas on a nonrebreather mask revealed pH at 7.2 on oxygen, CO2 of 80 and oxygen of 125. A trial of BIPAP was attempted, however, the patient could not tolerate the mask. He was then placed back on a nonrebreather with almost identical arterial blood gas of 7.20, 79, and 125. The MICU team was then called to evaluate the patient. PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease on 2 liters nasal cannula at home. Pulmonary function tests in [**2107**] showed an FEV of 0.62, FVC of 1.3 and FEV/FVC of 45%. 2. Peripheral vascular disease status post right femoral popliteal bypass graft. 3. Coronary artery disease status post percutaneous transluminal coronary angioplasty and myocardial infarction. 4. Hypertension. 5. Type 2 diabetes. 6. Benign prostatic hypertrophy status post transurethral resection of the prostate. 7. Depression. 8. Essential tremor. 9. Bladder cancer. 10. Benign positional vertigo. 11. Lung cancer metastatic to the liver. Recent biopsy performed with biopsy results pending. ALLERGIES: Sulfa rash. MEDICATIONS ON ADMISSION: Heparin, Tylenol #3, aspirin, Lactulose, Fluoxetine, Isosorbide mononitrate, Imdur, Lisinopril, Fluticasone, Atrovent, Albuterol, Senna and Colace. HOSPITAL COURSE: The [**Hospital 228**] hospital course was complicated by his continued respiratory distress. The patient continued to request no invasive measures including no intubation, no resuscitation and no chest tube placement. Essentially the patient wanted to die peacefully and not have any invasive measures done to sustain his life. At that point the patient was transferred to the MICU to the medical floor. He continued to have respiratory decline and was eventually unresponsive and made comfort measures only by his family whose daughter [**Name (NI) 4051**] [**Name (NI) 6203**] who is his health care proxy. The patient passed on [**2115-1-23**] at around 5:00 p.m. He died of respiratory failure secondary to lung cancer secondary to pneumonia. The patient's family declined a post mortem examination. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4263**] Dictated By:[**Doctor Last Name 6204**] MEDQUIST36 D: [**2115-1-24**] 10:01 T: [**2115-1-24**] 10:23 JOB#: [**Job Number 6205**]

507,518,511,491,162,197,250,401,412

{'Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Unspecified pleural effusion,Obstructive chronic bronchitis with (acute) exacerbation,Malignant neoplasm of other parts of bronchus or lung,Malignant neoplasm of liver, secondary,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Old myocardial infarction'}

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 an 83 year-old white male with a history of large left sided lung mass who recently had a biopsy who presented with mental status changes and vomiting followed by hypoxemia. He had a biopsy of his lung mass on [**2115-1-18**]. On the day prior to admission the patient complained of pain at his biopsy site, which is controlled with Percocet. On the morning of admission he developed a fever to 101.7 degrees Fahrenheit rectally. His O2 sats were 90% on 2.5 liters nasal cannula. A chest x-ray revealed left upper lobe and right lower lobe infiltrates and the patient was started on Levofloxacin for presumed pneumonia. Later that day he gradually became more lethargic and required more pain medication. After the one episode of vomiting the patient's O2 sats fell to the 80s on 2.5 liters per minute nasal cannula and he was 92% on 8 liters of nasal cannula. He was then transferred to the [**Hospital1 1444**] for further management. On arrival the patient required 100% nonrebreather face mask to keep his O2 sats in the high to mid 90s. A chest x-ray revealed left lower lobe collapse and consolidation with an additional infiltrate around the mass and a moderate sized left pleural effusion. He was given a dose of Levofloxacin and Flagyl in the Emergency Department. Arterial blood gas on a nonrebreather mask revealed pH at 7.2 on oxygen, CO2 of 80 and oxygen of 125. A trial of BIPAP was attempted, however, the patient could not tolerate the mask. He was then placed back on a nonrebreather with almost identical arterial blood gas of 7.20, 79, and 125. The MICU team was then called to evaluate the patient. MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease on 2 liters nasal cannula at home. Pulmonary function tests in [**2107**] showed an FEV of 0.62, FVC of 1.3 and FEV/FVC of 45%. 2. Peripheral vascular disease status post right femoral popliteal bypass graft. 3. Coronary artery disease status post percutaneous transluminal coronary angioplasty and myocardial infarction. 4. Hypertension. 5. Type 2 diabetes. 6. Benign prostatic hypertrophy status post transurethral resection of the prostate. 7. Depression. 8. Essential tremor. 9. Bladder cancer. 10. Benign positional vertigo. 11. Lung cancer metastatic to the liver. Recent biopsy performed with biopsy results pending. MEDICATION ON ADMISSION: Heparin, Tylenol #3, aspirin, Lactulose, Fluoxetine, Isosorbide mononitrate, Imdur, Lisinopril, Fluticasone, Atrovent, Albuterol, Senna and Colace. ALLERGIES: Sulfa rash. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: ### Response: {'Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Unspecified pleural effusion,Obstructive chronic bronchitis with (acute) exacerbation,Malignant neoplasm of other parts of bronchus or lung,Malignant neoplasm of liver, secondary,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Old myocardial infarction'}

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is a 61-year-old male with hypertension, anxiety, and gastroesophageal reflux disease, and no significant prior cardiac history, who presented to us today for acute onset of chest pain and shortness of breath. MEDICAL HISTORY: MEDICATION ON ADMISSION: ALLERGIES: PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

Acute myocardial infarction of other anterior wall, initial episode of care,Coronary atherosclerosis of native coronary artery,Pneumonitis due to inhalation of food or vomitus,Urinary tract infection, site not specified,Unspecified essential hypertension,Esophageal reflux

AMI anterior wall, init,Crnry athrscl natve vssl,Food/vomit pneumonitis,Urin tract infection NOS,Hypertension NOS,Esophageal reflux

Admission Date: [**2165-7-8**] Discharge Date: [**2165-7-18**] Date of Birth: [**2104-6-18**] Sex: M Service: CCU HISTORY OF PRESENT ILLNESS: The patient is a 61-year-old male with hypertension, anxiety, and gastroesophageal reflux disease, and no significant prior cardiac history, who presented to us today for acute onset of chest pain and shortness of breath. The patient was at work today, the day of admission, he noted a brief and sudden onset of chest pain, shortness of breath. He went to his primary care doctor's office, and was found to have ST elevations in V1 through V4. He presented to an outside hospital and received aspirin, Lopressor, was placed on a nitrodrip and a Heparin drip. His pain improved, but he still had ST elevations. The patient presented to our Catheterization Laboratory with the lowest systolic blood pressure in the 70s-90s. In the Catheterization Laboratory, the patient was found to have a normal left main artery. His left anterior descending artery was found to be totally occluded proximally just beyond the left marginal branch. His left circumflex artery was found to have two serial discrete 70-80% lesions. His right coronary artery was found to be 85% occluded at the origin and to have faint collaterals. His left anterior descending lesion was stented proximally with 0% residual occlusion. TIMI-III flow was noted in the LAD. MEDICATIONS AT HOME: 1. Prevacid 30 mg once a day. 2. Paxil 20 mg once a day. 3. Ativan 1 mg once a day. PHYSICAL EXAM ON ADMISSION TO CCU: Demonstrated a normotensive blood pressure of 104/68, heart rate of 95. He was sating 97% on 4 liters. He was afebrile. In general, the patient was lying in bed in no acute distress. His membranes were moist. His neck was supple. He had no jugular venous distention. On his chest examination, he had rales anteriorly. Patient, on cardiac exam, he had a regular rhythm. His abdomen demonstrated no abnormalities. His extremities were warm. He had good pulses, and he was alert and oriented times three. LABORATORY VALUES ON ADMISSION: Significant for a white count of 13.7. CK of 1862 and a troponin greater than 50. ELECTROCARDIOGRAM: Showed a normal sinus rhythm at 93 beats per minute, a normal axis and intervals. He had [**Street Address(2) 1766**] elevation in leads V2 to V3. On CCU day one, the patient arrived with an intra-aortic balloon pump inside of him. The patient was started on aspirin, Plavix, Integrilin. HOSPITAL COURSE: On hospital day two, the patient was running a low grade temperature overnight. Was given 1 gram of Vancomycin and was started on levofloxacin and Flagyl for presumed aspiration pneumonia. A chest x-ray obtained showed a left lower lobe opacity. The aortic balloon pump was still in place. He obtained an echocardiogram which showed an ejection fraction of 30% and left ventricular hypokinesis globally. On CCU day three, the patient had an episode of chest pain. A sublingual nitroglycerin was given. Subsequently, his blood pressures dropped a bit to systolics 70s. He was given a fluid bolus of 500 cc and his pressure increased to 100 systolic. His ACE inhibitor was increased to 25 mg 3x a day. On CCU day four, the patient's aortic balloon pump was removed. He was started on Coreg 3.125 and his captopril was held at 25 tid secondary to systolic blood pressures in the 90s. On CCU day five, the patient had an episode of lightheadedness. His captopril dose was held at 25 mg tid. He was given a 500 cc bolus of normal saline, and he responded appropriately. He also was complaining of one episode of [**3-18**] chest pain. An electrocardiogram was performed that showed no changes. Cardiac enzymes were sent. The pain resolved with Morphine. The decision was made to recath the patient secondary to persistent chest pain [**3-18**] and persistent electrocardiogram changes that were unresolved since admission. Postcatheterization procedure, the patient was transferred out to the floor. In the evening, he had an episode of chest pain with his blood pressures running in the 100 systolic. Morphine and Ativan were given. The patient was not chest pain free. The sheath was pulled from the patient. He had a vagal episode, and decreased his blood pressure. A 1 liter fluid bolus was given, and he became normotensive. He subsequently was still experiencing the chest pain. More Morphine was given. His blood pressure remained in the 60s systolic with heart rate in the 60s. 750 cc of fluid were given, and decision was made to transfer the patient to the CCU for closer monitoring. His pressures normalized in the CCU with systolic blood pressures ranging from 95-110. Of note, during these episodes of chest pain on the floor and into the CCU, the patient did not have any electrocardiogram changes, and enzymes were sent, but there were no subsequent changes in his cardiac enzymes as well. On hospital day nine, the patient remained stable in the CCU. A low dose beta blocker was started, and Coumadin was started as well. The Coumadin dose was 5 mg once a day. By this time, the patient was off levofloxacin and Flagyl for the presumed aspiration pneumonia on the previous hospital day two. By hospital day 10, the patient remained stable, normotensive, and afebrile, and was discharged to home. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: Full code. DISCHARGE DIAGNOSIS: Acute myocardial infarction. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg once a day. 2. Plavix 75 mg once a day. 3. Atorvastatin 10 mg once a day. 4. Protonix 40 mg once a day. 5. Paxil 30 mg once a day. 6. Lisinopril 5 mg once a day. 7. Carvedilol 12.5 mg twice a day. 8. Lovenox 80 mg subcutaneously every 12 hours for five days. FOLLOW-UP PLANS: The patient is to followup with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 51937**] in his office for an INR check at 2 pm on [**2165-7-22**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**] Dictated By:[**Last Name (NamePattern1) 3809**] MEDQUIST36 D: [**2165-8-2**] 15:43 T: [**2165-8-13**] 17:06 JOB#: [**Job Number 51938**]

410,414,507,599,401,530

{'Acute myocardial infarction of other anterior wall, initial episode of care,Coronary atherosclerosis of native coronary artery,Pneumonitis due to inhalation of food or vomitus,Urinary tract infection, site not specified,Unspecified essential hypertension,Esophageal reflux'}

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 61-year-old male with hypertension, anxiety, and gastroesophageal reflux disease, and no significant prior cardiac history, who presented to us today for acute onset of chest pain and shortness of breath. MEDICAL HISTORY: MEDICATION ON ADMISSION: ALLERGIES: PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: ### Response: {'Acute myocardial infarction of other anterior wall, initial episode of care,Coronary atherosclerosis of native coronary artery,Pneumonitis due to inhalation of food or vomitus,Urinary tract infection, site not specified,Unspecified essential hypertension,Esophageal reflux'}

CHIEF COMPLAINT: lethargy PRESENT ILLNESS: The pt is a 50yo M with PMHx significant for alcohol abuse and CAD with multiple MI's, prior MI [**2105**] with OM stent, and PCI at [**Hospital1 18**] [**2109-4-20**] of the proximal RCA and mid-RCA (both Taxus), LAD stent at [**Hospital1 112**] in [**2105**]. The patient initially was in the [**Hospital 5353**] Hospital ED on [**9-8**] with chest pain. EKG showed NSR, nonspecific ST-T changes per report. The paitent left AMA before further w/u was done. He then presented to [**Hospital3 **] via EMS on [**9-15**] with increase lethergy and jaundice for the last three days. He was transfeed to [**Hospital1 18**] ED for a GIB and a HCT of 21. He was transfused before transfer with 1 unit. . From the medicine admission note: Pt states he has never had liver problems or h/o jaundice, but has taken about 14 tylenol over past week for chronic back pain. Pt reports he was on an alcohol binge while in [**Location (un) 5354**] one week ago. Around the time he came back he developed chest pain and was seen in the [**Hospital3 **] ED where chest pain resolved with NG and he was discharged. Pt is very unclear about this - states that he had an MI but was only given SL NG and was discharged without admission. [**Hospital3 **] was contact[**Name (NI) **] and they currently have no record of EKGs or other records indicating that pt was seen one week ago - at last communication with RN in ED of [**Hospital1 **], it was felt that perphaps visit had not yet been logged in to computer and will need to contact again tomorrow. Since that time he developed melena and jaundice. He denies dizziness or chest pain but in the [**Hospital3 **] ED he was found to have elevated LFTs, Hct of 22, received 1u PRBC and transferred to [**Hospital1 18**]. Here pt refused EGD and NG lavage. In [**Hospital1 18**] ED received 2u PRBC, octreotide and PPIs as well as KCL for hypokalemia, N-acetylcysteine for elevated tylenol levels, and antibiotics for bandemia. RUQ showed gall baldder sludge but no bilary dilation. He was felt to have no ascites and so was not tapped. After receiving the two units of PRBC he desaturated to from 96% to 88% on RA. Received Lasix for volume overload . The paitent was then admitted to a medicine team via NF. He recieved a total of 3 transfusions here and his and his HCT has only gone up from 22.6 to 25.2. Also, he has having multiple episodes of melana. He went for an EGD today ([**9-16**]) but was not coorperative despite midazloam 3mg and meperidene 75mg. He also started to have hallucinations on the floor. Therefore, he was tx to the MICU for closer monitoring and intubation for EGD. . . ROS: denies CP, SOP, abd pain. Per wife, he always hs wheezing, not dx with a lung condition. He has been having increasing swelling in his left lower leg for the past 6 months. MEDICAL HISTORY: -alcohol abuse - pt reports that he drinks 2-3 beers per day, denies DTs. no prior history of liver disease -CAD s/p MI [**2105**], stent LAD [**2107**], stent mid and prox RCA in [**2108**] MEDICATION ON ADMISSION: Lisinopril 10 mg po qd Lipitor 10 mg po qd Atenolol 100 mg po qd Does not take ASA or plavix Oxycontin 30 [**Hospital1 **] oxycodone 120/month the patient had been taking many percoct in the week before admission ALLERGIES: Ibuprofen PHYSICAL EXAM: T 99.7 P 90 BP: 112/72, RR 20; O2sat 92% RA 95.8 KG Gen: Jaundiced, hallucinating HEENT: poor dentition, Sclera interic Neck: No LAD, No JVD Lungs: Lungs b/l wheezes CV: RRR nl s1s2 no mrg Abd: distended, diffusly tender to deep palpation, no rebound or gaurding, no ecchymosis, no spider angiomata, no caput medusae, no hepatomegaly, no [**Doctor Last Name 515**] sign Liver edge not felt. Ext: cheonic LE edema, ?h/o fasicotomy. 2+ pitting edema to the knee on the left. Neuro: AAOX3, minor asterixis. hallucinating FAMILY HISTORY: multiple MI's SOCIAL HISTORY: 90 tobacco pack yr history, lives alone, drinks beer and liquor [**1-24**] drinks per day, on diasbilty for the last 10 years Per the patient's wife: The patient has a h/o a sucide attempt by cutting his wrists 5 years ago. She dose not know of any inpatient ETOH detox stays, DT,s or seizures. The patient has been living alone for the last 6 months becaue she could not tolerate his drinking. recently, he has switched to vodka.

Acute alcoholic hepatitis,Acute respiratory failure,Acute and subacute necrosis of liver,Alcoholic gastritis, with hemorrhage,Acute posthemorrhagic anemia,Hepatorenal syndrome,Alcohol withdrawal,Pneumonitis due to inhalation of food or vomitus,Acute kidney failure, unspecified,Hyperosmolality and/or hypernatremia,Unspecified septicemia,Severe sepsis,Septic shock,Pneumonia, organism unspecified,Paroxysmal ventricular tachycardia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Alcohol abuse, continuous,Esophageal varices without mention of bleeding,Other and unspecified complications of medical care, not elsewhere classified,Benign neoplasm of colon,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Displacement of lumbar intervertebral disc without myelopathy,Pulmonary congestion and hypostasis,Unspecified sinusitis (chronic),Encounter for palliative care,Infection with microorganisms resistant to penicillins,Personal history of venous thrombosis and embolism,Percutaneous transluminal coronary angioplasty status,Aromatic analgesics, not elsewhere classified, causing adverse effects in therapeutic use

Ac alcoholic hepatitis,Acute respiratry failure,Acute necrosis of liver,Alchl gstritis w hmrhg,Ac posthemorrhag anemia,Hepatorenal syndrome,Alcohol withdrawal,Food/vomit pneumonitis,Acute kidney failure NOS,Hyperosmolality,Septicemia NOS,Severe sepsis,Septic shock,Pneumonia, organism NOS,Parox ventric tachycard,Hyp kid NOS w cr kid V,End stage renal disease,Alcohol abuse-continuous,Esoph varices w/o bleed,Complic med care NEC/NOS,Benign neoplasm lg bowel,Crnry athrscl natve vssl,Old myocardial infarct,Lumbar disc displacement,Pulm congest/hypostasis,Chronic sinusitis NOS,Encountr palliative care,Inf mcrg rstn pncllins,Hx-ven thrombosis/embols,Status-post ptca,Adv eff arom analgsc NEC

Admission Date: [**2110-9-15**] Discharge Date: [**2110-10-23**] Date of Birth: [**2060-1-1**] Sex: M Service: MEDICINE Allergies: Ibuprofen Attending:[**First Name3 (LF) 465**] Chief Complaint: lethargy Major Surgical or Invasive Procedure: intubation x2 colonoscopy EGD right femoral line left sunclavian line left cordis with Swan arterial line History of Present Illness: The pt is a 50yo M with PMHx significant for alcohol abuse and CAD with multiple MI's, prior MI [**2105**] with OM stent, and PCI at [**Hospital1 18**] [**2109-4-20**] of the proximal RCA and mid-RCA (both Taxus), LAD stent at [**Hospital1 112**] in [**2105**]. The patient initially was in the [**Hospital 5353**] Hospital ED on [**9-8**] with chest pain. EKG showed NSR, nonspecific ST-T changes per report. The paitent left AMA before further w/u was done. He then presented to [**Hospital3 **] via EMS on [**9-15**] with increase lethergy and jaundice for the last three days. He was transfeed to [**Hospital1 18**] ED for a GIB and a HCT of 21. He was transfused before transfer with 1 unit. . From the medicine admission note: Pt states he has never had liver problems or h/o jaundice, but has taken about 14 tylenol over past week for chronic back pain. Pt reports he was on an alcohol binge while in [**Location (un) 5354**] one week ago. Around the time he came back he developed chest pain and was seen in the [**Hospital3 **] ED where chest pain resolved with NG and he was discharged. Pt is very unclear about this - states that he had an MI but was only given SL NG and was discharged without admission. [**Hospital3 **] was contact[**Name (NI) **] and they currently have no record of EKGs or other records indicating that pt was seen one week ago - at last communication with RN in ED of [**Hospital1 **], it was felt that perphaps visit had not yet been logged in to computer and will need to contact again tomorrow. Since that time he developed melena and jaundice. He denies dizziness or chest pain but in the [**Hospital3 **] ED he was found to have elevated LFTs, Hct of 22, received 1u PRBC and transferred to [**Hospital1 18**]. Here pt refused EGD and NG lavage. In [**Hospital1 18**] ED received 2u PRBC, octreotide and PPIs as well as KCL for hypokalemia, N-acetylcysteine for elevated tylenol levels, and antibiotics for bandemia. RUQ showed gall baldder sludge but no bilary dilation. He was felt to have no ascites and so was not tapped. After receiving the two units of PRBC he desaturated to from 96% to 88% on RA. Received Lasix for volume overload . The paitent was then admitted to a medicine team via NF. He recieved a total of 3 transfusions here and his and his HCT has only gone up from 22.6 to 25.2. Also, he has having multiple episodes of melana. He went for an EGD today ([**9-16**]) but was not coorperative despite midazloam 3mg and meperidene 75mg. He also started to have hallucinations on the floor. Therefore, he was tx to the MICU for closer monitoring and intubation for EGD. . . ROS: denies CP, SOP, abd pain. Per wife, he always hs wheezing, not dx with a lung condition. He has been having increasing swelling in his left lower leg for the past 6 months. Past Medical History: -alcohol abuse - pt reports that he drinks 2-3 beers per day, denies DTs. no prior history of liver disease -CAD s/p MI [**2105**], stent LAD [**2107**], stent mid and prox RCA in [**2108**] - Per wife, in [**2082**], the patient had a motorcycle accident and broke his femur and had compartment syndrome leading to a fasicotomy in the right lower leg. He has had multiple DVT's since in that leg. - herniated lumbar disc with sciatica, on chronic pain medications Social History: 90 tobacco pack yr history, lives alone, drinks beer and liquor [**1-24**] drinks per day, on diasbilty for the last 10 years Per the patient's wife: The patient has a h/o a sucide attempt by cutting his wrists 5 years ago. She dose not know of any inpatient ETOH detox stays, DT,s or seizures. The patient has been living alone for the last 6 months becaue she could not tolerate his drinking. recently, he has switched to vodka. Family History: multiple MI's Physical Exam: T 99.7 P 90 BP: 112/72, RR 20; O2sat 92% RA 95.8 KG Gen: Jaundiced, hallucinating HEENT: poor dentition, Sclera interic Neck: No LAD, No JVD Lungs: Lungs b/l wheezes CV: RRR nl s1s2 no mrg Abd: distended, diffusly tender to deep palpation, no rebound or gaurding, no ecchymosis, no spider angiomata, no caput medusae, no hepatomegaly, no [**Doctor Last Name 515**] sign Liver edge not felt. Ext: cheonic LE edema, ?h/o fasicotomy. 2+ pitting edema to the knee on the left. Neuro: AAOX3, minor asterixis. hallucinating Pertinent Results: [**9-8**] from [**Hospital1 392**]: Total bili: [**7-30**], CKMB: 1.16, Trop I: <0.15, CK: 38, AST: 242, ALT: 59, HCT 28Plts: 90, . [**9-15**] from [**Hospital1 **]: HCT 21.8, K 2.5, Trop I 0.05, CK and MB not reported, ETOH: 327, BNP 418 Admission labs: [**2110-9-15**] 05:50PM BLOOD WBC-6.9 RBC-1.96*# Hgb-8.0*# Hct-22.9*# MCV-117*# MCH-40.8*# MCHC-34.8 RDW-20.9* Plt Ct-77* [**2110-9-15**] 05:50PM BLOOD PT-14.0* PTT-35.4* INR(PT)-1.3 [**2110-9-15**] 05:50PM BLOOD Glucose-74 UreaN-9 Creat-0.7 Na-132* K-2.9* Cl-88* HCO3-27 AnGap-20 [**2110-9-15**] 05:50PM BLOOD ALT-33 AST-134* CK(CPK)-35* AlkPhos-327* Amylase-81 TotBili-18.5* [**2110-9-15**] 05:50PM BLOOD Albumin-2.4* Calcium-7.7* Phos-3.7 Mg-1.6 [**2110-9-16**] 10:39AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE IgM HAV-NEGATIVE [**2110-9-15**] 05:50PM BLOOD ASA-NEG Ethanol-254* Acetmnp-5.6 Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Micro: Radiology: [**9-15**] RUQ US: Echogenic liver consistent with fatty infiltration. Other forms of liver disease including hepatitis and severe hepatic fibrosis/cirrhosis cannot be excluded on this examination. Nondistended gallbladder containing sludge. Associated mild gallbladder wall edema is a non-specific finding which can be seen in low albumin states. No definite evidence for cholecystitis. [**9-17**] echo: EF 40%, 1. The left atrium is normal in size. The left atrium is elongated. The right atrium is markedly dilated. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is mildly depressed. Resting regional wall motion abnormalities include basal and mid inferior and inferolateral akinesis.. 3.The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. 4.The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 5.Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. 6.There is no pericardial effusion. [**9-17**] CT abd: 1. Markedly fatty liver containing a subcentimeter hypodense lesion that is too small to accurately characterize. An additional focus of hyperdensity anteriorly within segment IV is incompletely characterized, and could represent a focus of fatty sparing. 6 month follow up CT is recommended. 2. No evidence of mesenteric vascular occlusion or secondary signs of mesenteric ischemia. 3. Bibasilar atelectasis. [**9-21**] renal US: The right and left kidneys measure 12.8 and 13.2 cm respectively without evidence of stones, masses or hydronephrosis. [**9-25**] CT torso: 1. Patchy bilateral pulmonary opacities and dense bilateral lower lobe atelectasis and consolidation, findings that suggest infectious process superimposed upon atelectasis. Bilateral pleural effusions. 2. Fatty infiltration of the liver. Interval increase in intraabdominal ascites. 3. No definite evidence of free intraperitoneal air. Two foci of gas within the right lower quadrant are likely located within decompressed and non-opacified loops of small bowel. Brief Hospital Course: A/P: Pt is a 50yo man with anemia, GI bleed, liver insufficiency, hyperbilirubinemia, bandemia, elevated troponin with new EKG changes, desaturation consistent with volume overload, alcohol abuse. Could not tolerate EGD therefore transferred to the MICU for intubation and EGD. 1. Blood loss Anemia and GI bleed- Likley [**12-25**] to GIB, acute on chronic since he was also anemic on [**9-8**] at [**Hospital1 392**]. GI preformed EGD which showed gastropathy and grade I varices, no active or h/o bleeding. He was transferred to MICU for intubation prior to this study. ABdominal CT scan revealed hyperdensity in the liver and fatty infiltration. A colonoscopy showed a non-bleeding small polyp. He was transfused to keep his hct>25. Hematocrit was monitored daily, and hct was kept >25. 2. ESLD: On admission, differential for this was tylenol toxicity vs. alcoholic hepatitis. On presentation, he was jaundiced, had evidence of GI bleeding. He had reportedly been on a recent EtOH binge in [**Location (un) 5354**]. His liver failure was likely a result of alcoholic hepatitis. He was initially treated with N-acetyl cysteine and lipitor was held. Liver was consulted and felt that the prognosis was poor. He was started on pentoxyfylline without much improvement. This was ultimately discontinued for ineffectiveness. RUQ US showed GB wall edema with sludge, no biliary obstruction, no ascites, some fatty infiltration of the liver. CT scan (no contrast) of the abdomen showed ascites with an enlarged liver, with evidence of fatty infiltration. Hepatitis serologies were negative for infection (Hep A, B, C). Bilirubin improved slightly with these supportive measures, but this still remained very elevated. INR was [**11-24**], with some improvement to vitamin K. Albumin was in the 2's as well. After 5-6 weeks of supportive care, liver team felt that possibility of improvement was remote. After discussion with family, patient was made CMO and transferred home for hospice care. 3. Hypercarbic Respiratory failure: Pt was initially intubated semi-electively for EGD, performed in MICU. This was difficult to wean post-procedure. The reasons for this were thought to be neuromuscular weakness, PNA. He was ultimately trached (after failing extubation). He was weaned from pressure support to trach mask, with adequate saturation on this. This was continued upon transfer home to hospice. 4. Encephalopathy: Patient had altered MS that was likely multifactorial. Neurology was consulted and felt that this was likely secondary to a toxic-metabolic cause. EEG was done; results were non-specific. LP was deferred given low likelihood for infectious etiology. MRI of the brain was performed and was negative for any focal lesion, enhancement, or other abnormality. Mental status cleared; confusion was likely a result of hepatic and uremic encephalopathy. 5. ID: Although initially afebrile on admission, he developed a WBC count and fever, bandemia. Ascites was tapped and was negative for signs of infection/SBP. CXR was suspicious for blossoming pneumonia. After intubation, he was treated for VAP with 7 days of imipenem with subsequent Vancomycin therapy for MRSA in his sputum. All blood/urine cultures remained negative. The only significant culture data was +MRSA in his sputum. He remained febrile with a leukocytosis, however; he did remain hemodynamically stable. He completed 13 days of vancomycin therapy before he was made CMO. 6. CAD: On [**9-8**], he went to an outside hospital with chest pain, had an EKG with "nonspecific ST-T changes", and once his pain resolved he left the ED AMA. Cardiology evaluated him and thought his current changes in the inferior lead was demand ischemia (in the setting of blood loss anemia). He has ruled out for an MI. An echocardiogram revealed a markedly dilated right atrium, 2+tr, moderate pulmonary hypertension, mildly dilated LV with basal, mid-inferior and inferolateral akinesis with 1+mr and EF 40%. His atenolol and aspirin were held while he had a GI bleed. Once hemodynamically stable, metoprolol was restarted. Patient also developed an atrial tachycardia; rate was controlled with beta-blocker as above. ASA was held given GI bleed. 7. Hepatorenal syndrome: Creatinine/renal function was normal on admission but then dramatically rose to 3-4 as liver function worsened. This was most likely due to hepatorenal syndrome. Renal was consulted and recommended starting Octreotide and midodrine. In addition, CVVHD was initiated to manage volume and electrolyte status. This was discontinued upon transition to CMO care. 8. Alcohol detox: He was initially actively withdrawing from alcohol on admission, with visual hallucinations. He was managed with benzodiazepines as necessary and transitioned to a versed drip in the MICU. 9. Disposition: After a prolonged course in the MICU without apparent improvment in liver or kidney function, patient was made CMO. This decision was discussed with the patient, his family, and various subspecialists involved in his care. He was discharged home with hospice level care, as per patient and family's wishes. Medications on Admission: Lisinopril 10 mg po qd Lipitor 10 mg po qd Atenolol 100 mg po qd Does not take ASA or plavix Oxycontin 30 [**Hospital1 **] oxycodone 120/month the patient had been taking many percoct in the week before admission Discharge Medications: 1. Ativan 0.5 mg Tablet Sig: [**11-24**] Tablet(s) PO q1-2 hrs as needed: sublingual tablets. Disp:*60 tabs* Refills:*2* 2. Morphine Concentrate 20 mg/mL Solution Sig: 15-30 mg PO q1 hr as needed for pain: sublingual. Disp:*qs 1* Refills:*0* 3. Hydroxyzine HCl 10 mg/5 mL Syrup Sig: [**11-24**] PO every 4-6 hours as needed for itching. Disp:*qs 1* Refills:*2* 4. Morphine 20 mg/5 mL Solution Sig: 5-20 mg PO q2 hrs as needed for pain: immediate release. Disp:*qs 1* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: GI bleed Grade 1 esophageal varices Colonic polyp Alcohol withdrawal Alcoholic hepatitis internal hemorrhoids Acetaminophen toxicity Fatty liver Discharge Condition: Poor Discharge Instructions: Please give medications as per prescribed [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**] Completed by:[**2110-10-23**]

571,518,570,535,285,572,291,507,584,276,038,995,785,486,427,403,585,305,456,999,211,414,412,722,514,473,V667,V090,V125,V458,E935

{'Acute alcoholic hepatitis,Acute respiratory failure,Acute and subacute necrosis of liver,Alcoholic gastritis, with hemorrhage,Acute posthemorrhagic anemia,Hepatorenal syndrome,Alcohol withdrawal,Pneumonitis due to inhalation of food or vomitus,Acute kidney failure, unspecified,Hyperosmolality and/or hypernatremia,Unspecified septicemia,Severe sepsis,Septic shock,Pneumonia, organism unspecified,Paroxysmal ventricular tachycardia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Alcohol abuse, continuous,Esophageal varices without mention of bleeding,Other and unspecified complications of medical care, not elsewhere classified,Benign neoplasm of colon,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Displacement of lumbar intervertebral disc without myelopathy,Pulmonary congestion and hypostasis,Unspecified sinusitis (chronic),Encounter for palliative care,Infection with microorganisms resistant to penicillins,Personal history of venous thrombosis and embolism,Percutaneous transluminal coronary angioplasty status,Aromatic analgesics, not elsewhere classified, causing adverse effects in therapeutic use'}

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: lethargy PRESENT ILLNESS: The pt is a 50yo M with PMHx significant for alcohol abuse and CAD with multiple MI's, prior MI [**2105**] with OM stent, and PCI at [**Hospital1 18**] [**2109-4-20**] of the proximal RCA and mid-RCA (both Taxus), LAD stent at [**Hospital1 112**] in [**2105**]. The patient initially was in the [**Hospital 5353**] Hospital ED on [**9-8**] with chest pain. EKG showed NSR, nonspecific ST-T changes per report. The paitent left AMA before further w/u was done. He then presented to [**Hospital3 **] via EMS on [**9-15**] with increase lethergy and jaundice for the last three days. He was transfeed to [**Hospital1 18**] ED for a GIB and a HCT of 21. He was transfused before transfer with 1 unit. . From the medicine admission note: Pt states he has never had liver problems or h/o jaundice, but has taken about 14 tylenol over past week for chronic back pain. Pt reports he was on an alcohol binge while in [**Location (un) 5354**] one week ago. Around the time he came back he developed chest pain and was seen in the [**Hospital3 **] ED where chest pain resolved with NG and he was discharged. Pt is very unclear about this - states that he had an MI but was only given SL NG and was discharged without admission. [**Hospital3 **] was contact[**Name (NI) **] and they currently have no record of EKGs or other records indicating that pt was seen one week ago - at last communication with RN in ED of [**Hospital1 **], it was felt that perphaps visit had not yet been logged in to computer and will need to contact again tomorrow. Since that time he developed melena and jaundice. He denies dizziness or chest pain but in the [**Hospital3 **] ED he was found to have elevated LFTs, Hct of 22, received 1u PRBC and transferred to [**Hospital1 18**]. Here pt refused EGD and NG lavage. In [**Hospital1 18**] ED received 2u PRBC, octreotide and PPIs as well as KCL for hypokalemia, N-acetylcysteine for elevated tylenol levels, and antibiotics for bandemia. RUQ showed gall baldder sludge but no bilary dilation. He was felt to have no ascites and so was not tapped. After receiving the two units of PRBC he desaturated to from 96% to 88% on RA. Received Lasix for volume overload . The paitent was then admitted to a medicine team via NF. He recieved a total of 3 transfusions here and his and his HCT has only gone up from 22.6 to 25.2. Also, he has having multiple episodes of melana. He went for an EGD today ([**9-16**]) but was not coorperative despite midazloam 3mg and meperidene 75mg. He also started to have hallucinations on the floor. Therefore, he was tx to the MICU for closer monitoring and intubation for EGD. . . ROS: denies CP, SOP, abd pain. Per wife, he always hs wheezing, not dx with a lung condition. He has been having increasing swelling in his left lower leg for the past 6 months. MEDICAL HISTORY: -alcohol abuse - pt reports that he drinks 2-3 beers per day, denies DTs. no prior history of liver disease -CAD s/p MI [**2105**], stent LAD [**2107**], stent mid and prox RCA in [**2108**] MEDICATION ON ADMISSION: Lisinopril 10 mg po qd Lipitor 10 mg po qd Atenolol 100 mg po qd Does not take ASA or plavix Oxycontin 30 [**Hospital1 **] oxycodone 120/month the patient had been taking many percoct in the week before admission ALLERGIES: Ibuprofen PHYSICAL EXAM: T 99.7 P 90 BP: 112/72, RR 20; O2sat 92% RA 95.8 KG Gen: Jaundiced, hallucinating HEENT: poor dentition, Sclera interic Neck: No LAD, No JVD Lungs: Lungs b/l wheezes CV: RRR nl s1s2 no mrg Abd: distended, diffusly tender to deep palpation, no rebound or gaurding, no ecchymosis, no spider angiomata, no caput medusae, no hepatomegaly, no [**Doctor Last Name 515**] sign Liver edge not felt. Ext: cheonic LE edema, ?h/o fasicotomy. 2+ pitting edema to the knee on the left. Neuro: AAOX3, minor asterixis. hallucinating FAMILY HISTORY: multiple MI's SOCIAL HISTORY: 90 tobacco pack yr history, lives alone, drinks beer and liquor [**1-24**] drinks per day, on diasbilty for the last 10 years Per the patient's wife: The patient has a h/o a sucide attempt by cutting his wrists 5 years ago. She dose not know of any inpatient ETOH detox stays, DT,s or seizures. The patient has been living alone for the last 6 months becaue she could not tolerate his drinking. recently, he has switched to vodka. ### Response: {'Acute alcoholic hepatitis,Acute respiratory failure,Acute and subacute necrosis of liver,Alcoholic gastritis, with hemorrhage,Acute posthemorrhagic anemia,Hepatorenal syndrome,Alcohol withdrawal,Pneumonitis due to inhalation of food or vomitus,Acute kidney failure, unspecified,Hyperosmolality and/or hypernatremia,Unspecified septicemia,Severe sepsis,Septic shock,Pneumonia, organism unspecified,Paroxysmal ventricular tachycardia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Alcohol abuse, continuous,Esophageal varices without mention of bleeding,Other and unspecified complications of medical care, not elsewhere classified,Benign neoplasm of colon,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Displacement of lumbar intervertebral disc without myelopathy,Pulmonary congestion and hypostasis,Unspecified sinusitis (chronic),Encounter for palliative care,Infection with microorganisms resistant to penicillins,Personal history of venous thrombosis and embolism,Percutaneous transluminal coronary angioplasty status,Aromatic analgesics, not elsewhere classified, causing adverse effects in therapeutic use'}

CHIEF COMPLAINT: Pt presented as a trauma after being thrown 60 feet from a boat at high speeds and landing on land PRESENT ILLNESS: Pt was driving boat while intoxicated, ran the boat aground and was thrown into rocks along the shore. He suffered multiple broken ribs on the left side, flail chest, and a T3 transverse process fracture. MEDICAL HISTORY: None MEDICATION ON ADMISSION: None ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: HR 92 BP 148/91 RR 14 Temp-Hypothermic-not registering HEENT: Left Cheek abrasion Neck: C collar, on board CV: RRR Resp: Clear b/l, Left CT in place Abd: Distended GU: nml tone, no gross blood Ex: 2+ femoral pulses, 2+ DP, L elbow abrasion FAMILY HISTORY: The patient has 4 sisters. [**Name (NI) **] denies a family history of cancer or blood disorders. SOCIAL HISTORY: The patient works in Quality Assurance for a company that manufactures metals for jet planes. He has children. Smokes 1ppd, Consumes 1L vodka/day.

Flail chest,Closed fracture of dorsal [thoracic] vertebra without mention of spinal cord injury,Empyema without mention of fistula,Unspecified septicemia,Severe sepsis,Acute respiratory failure,Pneumonia due to Hemophilus influenzae [H. influenzae],Contusion of lung without mention of open wound into thorax,Accident to watercraft causing other injury to occupant of small boat, powered,Closed fracture of scapula, unspecified part,Laparoscopic surgical procedure converted to open procedure

Flail chest,Fx dorsal vertebra-close,Empyema w/o fistula,Septicemia NOS,Severe sepsis,Acute respiratry failure,H.influenzae pneumonia,Lung contusion-closed,Boat acc inj NEC-power,Fx scapula NOS-closed,Lap surg convert to open

Name: [**Known lastname 12662**],[**Known firstname **] W. Unit No: [**Numeric Identifier 12663**] Admission Date: [**2150-7-4**] Discharge Date: [**2150-7-22**] Date of Birth: [**2097-10-25**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 203**] Addendum: The patient was evaluated by speech therapy on [**2150-7-21**] with the passe-muir valve in place. The patient passed his bedside swallow eval and was permitted to take honey-thickened liquids and pureed foods as a result. Patient was started on ASA 325 mg q day for high platelet count on [**7-21**], and his lasix dose was decreased to 20 mg [**Hospital1 **]. Discharge Disposition: Extended Care Facility: [**Hospital **] Medical Center - [**Hospital1 2314**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 206**] MD [**MD Number(1) 207**] Completed by:[**2150-7-21**] Admission Date: [**2150-7-4**] Discharge Date: [**2150-7-22**] Date of Birth: [**2097-10-25**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1481**] Chief Complaint: Pt presented as a trauma after being thrown 60 feet from a boat at high speeds and landing on land Major Surgical or Invasive Procedure: Tracheostomy, Percutaneous Endoscopic Gastrostomy [**7-16**] Left VATS, converted to thoracotomy with decortication [**7-15**] History of Present Illness: Pt was driving boat while intoxicated, ran the boat aground and was thrown into rocks along the shore. He suffered multiple broken ribs on the left side, flail chest, and a T3 transverse process fracture. Past Medical History: None Social History: The patient works in Quality Assurance for a company that manufactures metals for jet planes. He has children. Smokes 1ppd, Consumes 1L vodka/day. Family History: The patient has 4 sisters. [**Name (NI) **] denies a family history of cancer or blood disorders. Physical Exam: HR 92 BP 148/91 RR 14 Temp-Hypothermic-not registering HEENT: Left Cheek abrasion Neck: C collar, on board CV: RRR Resp: Clear b/l, Left CT in place Abd: Distended GU: nml tone, no gross blood Ex: 2+ femoral pulses, 2+ DP, L elbow abrasion Pertinent Results: [**2150-7-4**] 02:30AM WBC-18.2* RBC-4.30* HGB-13.3* HCT-40.2 MCV-93 MCH-31.0 MCHC-33.2 RDW-14.1 [**2150-7-4**] 02:30AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS cocaine-NEG amphetmn-NEG mthdone-NEG [**2150-7-4**] 02:30AM ASA-NEG ETHANOL-136* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2150-7-4**] 02:30AM URINE RBC-[**6-16**]* WBC-[**3-11**] BACTERIA-FEW YEAST-NONE EPI-0-2 [**2150-7-4**] 02:28AM GLUCOSE-108* LACTATE-4.3* NA+-145 K+-3.2* CL--110 TCO2-18* [**2150-7-4**] 02:30AM ASA-NEG ETHANOL-136* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2150-7-4**] 01:06PM TYPE-ART PO2-77* PCO2-43 PH-7.35 TOTAL CO2-25 BASE XS--1 [**2150-7-4**] 06:09AM TYPE-ART PO2-109* PCO2-54* PH-7.20* TOTAL CO2-22 BASE XS--7 [**2150-7-4**] 05:29AM GLUCOSE-111* UREA N-15 CREAT-0.9 SODIUM-142 POTASSIUM-4.0 CHLORIDE-111* TOTAL CO2-17* ANION GAP-18 Brief Hospital Course: 52 year-old male admitted on [**2150-7-4**] from trauma bay after he was ejected from his boat. He had been in a high-speed boating accident. He had been transferred from [**Hospital **] Hospital, where a chest tube was placed on his left side. Patient was hemodynamically stable, however imaging at [**Hospital1 18**] revealed that he had left-sided displaced rib fractures and a T3 transverse procese fracture. He was alert and oriented and admitted to the trauma service in the Trauma-ICU. Upon admission to the T-SICU, the patient had an epidural placed for pain management, and the chest tube output was observed on a daily basis. The patient started to shows signs of ETOH withdrawl on [**7-6**]. On [**7-8**], the chest tube was placed to waterseal, but the patient displayed a much-increased work of breathing. The chest tube output considerably dropped on this day, while the patient's CXRs continued to worsen. The patient had another chestt ube placed on the left side on [**7-8**] because a CT scan indicated worsening pleural effusion and left lung collapse. The old chest tube was removed because it had been clogged. The patient was then intubated later that same evening. A bronchoscopy and BAL was performed that same night. Vanco/Zosyn were started for empiric therapy. Cultures from the BAL on [**7-8**] revealed the patient had developed a H flu pneumonia. The vanc/zosyn was d/c'd and the patient was started on ceftriaxone and naficillin for the pneumonia and for pleural fluid cultures growing MSSA. The patient remained on antibiotics throughout the remainder of his time on [**Hospital1 18**]. Despite the presence of a new chest tube, the patient had persistent consolidation on CXR. On [**7-13**], the patient had a repeat CT of the chest, which showed a large empyema of the left chest. The patient underwent a VATS converted to open posterolateral thoracotomy and decortication by Thoracic Surgery on [**7-14**]. On [**7-15**], the patient underwent placement of a PEG and tracheostomy. A rib specimen was sent to pathology and found to have a myeloid predominance. Heme/onc was consulted and felt as though this was likely a reactive response to MSSA. If his leukocytosis does not normalize with resolution of his infection, they recommend that the patient be seen in the outpatient hematology clinic for further evaluation. At that time, they would consider performing a bone marrow biopsy for pathologic review, flow cytometry, and cytogenetic analysis. From [**7-15**] to [**7-20**], the patient's chest tubes were managed in the T-SICU. The posterior chest tube was removed on [**7-18**], and on [**7-20**], the anterior chest tube was converted to an empyema tube. The patient's tube feeds were at goal rate on [**7-20**], and the patient's vent settings were at a PEEP of 5 and pressure support of 10. The patient worked with physical therpy and occupational therapy during his time in teh T-SICU. He was moveing all extremities and communicating with the T-SICU staff on the day of discharge. The plan for the antibiotics was to complete a 6-week coarse for the empyema. Medications on Admission: None Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 3. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML Mucous membrane [**Hospital1 **] (2 times a day). 4. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q6H (every 6 hours) as needed. Disp:*2 MDI* Refills:*0* 5. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q6H (every 6 hours). Disp:*2 MDI* Refills:*2* 6. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2 times a day). 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 11. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed. Disp:*400 ML(s)* Refills:*0* 12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 13. Labetalol 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 15. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp:*30 Tablet(s)* Refills:*2* 16. Diazepam 5 mg/mL Syringe Sig: One (1) mL Injection Q6H (every 6 hours) as needed for anxiety. mL 17. Furosemide 10 mg/mL Solution Sig: Forty (40) mg Injection [**Hospital1 **] (2 times a day). mg 18. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2) grams Intravenous Q6H (every 6 hours) for 6 weeks: On week 2 of 6 week course scheduled to end [**2150-8-20**]. Disp:*31 * Refills:*0* 19. Ceftriaxone-Dextrose (Iso-osm) 1 gram/50 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours) for 6 weeks: One week 2 of 6 week course scheduled to end on [**2150-8-20**]. Disp:*31 doses* Refills:*0* 20. Labetalol 5 mg/mL Solution Sig: Two (2) mg Intravenous Q4H (every 4 hours) as needed. mg Discharge Disposition: Extended Care Facility: [**Hospital **] Medical Center - [**Hospital1 3597**] Discharge Diagnosis: 1. Fractures of the left second through tenth rib, with two separate fractures involving ribs three through eight, leading to a flail chest. 2. Lung contusion caused by medial displacement of left fifth rib. 3. Left Scapula Fracture 4. Bilateral loculated pleural effusion left >> right, left evolving to empyema 5. Thrombus in the left cephalic vein Discharge Condition: Minimal vent settings, tolerating tube feeds, pain is well controlled. Discharge Instructions: Diet: Tubefeeding- Replete w/fiber Full strength; Starting rate: 25 ml/hr; Advance rate by 25 q4h Goal rate: 100 ml/hr Residual Check: q4h Hold feeding for residual >= : 250 Flush w/ 30 ml water q4h Abx: You will need to complete a 6 week course of Naficillin and Ceftriaxone. Scheduled to end [**2150-8-20**] L-scapula fracture-patient's arm to remain in sling if needed for comfort and non weightbearing. Followup Instructions: -Please call the office of Dr. [**Last Name (STitle) **] (trauma surgery) [**Telephone/Fax (1) 2981**] to make a followup appointment in the next [**1-7**] weeks. Please call the office of Dr. [**First Name (STitle) **] (thoracic surgery) at [**Telephone/Fax (1) 170**] to make a follow up appointment for 2-3 weeks. You will need a chest x ray on the day of your appointment. Please present to [**Location (un) **] of the [**Hospital Ward Name 23**] building for a chest x ray 30 min prior to your appointment -Heme/Onc-If patient's leukocytosis does not improve with resolution of empyema, he will need to be seen in outpatient Heme/[**Hospital **] clinic for further evaluation. -Ortho-L scapula fracture-Please call [**Telephone/Fax (1) 1228**] to schedule an outpatient appointment with orthopedics after you have been discharged from rehab.

807,805,510,038,995,518,482,861,E831,811,V644

{'Flail chest,Closed fracture of dorsal [thoracic] vertebra without mention of spinal cord injury,Empyema without mention of fistula,Unspecified septicemia,Severe sepsis,Acute respiratory failure,Pneumonia due to Hemophilus influenzae [H. influenzae],Contusion of lung without mention of open wound into thorax,Accident to watercraft causing other injury to occupant of small boat, powered,Closed fracture of scapula, unspecified part,Laparoscopic surgical procedure converted to open procedure'}

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: Pt presented as a trauma after being thrown 60 feet from a boat at high speeds and landing on land PRESENT ILLNESS: Pt was driving boat while intoxicated, ran the boat aground and was thrown into rocks along the shore. He suffered multiple broken ribs on the left side, flail chest, and a T3 transverse process fracture. MEDICAL HISTORY: None MEDICATION ON ADMISSION: None ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: HR 92 BP 148/91 RR 14 Temp-Hypothermic-not registering HEENT: Left Cheek abrasion Neck: C collar, on board CV: RRR Resp: Clear b/l, Left CT in place Abd: Distended GU: nml tone, no gross blood Ex: 2+ femoral pulses, 2+ DP, L elbow abrasion FAMILY HISTORY: The patient has 4 sisters. [**Name (NI) **] denies a family history of cancer or blood disorders. SOCIAL HISTORY: The patient works in Quality Assurance for a company that manufactures metals for jet planes. He has children. Smokes 1ppd, Consumes 1L vodka/day. ### Response: {'Flail chest,Closed fracture of dorsal [thoracic] vertebra without mention of spinal cord injury,Empyema without mention of fistula,Unspecified septicemia,Severe sepsis,Acute respiratory failure,Pneumonia due to Hemophilus influenzae [H. influenzae],Contusion of lung without mention of open wound into thorax,Accident to watercraft causing other injury to occupant of small boat, powered,Closed fracture of scapula, unspecified part,Laparoscopic surgical procedure converted to open procedure'}

CHIEF COMPLAINT: Pulmonary Embolus PRESENT ILLNESS: 57 year old male with recent admission for dural AV fistulas s/p embolization ([**4-18**] and [**4-21**]) and recent treatment for pneumonia (bibasilar infiltrates on CTA) who presented to [**Hospital1 2519**] on [**5-4**] with calf pain and found to have bilateral LE clots, pulmonary saddle embolus (bilateral) had 2 coil embolizations and was transferred to [**Hospital1 18**] MICU on [**5-4**] MEDICAL HISTORY: 1. Left parietal intraparenchymal hemorrhage 2. Left Dural AV Fistulas x 2: Embolized at [**Hospital1 1774**] on [**2124-4-18**] and MEDICATION ON ADMISSION: Baclofen 10 PO TID Tylenol 650 prn Vicodin prn Dilantin 100 PO TID Protonix 40 Levaquin 500 PO daily Flagyl 500 PO Q8 hrs ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: VS: T:98.6 BP: 104/68, HR: 84, RR: 20, 02 sat: 98%RA Gen: Pleasant male, A&O x3, NAD HEENT: PERRL, EOMI CV: RRR, no murmur Chest: CTAB, no wheezing, no crackles. Abd: soft, NT ND BS+ Ext: no edema, no calf pain on palpation, DP's palpable bilaterally. Upper extremities also no edema or pain. FAMILY HISTORY: Father had lung ca. Mother had Gyn ca of some sort. SOCIAL HISTORY: lives alone in home in [**Hospital1 **], had been at rehab prior to this admission follwoing his ICH. Denies any h/o tob/etoh/drug use. Works as a music teacher.

Iatrogenic pulmonary embolism and infarction,Acute venous embolism and thrombosis of unspecified deep vessels of lower extremity,Cerebral aneurysm, nonruptured,Other and unspecified hyperlipidemia,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation

Iatrogen pulm emb/infarc,Ac DVT/embl low ext NOS,Nonrupt cerebral aneurym,Hyperlipidemia NEC/NOS,Hx TIA/stroke w/o resid,Abn react-surg proc NEC

Admission Date: [**2124-5-5**] Discharge Date: [**2124-5-8**] Date of Birth: [**2066-6-27**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2186**] Chief Complaint: Pulmonary Embolus Major Surgical or Invasive Procedure: Inferior vena cava filter placement. History of Present Illness: 57 year old male with recent admission for dural AV fistulas s/p embolization ([**4-18**] and [**4-21**]) and recent treatment for pneumonia (bibasilar infiltrates on CTA) who presented to [**Hospital1 2519**] on [**5-4**] with calf pain and found to have bilateral LE clots, pulmonary saddle embolus (bilateral) had 2 coil embolizations and was transferred to [**Hospital1 18**] MICU on [**5-4**] Past Medical History: 1. Left parietal intraparenchymal hemorrhage 2. Left Dural AV Fistulas x 2: Embolized at [**Hospital1 1774**] on [**2124-4-18**] and [**2124-4-21**] by Dr [**Last Name (STitle) **] [**Name (STitle) **]. According to [**Hospital1 1774**] records they are syncronous with one at left distal transverse sinus and proximal left sigmoid sinus with cortical venous reflux toward left side vein of [**Last Name (un) 70890**] and another at the left side skull base around the foramen magnum level mainly supplied from the left ascending pharyngeal [**Last Name (un) **] with cortical venous reflux. 3.Recent [**Hospital1 **]-basilar pna on levo/flagyl 4.Recent abdominal pain s/p exlap which was unrevealing within last several days (admission [**Date range (3) 101093**]) 5.dyslipidemia 6.elevated PSA 7.cervical radiculopathy Social History: lives alone in home in [**Hospital1 **], had been at rehab prior to this admission follwoing his ICH. Denies any h/o tob/etoh/drug use. Works as a music teacher. Family History: Father had lung ca. Mother had Gyn ca of some sort. Physical Exam: VS: T:98.6 BP: 104/68, HR: 84, RR: 20, 02 sat: 98%RA Gen: Pleasant male, A&O x3, NAD HEENT: PERRL, EOMI CV: RRR, no murmur Chest: CTAB, no wheezing, no crackles. Abd: soft, NT ND BS+ Ext: no edema, no calf pain on palpation, DP's palpable bilaterally. Upper extremities also no edema or pain. Pertinent Results: [**2124-5-5**] 01:05AM BLOOD WBC-11.8* RBC-3.98* Hgb-11.9* Hct-35.2* MCV-89 MCH-29.8 MCHC-33.6 RDW-13.7 Plt Ct-152 [**2124-5-8**] 06:35AM BLOOD WBC-5.4 RBC-3.70* Hgb-11.3* Hct-32.6* MCV-88 MCH-30.6 MCHC-34.8 RDW-13.8 Plt Ct-218 [**2124-5-5**] 01:05AM BLOOD PT-16.8* PTT-33.0 INR(PT)-1.5* [**2124-5-8**] 06:35AM BLOOD Glucose-94 UreaN-8 Creat-0.9 Na-139 K-4.3 Cl-105 HCO3-25 AnGap-13 [**2124-5-5**] 01:05AM BLOOD ALT-76* AST-47* LD(LDH)-413* AlkPhos-82 TotBili-0.4 [**2124-5-5**] 01:05AM BLOOD Phenyto-3.3* [**2124-5-7**] 08:15AM BLOOD Phenyto-13.2 . STUDY: CTA of the head with and without contrast. TECHNIQUE: Following a no contrast head CT, axial multidetector CT images of the head were obtained during the intravenous contrast administration of nonionic contrast material. Multiplanar two-dimensional reformatted images and volume-rendered three-dimensional reformatted images were obtained. COMPARISON: Prior CT of the head without contrast dated [**5-5**], [**2124**]. NON-CONTRAST HEAD CT: Again, left temporal and parietal vasogenic edema and effacement of the sulci is demonstrated. Areas of high density likely consistent with embolization material in a previously known and reported vascular malformation. HEAD CTA: On the left temporal lobe, there is a subtle area of thin enhancement, measuring approximately 27.2 x 27.8 mm in size, vasogenic edema is demonstrated extending superiorly and producing effacement of the sulci. No frank evidence of vascular malformation is identified or aneurysm. Normal pattern of enhancement is demonstrated in major arterial vascular structures. There is no evidence of significant midline shifting or deviation of the normally midline structures. In the multiplanar two-dimensional and volume- rendered reformatted images, there is no evidence of vascular stenosis or flow-related abnormality, hypoplasia of the A1 segment on the right is demonstrated. No aneurysms are identified. The vertebrobasilar system is patent with dominance of the left vertebral artery. No vascular malformation is identified and the embolization cast is unchanged. IMPRESSION: Persistent vasogenic edema with a faint and subtle area of thin ring enhancement identified on the left temporal lobe as described above, correlation with MRI and MRA is recommended for further characterization. . INDICATION: DVT, assess for DVT in the bilateral upper extremities. COMPARISON: None available. BILATERAL UPPER EXTREMITY VENOUS ULTRASOUND: Grayscale and color Doppler son[**Name (NI) 493**] images were obtained that demonstrate wall-to-wall flow in the right subclavian with normal response to respiration. There is a nonocclusive clot in the left subclavian which does not compress. The left internal jugular appears clear and demonstrates compression. There is nonocclusive clot in the left axilla, and one of the brachial veins. In the SCV the clot is more echogenic and retracted and in the more distal SVC and axillary vein the less echogenic material is wall-to-wall. The right internal jugular, axillary, and both brachial demonstrate wall-to- wall flow with normal compression. The right cephalic and basilic are patent. IMPRESSION: Nonocclusive, likly subacute DVT of the left subclavian vein extending to the axillary and one of the brachial veins. . INDICATION: DVT on the left lower extremity, evaluate for one on the right. COMPARISON: None available. PORTABLE RIGHT LOWER EXTREMITY VENOUS ULTRASOUND: The left common femoral demonstrates low flow. On the right, there is normal response to respiration. The right common femoral, superficial femoral and popliteal veins compress and show wall-to-wall flow with normal response or augmentation. Right calf veins demonstrated. IMPRESSION: No DVT of the right lower extremity. Brief Hospital Course: PATIENT initially presented to [**Hospital3 4107**] on [**5-4**] with calf pain and found to have bilateral LE clots, pulmonary saddle embolus (bilateral) had 2 coil embolizations and was transferred to [**Hospital1 18**] MICU on [**5-4**]. In the ICU the patient remained HD stable and had good 02 sats on room air. IVC filter placed yesterday and following CTA head showed no new areas to intervene on. Patient evaluated by neurosurgery and he was put on dilantin. Prior to transfer to the floor the patient's dilantin level was low, he received increased dose. . #Pulmonary Embolus/DVT: Per MICU team and neurosurgery, the risk of anticoagulation given his recent intraparenchymal hemorrhage outweights the benefit of anticoagulation for PEs. Patient continued to sat well on room air. He was found to have a LUE clot as well but per MICU no plans for SVC filter as clinically insignificant. -Hold aspirin, hold heparin SQ, absolutely no anticoagulation for 1 month. -f/u outpatient neurosurgery in 4 weeks. -tylenol for pain. . #Recent left parietal intraparenchymal hemorrhage:likely [**2-21**] vascular malformation with dural AVM's and aneurysm reported on OSH CTA head/MRI. s/p embolization of dural AVM's x2. Dilantin level low initially, given load in the MICU and now on increased dose. -continue dilantin (increased to 200 [**Hospital1 **]) . Medications on Admission: Baclofen 10 PO TID Tylenol 650 prn Vicodin prn Dilantin 100 PO TID Protonix 40 Levaquin 500 PO daily Flagyl 500 PO Q8 hrs Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain: Maximum dose 4 g daily. 2. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). Disp:*120 Capsule(s)* Refills:*2* 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Left lower extremity and left upper extremity deep venous thrombosis Bilateral pulmonary emboli Recent left parietal intraparenchymal hemorrhage tatus post AV dural fistula embolization X 2 at [**Hospital3 2358**] . Secondary: Dysplipidemia History of cervical radiculopathy Discharge Condition: Afebrile, normotensive, comfortable on room air Discharge Instructions: You have been evaluated for your leg pain. You were found to have a blood clot in the leg and in the arm as well as blood clot that had travelled to the lungs. Due to your recent neurosurgical procedures, you cannot take blood thinners for these clots. You had a filter put in the inferior vena cava in order to protect you from further blood clots travelling to the lung. . You SHOULD NOT TAKE aspirin or ibuprofen for the next month due to your recent neurosurgery. Please discuss this at your visit with the Neurosurgeons in one month. . We increased your dilantin to 200 mg twice per day. Please discuss your need for this medication at your [**Hospital 4695**] clinic visit. . Please contact your primary care physician or return to the emergency room should you develop any of the following symptoms: fever > 101, chills, difficulty breathing, coughing up blood, chest pain, increased leg pain or swelling, slurred speech, numbness, tingling or weakness of either arm or leg, or any other concerns. Followup Instructions: You can obtain a new primary care physician at [**Hospital **] at [**Hospital1 18**]. Please call our office at [**Telephone/Fax (1) 250**] to make an appointment. You can make an appointment with Dr. [**First Name (STitle) **] [**Name (STitle) **] or another male provider of your choice; it would be ideal to be seen within the next 1-2 weeks. . Please contact your Neurosurgeon at the [**Hospital3 2358**] for a follow up appointment within the next 3-4 weeks. If you prefer, you can follow up with the Neurosurgery Department at [**Hospital1 18**]. To follow up at [**Hospital1 18**], call the Neurosurgery Department at ([**Telephone/Fax (1) 18865**] to make a follow up appointment within the next [**3-22**] weeks.

415,453,437,272,V125,E878

{'Iatrogenic pulmonary embolism and infarction,Acute venous embolism and thrombosis of unspecified deep vessels of lower extremity,Cerebral aneurysm, nonruptured,Other and unspecified hyperlipidemia,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation'}

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: Pulmonary Embolus PRESENT ILLNESS: 57 year old male with recent admission for dural AV fistulas s/p embolization ([**4-18**] and [**4-21**]) and recent treatment for pneumonia (bibasilar infiltrates on CTA) who presented to [**Hospital1 2519**] on [**5-4**] with calf pain and found to have bilateral LE clots, pulmonary saddle embolus (bilateral) had 2 coil embolizations and was transferred to [**Hospital1 18**] MICU on [**5-4**] MEDICAL HISTORY: 1. Left parietal intraparenchymal hemorrhage 2. Left Dural AV Fistulas x 2: Embolized at [**Hospital1 1774**] on [**2124-4-18**] and MEDICATION ON ADMISSION: Baclofen 10 PO TID Tylenol 650 prn Vicodin prn Dilantin 100 PO TID Protonix 40 Levaquin 500 PO daily Flagyl 500 PO Q8 hrs ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: VS: T:98.6 BP: 104/68, HR: 84, RR: 20, 02 sat: 98%RA Gen: Pleasant male, A&O x3, NAD HEENT: PERRL, EOMI CV: RRR, no murmur Chest: CTAB, no wheezing, no crackles. Abd: soft, NT ND BS+ Ext: no edema, no calf pain on palpation, DP's palpable bilaterally. Upper extremities also no edema or pain. FAMILY HISTORY: Father had lung ca. Mother had Gyn ca of some sort. SOCIAL HISTORY: lives alone in home in [**Hospital1 **], had been at rehab prior to this admission follwoing his ICH. Denies any h/o tob/etoh/drug use. Works as a music teacher. ### Response: {'Iatrogenic pulmonary embolism and infarction,Acute venous embolism and thrombosis of unspecified deep vessels of lower extremity,Cerebral aneurysm, nonruptured,Other and unspecified hyperlipidemia,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation'}

CHIEF COMPLAINT: PRESENT ILLNESS: 76 year-old male, status post endovascular abdominal aortic aneurysm repair on [**1-12**] at [**Hospital6 2561**]. Transferred to our institution for ICU bed. The patient presented for an elective aortic aneurysm repair that was complicated by intraoperative bleeding secondary to left iliac artery injury at the outside institution. Intraoperative hematocrit at the institution was 11 with an estimated blood loss of 3 liters to 5 hour case. Postoperatively, the patient was aggressively resuscitated with packed red blood cells, FFP and Crystalloid. The patient had a shocked liver with a transaminase in the 7000's. Also, acute renal failure ensued. The patient developed pulmonary edema, pseudomonal pneumonia which was treated at the outside institution with Zosyn and Cipro. The patient developed a septic shock picture on [**1-16**] which required pressor support. MEDICAL HISTORY: Hypercholesterolemia, type II diabetes, hypertension, colon cancer, coronary artery disease, status post myocardial infarction, peripheral vascular disease. First degree AV block, anemia. MEDICATION ON ADMISSION: Lisinopril, Lipitor, Nifedipine, Avandia, Lopressor. ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

Septicemia due to pseudomonas,Septic shock,Acute kidney failure with lesion of tubular necrosis,Hyposmolality and/or hyponatremia,Acute and chronic respiratory failure,Atrial fibrillation,Cyst and pseudocyst of pancreas,Congestive heart failure, unspecified,Anoxic brain damage,Pressure ulcer, lower back,Hemorrhage complicating a procedure,Severe sepsis,Other diseases of spleen,Fitting and adjustment of cardiac pacemaker,Unspecified vascular insufficiency of intestine

Pseudomonas septicemia,Septic shock,Ac kidny fail, tubr necr,Hyposmolality,Acute & chronc resp fail,Atrial fibrillation,Pancreat cyst/pseudocyst,CHF NOS,Anoxic brain damage,Pressure ulcer, low back,Hemorrhage complic proc,Severe sepsis,Spleen disease NEC,Ftng cardiac pacemaker,Vasc insuff intest NOS

Admission Date: [**2163-1-19**] Discharge Date: [**2163-2-17**] Date of Birth: [**2086-11-3**] Sex: M Service: VSU SERVICE: Vascular surgery. HISTORY OF PRESENT ILLNESS: 76 year-old male, status post endovascular abdominal aortic aneurysm repair on [**1-12**] at [**Hospital6 2561**]. Transferred to our institution for ICU bed. The patient presented for an elective aortic aneurysm repair that was complicated by intraoperative bleeding secondary to left iliac artery injury at the outside institution. Intraoperative hematocrit at the institution was 11 with an estimated blood loss of 3 liters to 5 hour case. Postoperatively, the patient was aggressively resuscitated with packed red blood cells, FFP and Crystalloid. The patient had a shocked liver with a transaminase in the 7000's. Also, acute renal failure ensued. The patient developed pulmonary edema, pseudomonal pneumonia which was treated at the outside institution with Zosyn and Cipro. The patient developed a septic shock picture on [**1-16**] which required pressor support. The patient also underwent hemodialysis at the outside institution. The patient arrived at our institution on [**2163-1-19**]. PAST MEDICAL HISTORY: Hypercholesterolemia, type II diabetes, hypertension, colon cancer, coronary artery disease, status post myocardial infarction, peripheral vascular disease. First degree AV block, anemia. PAST SURGICAL HISTORY: Colon resection for cancer. CABG. Left femoral stent placement. Carotid endarterectomy. Pacemaker. MEDICATIONS ON ADMISSION: Lisinopril, Lipitor, Nifedipine, Avandia, Lopressor. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: On presentation, temperature was 100.6; heart rate 81; blood pressure 109/34; respiratory rate 20, 92%. The patient was on assist control, 60%, 20 by 600 with PEEP of 20. CVP was 22. Pulmonary artery pressures were 62 over 31. The patient was sedated, with sluggish pupils. Heart was regular rate and rhythm. He had decreased breath sounds at bilateral bases. Abdomen was soft and distended. There was 2+ edema with dopplerable PT and DP bilaterally. The patient was admitted to the vascular surgery service. A summary, in a concise fashion, is shown below in order of systems. HOSPITAL COURSE: Neurologically, the patient was sedated with Propofol for prolonged periods of time as well as Fentanyl and Ativan. When the patient was lightened from all sedation, he intermittently moved his upper extremities but never moved his lower extremities and also never followed commands. Cardiovascularly, the patient had intermittent uses of Levophed for hypotension, particularly toward the end of his hospital course when he became septic. The patient had bigeminy, multiple PVC's and sporadic atrial fibrillation for which he was started on heparin. Pulmonary: The patient was vented on assist control, SIMV at all times. He did not tolerate pressure support weans. Gastrointestinal: The patient was initially started on tube feeds with an abdominal CT scan early on admission in our institution revealed question of ischemic colitis. Tube feeds were stopped. TPN was initiated. The patient's abdomen became distended the second week of [**Month (only) 404**] significantly. He had an elevated white count of 36,000 as well as fevers and hypotension. It was decided at this time to drain a pancreatic pseudo cyst. Cultures from this were essentially negative, however, the patient did began to have some hemorrhagic episodes into the pancreatic pseudo cyst where the percutaneous needle was placed. This required multiple units of transfusion. At this time, heparin was discontinued. The patient also had splenic infarct noted on his CAT scan. Genitourinary: The patient was initially started on CPVH which was weaned off; however, at the end, the creatinine increased and his urine output decreased. Hematologically, he was on heparin for atrial fibrillation which was discontinued toward the end of the admission. Infectious disease: The patient was on broad spectrum antibiotics through the entire course. He did have pseudomonas and yeast in his sputum. Endocrine: The patient was on insulin sliding scale and the patient required insulin drip during the admission. The patient became septic toward the end of the admission, requiring increased pressors and his creatinine increased. His urine output decreased. It was decided at this time, after extensive discussions with the family, that further care should not be instituted. The transplant surgery service was willing to do an exploratory laparotomy and to explore any pancreatic necrosis as well as any issues which would have been found in the abdomen; however, in discussion with the family, it was decided that no intervention would be done. The patient remained comfort measures only and the patient expired thereafter shortly on [**2163-2-19**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 5697**] Dictated By:[**Name8 (MD) 368**] MEDQUIST36 D: [**2163-2-20**] 15:58:00 T: [**2163-2-21**] 07:09:14 Job#: [**Job Number 106421**]

038,785,584,276,518,427,577,428,348,707,998,995,289,V533,557

{'Septicemia due to pseudomonas,Septic shock,Acute kidney failure with lesion of tubular necrosis,Hyposmolality and/or hyponatremia,Acute and chronic respiratory failure,Atrial fibrillation,Cyst and pseudocyst of pancreas,Congestive heart failure, unspecified,Anoxic brain damage,Pressure ulcer, lower back,Hemorrhage complicating a procedure,Severe sepsis,Other diseases of spleen,Fitting and adjustment of cardiac pacemaker,Unspecified vascular insufficiency of intestine'}

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: 76 year-old male, status post endovascular abdominal aortic aneurysm repair on [**1-12**] at [**Hospital6 2561**]. Transferred to our institution for ICU bed. The patient presented for an elective aortic aneurysm repair that was complicated by intraoperative bleeding secondary to left iliac artery injury at the outside institution. Intraoperative hematocrit at the institution was 11 with an estimated blood loss of 3 liters to 5 hour case. Postoperatively, the patient was aggressively resuscitated with packed red blood cells, FFP and Crystalloid. The patient had a shocked liver with a transaminase in the 7000's. Also, acute renal failure ensued. The patient developed pulmonary edema, pseudomonal pneumonia which was treated at the outside institution with Zosyn and Cipro. The patient developed a septic shock picture on [**1-16**] which required pressor support. MEDICAL HISTORY: Hypercholesterolemia, type II diabetes, hypertension, colon cancer, coronary artery disease, status post myocardial infarction, peripheral vascular disease. First degree AV block, anemia. MEDICATION ON ADMISSION: Lisinopril, Lipitor, Nifedipine, Avandia, Lopressor. ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: ### Response: {'Septicemia due to pseudomonas,Septic shock,Acute kidney failure with lesion of tubular necrosis,Hyposmolality and/or hyponatremia,Acute and chronic respiratory failure,Atrial fibrillation,Cyst and pseudocyst of pancreas,Congestive heart failure, unspecified,Anoxic brain damage,Pressure ulcer, lower back,Hemorrhage complicating a procedure,Severe sepsis,Other diseases of spleen,Fitting and adjustment of cardiac pacemaker,Unspecified vascular insufficiency of intestine'}

CHIEF COMPLAINT: PRESENT ILLNESS: This is a 39 year old male with newly diagnosed diabetes with a history of kidney donation, recent septic knee Staph, approximately one week ago, that was treated. Details unknown. Today, he was going to follow- up appointment at medical doctor, where he was found unresponsive in the car in the parking lot. Noted by EMS to be pulseless with mottled skin. Noted at outside Emergency Department to have pulse after intravenous fluids, approximately 500 cc of normal saline. Initial vitals in the Emergency Department at the outside hospital were pulse of 108, blood pressure 131/83, breathing at 28, temperature of 98.8, oxygenating 98 percent on nonrebreather. MEDICAL HISTORY: Kidney donor in [**2162**]. Status post knee arthrocentesis one week prior to admission. MEDICATION ON ADMISSION: ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: Mother with a history of cancer; dad with a history of heart attack; brother with a history of diabetes. SOCIAL HISTORY: Brother is [**Name (NI) **], contact number at home is [**Telephone/Fax (1) 55870**], at work is [**Telephone/Fax (1) 55871**]. No history of tobacco. No history of intravenous drug abuse. Drinks about three to four drinks per day. He works at a supermarket.

Pyogenic arthritis, lower leg,Methicillin susceptible Staphylococcus aureus septicemia,Severe sepsis,Pneumonitis due to inhalation of food or vomitus,Pulmonary collapse,Urinary tract infection, site not specified,Alkalosis,Diabetes with ketoacidosis, type I [juvenile type], not stated as uncontrolled

Pyogen arthritis-l/leg,Meth susc Staph aur sept,Severe sepsis,Food/vomit pneumonitis,Pulmonary collapse,Urin tract infection NOS,Alkalosis,DMI keto nt st uncntrld

Admission Date: [**2182-5-22**] Discharge Date: [**2182-7-9**] Date of Birth: [**2142-12-7**] Sex: M Service: MED HISTORY OF PRESENT ILLNESS: This is a 39 year old male with newly diagnosed diabetes with a history of kidney donation, recent septic knee Staph, approximately one week ago, that was treated. Details unknown. Today, he was going to follow- up appointment at medical doctor, where he was found unresponsive in the car in the parking lot. Noted by EMS to be pulseless with mottled skin. Noted at outside Emergency Department to have pulse after intravenous fluids, approximately 500 cc of normal saline. Initial vitals in the Emergency Department at the outside hospital were pulse of 108, blood pressure 131/83, breathing at 28, temperature of 98.8, oxygenating 98 percent on nonrebreather. Course notable for knee bursa aspiration of approximately 10 cc of serosanguinous fluid with gram stain with many gram positive cocci in clusters. He was given one gram of Vancomycin, one gram of Ceftriaxone and 500 mg of intravenous Flagyl. His white blood cell count was 21.2 with a hematocrit of 44, glucose of 387, bicarbonate of 10, anion gap of 28 and creatinine of 2.0. Arterial blood gases was 7.14. PAC02 of 24, PA02 of 90 on four liters of nasal cannula. He was given four liters of fluid, started on insulin drip at five units an hour. An electrocardiogram showed sinus tachycardia at 118 beats per minute, otherwise normal. He was found speaking full sentences, intubated and transferred. In the Emergency Department at [**Hospital1 188**], initial vitals were temperature of 37.1 degrees C., blood pressure 110/43; pulse of 115; breathing at 12 with 100 percent saturations on ventilation. Urinalysis showed positive ketones and positive glucose. Insulin drip was kept at five units an hour. He was on ventilatory settings with assist control of 800 tidal volume by 16 rate; PEEP of 5, FI02 of 100 percent. He was on Ativan at 2 mg with Propofol drip of 2. Lactate was checked and was 2.4. Right subclavian line was placed. Initially, temperature was 37.2 with a central venous pressure of 12, PEEP of 5, SV02 of 80, heart rate of 119, Map of 85. His blood pressure was 123/66 post 4800 cc of intravenous fluids. Ortho evaluated right knee fluctuance and transferred to Medical Intensive Care Unit. Arterial blood gases at that time was 7.16, PAC02 of 37, PA02 of 181. Respiratory rate was increased from 16 to 20. The patient was actually breathing at 24. Repeat lactate was 1.6. Central venous pressure of 18. Orthopedics did an incision and drainage at the bedside and it showed infectious prepatellar bursitis with gram stain and cultures sent and the patellar tendon was washed. PAST MEDICAL HISTORY: Kidney donor in [**2162**]. Status post knee arthrocentesis one week prior to admission. ALLERGIES: No known drug allergies. FAMILY HISTORY: Mother with a history of cancer; dad with a history of heart attack; brother with a history of diabetes. MEDICATIONS: None. SOCIAL HISTORY: Brother is [**Name (NI) **], contact number at home is [**Telephone/Fax (1) 55870**], at work is [**Telephone/Fax (1) 55871**]. No history of tobacco. No history of intravenous drug abuse. Drinks about three to four drinks per day. He works at a supermarket. PHYSICAL EXAMINATION: He was intubated and sedated. Vital signs were blood pressure of 105/91; heart rate of 103; CPP of 18; weighing 120 kg. Head, eyes, ears, nose and throat: Anicteric. Pupils are equal, round, and reactive to light and accommodation. Neck supple. No lymphadenopathy. Pulmonary: Clear to auscultation bilaterally, no wheezes. Cardiovascular: Tachycardia, no murmurs, rubs or gallops. Abdomen: Obese, soft, nondistended, nontender, normoactive bowel sounds. Extremities: No cyanosis, clubbing or edema. Knee: Right knee with bursa puncture wound, fluctuant effusion, warm. Skin: Mottled, improved after intravenous fluids and resuscitation. Neurologic: Intubated, sedated. Spontaneously moving all extremities. LABORATORY DATA: White blood cell count of 23.2; hematocrit of 40.2; platelets of 501; neutrophils 59, bands 30, lymphocytes 5, monos 0. Lactate initially of 2.4, decreased down to 1.5. Chemistry showed a sodium of 138; potassium of 3.1; chloride 102; bicarbonate of 11; BUN 38; creatinine 1.5; glucose of 270. Calcium 8.1, magnesium 2.5, phosphorus 53. Urinalysis showed pH of 5, urobilinogen 4, bilirubin small leukocytes, negative blood, large proteins 30, glucose 100, ketones 50. Chest x-ray showed mild cephalization with pulmonary vascular engorgement. Films of the knee, three views, show no bony structure, no fracture, no effusion. Outside hospital knee aspiration showed many gram positive cocci in clusters, suggestive of staph. HOSPITAL COURSE: Sepsis/Fevers: The patient was declared septic for prepatellar bursitis on day one to two of admission. He was started on protocol and aggressively hydrated. He was also started on Vancomycin and Ceftriaxone for gram positive cocci in cultures, not speciated yet. Outside hospital call had said that the patient had become bacteremic from MSSA. At this time, the patient had Vancomycin discontinued, continue Ceftriaxone, started on Oxacillin on [**5-24**]. With evidence of bacteremia from an outside hospital cultures and the patient's persistent temperature spikes, there was concern to whether the patient had seated one of his cardiac valves. A TTE was then done, which was negative and then a transesophageal echocardiogram was done which was also negative for endocarditis. With no other clear source of fevers, we considered whether the patient may have had a ventilatory associated pneumonia, versus urinary tract infection versus further seeding of the knee. A urinalysis was initially unremarkable and he was started on empirically on Ceftazidime, Flagyl, both minimally dosed to cover for gram negative rods, pneumonia and aspiration pneumonia on [**5-27**]. Levorphan and Dobutamine were used transiently for episodes of hypotension that were noted through the initial part of the hospital course. Chest x-rays were taken almost on a daily basis. Left lower lobe pneumonia atelectasis was finally accessed to be atelectasis secondary to body habitus. Ceptaz and Flagyl were discontinued. Ceptaz was also discontinued because a rash had developed after several days of administration. The patient continued to spike fevers, despite continued antibiotics, negative blood cultures, sputum cultures and urine cultures here. The only cultures positive were the cultures taken from the knee site which were MSSA. Lines were changed consistently with cultures sent each time, all returning back negative growth to date. Thoracentesis was sent for culture and gram stain, both negative growth. Liver function tests, amylase and lipase were all within normal limits. With high suspicion for drug fevers in the setting of continued total body rash, we discontinued the Oxacillin and placed the patient on Clindamycin on [**6-6**]. Infectious disease was consulted on [**6-7**] and we continued to check peripheral access to assess for drug rash fevers. Surveillance blood cultures were taken throughout the hospital stay. There were persistent fevers and we needed to consider other sources, such as abdominal source, osteomyelitis and other sources were considered. Surveillance urinalysis grew Enterobacter cloacae and the patient was consequently started on Levofloxacin and given the treatment for seven days. He had continued fevers despite being off the Oxacillin for 96 hours. At this point, he no longer had drug fevers. LENIs of left lower leg were done and they successfully ruled out a deep vein thrombosis or blood clot as another source of fever. With renal function improved, the patient on [**6-11**] had a bone scan which showed increased uptake in the knee area as expected and increased uptake in the thoracic lumbar area. CT of the chest, abdomen and pelvis showed inflammatory changes in the left paraspinal area in the upper lumbar region. CT and bone scan were concerning for infection. At this point, he was afebrile for a couple of days. We were not comfortable with inflammatory changes in the paraspinal area. Hence, ultrasound was done, which was consistent with hematoma, not abscess. Interventional radiology was contact[**Name (NI) **] and they were able to take samples, which were sent off for culture. We were still concerned for abscess versus osteomyelitis versus discitis. Hence, we had the patient go down for magnetic resonance scan of the thoracic and lumbar spine. The [**Location (un) 1131**] on the magnetic resonance scan of the area that ws called inflammatory changes on CT, was this time read as an abscess. The patient had an abscess in the left paraspinal area that was initially called inflammatory changes and was also noted to have an epidural abscess in the region of T11 to T12. Dr. [**Last Name (STitle) 1338**] from neurosurgery was consulted and he took the patient to the operating room for incision and drainage. He removed approximately 500 cc of pus and performed a T11 to T12 laminectomy. Cultures taken in the operating room grew out MSSA, hence, the patient was taken off the clindamycin on [**6-23**]. Allergy consult was obtained and recommended desensitization to Oxacillin which was done on [**6-22**]. Once on full doses of Oxacillin, the patient's Clindamycin was discontinued. Respiratory failure: The patient was intubated for airway protection on arrival and was left on the ventilator since the patient was being taken to the operating room for patellar wash-out. With development of sepsis, the patient was kept on a ventilator and was placed on low tidal volumes for lung protective strategy, being kept on assist control. Once willing to wean off ventilator, the patient failed. We kept the patient on ventilator while we treated the multiple etiologies that were contributing to his respiratory failure: Volume over load, approximately 33 liters; body habitus; acidemia; sepsis, renal failure. As multiple etiologies improved, we attempted to wean the patient; however, he continued to fail. The patient was noted to like higher amounts of PEEP with this parameter, just as he tolerated decreased amounts of FI02. He would occasionally desaturate with turns, which at the time, were secondary to plugging and responsive to increased suctioning. During the periods of desaturations, the patient was given one hour boluses of increased PEEP and FI02. Once returned to [**Location 213**], we changed back to previous settings. The patient was weaned off sedation and began waking up but still failing to come off the ventilator. CT surgery was consulted for tracheostomy secondary to failure to wean. Tracheostomy was placed on [**6-5**]. The patient was eventually weaned from assist control to pressure support, which he tolerated well. The pressure support and PEEP were weaned down as tolerated. Along with the patient's polyneuropathy, he was noted to have severe diaphragmatic weakness, contributing to failure to wean. His recipe was followed on a daily basis and noted to improve to the low 50's by [**6-23**]. He was tolerating longer and longer trials of pressure support, ultimately was maintained on pressure support and decrease in the pressure support and PEEP. He was able to tolerate pressure support of 15 and PEEPs of 10. Acute renal failure: The patient is a single kidney donor and had developed acute renal failure secondary to hypertension and hypervolemia, developing an ATN picture. FENA was checked and noted to be 3.5, further supporting a diagnosis of ATN. Oliguria noted on day three. Renal was consulted to assist for management and help clarify picture. Their impression was that the patient had developed renal failure, secondary to ATN sepsis. Their recommendation was to start Lasix 60 mg three times a day. This was not started until [**5-29**]. An ultrasound of the kidney was done to rule out pyelonephritis as a source of which the result was negative. The patient had excellent response to the Lasix and thus was placed on Lasix drip and continued diuresis with negative 1 to 2 liters net per day for several days. He was then placed from Lasix drip to prn Lasix secondary to the development of hyponatremia on [**6-1**]. The patient had creatinine peak of 8.5 and began to return to normal. He was noted to have spontaneous diuresis on [**6-4**], secondary to post ATN diuresis. Creatinine and renal function returned to baseline and was at baseline on [**6-23**]. Total body weakness: Once sedation was off, the patient was noted to have severe weakness. He was unable to move his lower or upper extremities. Toes were down going on examination. Neurology was consulted. EEG was done and was consistent with an ICD polyneuropathy. Neurologic recommended an lumbar puncture to rule out GBS. Lumbar puncture was attempted but failed and eventually was aborted, due to low suspicion. Their impression was that this was all secondary to severe ICD polyneuropathy and not GBS or, in otherwise called [**Last Name (un) **]-[**Location (un) **] syndrome. The patient had not received any steroids or neuromuscular blockers during this hospital. Noted to have some movement in toes and fingers on [**6-20**] for the first time. Anemia: The patient's anemia was most likely secondary to anemia of chronic disease. This further worsened, due to phlebotomy and chronic renal disease. The patient was treated several times while in the hospital with repeated blood transfusions, when his hematocrit dropped to less than 21. He was subsequently started on Ferrous Gluconate and 40,000 units of Epo subcutaneous q. week on [**2182-6-22**] to help facilitate his erythropoiesis and to eliminate it as one of the causes his failure to wean. Hyperglycemia: No previous history of diabetes. The patient was noted to have very elevated blood sugars in this setting which was of concern. [**Last Name (un) **] was consulted on day one of admission and their interpretation was that this patient had developed diabetes type I. He was started on an insulin drip with great control of his blood sugars. Eventually, over the course of his hospital stay, he was transitioned to subcutaneous doses of Glargine with regular insulin sliding scale coverage. Rash: The patient was noted to develop drug rash, secondary to Ceftazidime on [**5-30**]. The Ceftazidime was discontinued and Flagyl was as well. The rash continued and became worse despite discontinuation of Ceftazidime and Flagyl. We then discontinued Oxacillin [**6-6**] with subsequent improvement of rash and resolution; hence, the patient became allergic to Oxacillin and Ceftazidime. The patient was then desensitized to Oxacillin on [**6-22**] to [**6-23**] with no notable rash after those days. Hyponatremia: Secondary to Lasix diuresis and minimal free water replacement. Lasix was stopped and free water deficit was replenished and hyponatremia was resolved. The patient had a second episode of hyponatremia, again secondary to aggressive diuresis with Lasix. Lasix was stopped and free water deficit was replenished and hyponatremia resolved. Alkalemia: The patient was noted to have a transient alkalemia secondary to hyperventilation. Respiratory rate was corrected on the vent settings and alkalemia resolved. No further episodes of alkalemia. Prepatellar bursitis: The patient had been given a steroid injection in the right knee, which consequently became infected. At outside hospital, laboratory studies were notable to grow gram positive cocci. He was placed on Vancomycin, Ceftriaxone and an orthopedic consult was called to evaluate for consideration of debridement. The patient had a bedside wash-out and debridement on the day of admission. The patient was taken on hospital day number two, for wash-out to the operating room. Cultures were taken and sent. Cultures resulted in growing MSSA. He was then started on Oxacillin on day [**5-24**] and Vancomycin was discontinued. He had wash-out number two on [**2182-5-25**]. He was subsequently taken for wash-out number three on [**5-27**] and noted to have frank pus. Wash-out four was done on [**6-5**] and wash-out number five was done on [**6-10**]. On [**6-10**], he was noted to have osteonecrotic bone for osteonecrotic patella; hence, had subsequent patellectomy with extensor reconstruction. Metabolic acidosis: The patient was noted to have ketones in the urine and to be hypoglycemia. Without a past history of diabetes, it was the impression of the team that the patient was indeed showing evidence of diabetes. He was placed on an insulin drip with tight control of blood sugars and chemistries were checked q. 3 hours until gap closed and no longer acidotic. In large part, his metabolic acidosis was secondary to his DKA. He was given aggressive intravenous fluid hydration to correct his dehydration. His urine ketones were followed and chemistries were followed very closely. Insulin drip was titrated for aggressive blood sugar control. His gap closed but he was still very acidotic with non anion gap acidosis. Hence, he was started on bicarbonate per recommendations of renal. Despite bicarbonate supplementation, he continued to be acidemic. Other considerations were very elevated BUN/anemia versus hyperkalemic acidosis secondary to aggressive intravenous fluid hydration with normal saline versus sepsis. Ventilator was used to help correct the acidosis. Once his DKA had resolved, his hyperphosphatemia was treated with Amphojel, with normalization of his uremia/BUN. His metabolic acidosis resolved. Depression: The patient was started on Celexa 20 mg q. h.s., given Ativan for anxiety prn and a psychiatric consult placed with subsequent following throughout the hospital course. Fluids, electrolytes and nutrition: Nutrition was consulted and with their assistance, and continued following throughout his hospitalized stay, we were able to provide him with adequate nutrition. The patient had a percutaneous endoscopic gastrostomy placed and was continued on tube feeds throughout the entire stay. Electrolytes were checked on a daily basis and repleted as necessary. Prophylaxis: The patient was maintained on pneumo boots and then subsequently placed on Lovenox for deep vein thrombosis prophylaxis. Physical therapy and occupational therapy consults were both placed and they followed the patient throughout the remainder of his course. Speech and swallow evaluation was placed, primarily for evaluation for Passy-Muir valve. Once the patient was on lower settings of PEEP, Passy-Muir was supplied to the patient. In the interim, the patient was using a laryngoscopic device to provide vibrations to his vocal cords, to be able to speak. The remainder of this hospital course will be dictated by the next physician. [**Name10 (NameIs) **] dictation covers [**5-22**] to5/30. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-797 Dictated By:[**Last Name (NamePattern1) 49203**] MEDQUIST36 D: [**2182-7-4**] 23:29:25 T: [**2182-7-5**] 05:30:10 Job#: [**Job Number 55872**] Admission Date: [**2182-6-25**] Discharge Date:[**2182-7-3**] Date of Birth: [**2142-12-7**] Sex: M Service: MED NOTE: This discharge summary spans the dates beginning [**2182-6-25**] through [**2182-7-4**]. This is an addendum. ADDENDUM TO HOSPITAL COURSE: Fevers: The patient continued to spike fevers, despite Oxacillin treatment of his known MSSA bacteremia and lumbar paraspinal abscess. He underwent a transesophageal echocardiogram that was negative for evidence of endocarditis. On [**2182-6-28**], the patient underwent a magnetic resonance scan of the entire spine to evaluate the known lumbar epidural abscess, as well as to look for any other evidence of infection. The magnetic resonance scan revealed an epidural inflammatory process, extending from the foramen magnum down to the mid thoracic spine. Neurosurgery was reconsulted and the patient was taken to the operating room for another drainage procedure. In the operating room, it was noted that the cervical cord was being compressed by granulation tissue. A portion of this granulation tissue was stripped off. There was no fluid to be drained. It still was not clear if this represented the source of the patient's continued fevers. A sputum culture grew Enterobacter cloaca. The patient was actually treated with a course of Aztreonam; however, the Enterobacter was showing sensitives to Aztreonam. ACT test was performed which revealed evidence of a lingular pneumonia. The patient's antibiotics were, therefore, switched to a course of Levaquin. At the time of dictation, the patient is on day two of ten of his Levaquin course. This CT test also revealed evidence of a loculated effusion on the right pleural space. It was felt that this was unlikely to be infectious in nature; however, if the patient continued to spike high fevers, then he may need a more definitive drainage procedure. Additionally, there was a thought of drug fever as the patient had a prior allergy to Oxacillin, for which he was desensitized and he had a peripheral eosinophilia and a mild rash. At the time of this dictation it is not entirely clear what the source of his recurrent fevers were; however, his fever curve had been titrating down. Paraplegia: Initially it was thought that the patient's weakness, inability to wean from the vent was due to IC polymyopathy; however, when the epidural granulation tissue of the cervical spine was revealed by the magnetic resonance scan, it was felt that there was likely an epidural abscess secondary to his MSSA infection and that the development of granulation tissue caused compression of the cervical cord, as well as the possibility of septic thrombophlebitis, causing cord infarcts. As mentioned previously, after neurosurgery and neurology evaluation, the patient was taken to the operating room for stripping of this granulation tissue and relief of the pressure on the cord. Physical therapy and occupational therapy worked closely with the patient and he will need long term spinal cord rehabilitation in order to achieve significant improvement. Respiratory failure: As mentioned above, it was felt that diaphragmatic weakness, secondary to cervical cord lesion was the likely etiology for his inability to wean off the vent. The patient is status post a tracheostomy and was maintained on pressure support settings and will likely be vent dependent until significant cervical cord function is returned. Diabetes: The patient's sugars remained in excellent range on his twice a day Lentis dosing. The remainder of this discharge summary, including the patient's diagnoses, discharge medications will be dictated as a part of an addendum to this summary. [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 2019**] Dictated By:[**Last Name (NamePattern1) 12327**] MEDQUIST36 D: [**2182-7-3**] 22:28:38 T: [**2182-7-4**] 04:31:23 Job#: [**Job Number 55873**] Admission Date: [**2182-5-22**] Discharge Date:[**2182-7-9**] Date of Birth: [**2142-12-7**] Sex: M Service: MED ADDENDUM: HOSPITAL COURSE: The remainder of the [**Hospital 228**] hospital stay was uneventful. He had a speech and swallow evaluation which cleared him to tolerate all p.o. which he did without problem. Additionally, he remained afebrile except for an occasional low grade temperature that was not pursued. His culture data remained negative. Therefore, he was discharged to rehabilitation facility. DISCHARGE DIAGNOSES: Diabetic ketoacidosis. New onset diabetes mellitus. Methicillin sensitive Staphylococcus aureus. Bacteremia. Methicillin sensitive Staphylococcus aureus left septic knee joint. Lumbar paraspinal epidural abscess, cervical epidural abscess. Respiratory failure. Paraplegia. Pneumonia. SURGICAL PROCEDURES: Percutaneous J tube. Bronchoscopy. Lumbar puncture. Tracheostomy. Open debridement of the right knee. Thoracentesis. Serial incision and drainage washouts of the right knee. C4 to C7 laminectomies and stripping of the cervical epidural granulation tissue, drainage of the lumbar paraspinal abscess and T11 to T12 laminectomies. MEDICATIONS ON DISCHARGE: 1. Lansoprazole 30 mg NG once daily. 2. Celexa 20 mg NG once daily. 3. Multivitamin one once daily. 4. Vitamin C 500 mg twice a day. 5. Zinc 220 once daily. 6. Ferrous Gluconate 300 mg once daily. 7. Albuterol meter dose inhaler two to four puffs q4hours p.r.n. wheeze. 8. Enoxaparin 40 mg subcutaneously once daily. 9. Epogen 10,000 units one injection three times a week q.Tuesday, Thursday and Saturday. 10. Ambien 5 mg tablet, one to two q.h.s. p.r.n. insomnia. 11. Fentanyl patch 75 mcg per hour q72hours. 12. Oxycodone 5 mg one to two tablets q3hours as needed for breakthrough pain. 13. Levaquin 500 mg tablet one once daily times four days. 14. Oxacillin two grams intravenously q4hours times seven and one half weeks. 15. Insulin-Glargine subcutaneously 50 units twice a day with a regular insulin sliding scale. FOLLOW UP: Follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9404**] of infectious disease on [**2182-8-5**]. Follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of orthopedics on [**2182-7-26**]. Follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2182-8-21**]. Follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1338**] of neurosurgery. He will need to call to schedule this appointment. Follow-up magnetic resonance imaging of his spine on [**2182-7-31**]. [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 2019**] Dictated By:[**Last Name (NamePattern1) 12327**] MEDQUIST36 D: [**2182-7-7**] 11:25:50 T: [**2182-7-7**] 12:19:51 Job#: [**Job Number 55874**] Name: [**Known lastname 10483**], [**Known firstname **] Unit No: [**Numeric Identifier 10484**] Admission Date: Discharge Date: [**2182-7-9**] Date of Birth: [**2142-12-7**] Sex: M Service: MED This is an addendum for the remainder of the hospital course. Patient spiked a recurrent fever to 101. Initially a diagnostic thoracentesis of the right loculated effusion was planned. However, after evaluation by ultrasound the fluid was an insignificant amount and nothing amenable to thoracentesis. It was felt that this was an unlikely cause of his fever, and therefore no further procedures were pursued. Additionally, patient developed an increased skin rash, that with his history of oxacillin allergy as well as peripheral eosinophilia. It was felt that the fever could be secondary to a drug allergy. Therefore, patient's oxacillin was changed to vancomycin one gram q. 12 hours, and this medication will be continued for another seven-and-a-half weeks as per the original plan. Thus, patient was discharged to [**Hospital 4418**] [**Hospital **] Rehab on [**2182-7-9**]. The patient's discharge diagnoses and discharge medications are the same as the prior discharge summary with the exception of oxacillin for which vancomycin will be substituted one gram q. 12 hours times seven-and-a-half weeks. [**Name6 (MD) **] [**Last Name (NamePattern4) **], MD [**MD Number(1) 7079**] Dictated By:[**Last Name (NamePattern1) 8833**] MEDQUIST36 D: [**2182-7-9**] 15:17:44 T: [**2182-7-9**] 15:36:45 Job#: [**Job Number 10485**]

711,038,995,507,518,599,276,250

{'Pyogenic arthritis, lower leg,Methicillin susceptible Staphylococcus aureus septicemia,Severe sepsis,Pneumonitis due to inhalation of food or vomitus,Pulmonary collapse,Urinary tract infection, site not specified,Alkalosis,Diabetes with ketoacidosis, type I [juvenile type], not stated as uncontrolled'}

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: This is a 39 year old male with newly diagnosed diabetes with a history of kidney donation, recent septic knee Staph, approximately one week ago, that was treated. Details unknown. Today, he was going to follow- up appointment at medical doctor, where he was found unresponsive in the car in the parking lot. Noted by EMS to be pulseless with mottled skin. Noted at outside Emergency Department to have pulse after intravenous fluids, approximately 500 cc of normal saline. Initial vitals in the Emergency Department at the outside hospital were pulse of 108, blood pressure 131/83, breathing at 28, temperature of 98.8, oxygenating 98 percent on nonrebreather. MEDICAL HISTORY: Kidney donor in [**2162**]. Status post knee arthrocentesis one week prior to admission. MEDICATION ON ADMISSION: ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: Mother with a history of cancer; dad with a history of heart attack; brother with a history of diabetes. SOCIAL HISTORY: Brother is [**Name (NI) **], contact number at home is [**Telephone/Fax (1) 55870**], at work is [**Telephone/Fax (1) 55871**]. No history of tobacco. No history of intravenous drug abuse. Drinks about three to four drinks per day. He works at a supermarket. ### Response: {'Pyogenic arthritis, lower leg,Methicillin susceptible Staphylococcus aureus septicemia,Severe sepsis,Pneumonitis due to inhalation of food or vomitus,Pulmonary collapse,Urinary tract infection, site not specified,Alkalosis,Diabetes with ketoacidosis, type I [juvenile type], not stated as uncontrolled'}

CHIEF COMPLAINT: Speech arrest PRESENT ILLNESS: 65 y/o RH man with a previous medical history significant for HTN and HLD presents with new onset of speech arrest. MEDICAL HISTORY: HTN HLD s/p TURP GERD Nephrolithiasis Inguinal hernia MEDICATION ON ADMISSION: Lisinopril, HCTZ, Atenolol, Zocor ALLERGIES: Aspirin / Motrin PHYSICAL EXAM: Afebrile at 98.3 F, 162/84, 90 bpm; RR 12 with SaO2: 100% in RA FAMILY HISTORY: His sister died from breast cancer. Another sister died of stroke at age 40. SOCIAL HISTORY: Lives with his wife and two children. Denies drinking or smoking. No illicit drugs. Owns a cleaning company.

Cerebral embolism with cerebral infarction,Ostium secundum type atrial septal defect,Unspecified essential hypertension,Esophageal reflux,Calculus of kidney,Inguinal hernia, without mention of obstruction or gangrene, unilateral or unspecified (not specified as recurrent),Occlusion and stenosis of carotid artery without mention of cerebral infarction

Crbl emblsm w infrct,Secundum atrial sept def,Hypertension NOS,Esophageal reflux,Calculus of kidney,Unilat inguinal hernia,Ocl crtd art wo infrct

Admission Date: [**2147-9-17**] Discharge Date: [**2147-9-21**] Date of Birth: [**2082-4-20**] Sex: M Service: NEUROLOGY Allergies: Aspirin / Motrin Attending:[**Last Name (NamePattern1) 1838**] Chief Complaint: Speech arrest Major Surgical or Invasive Procedure: Thrombolysis History of Present Illness: 65 y/o RH man with a previous medical history significant for HTN and HLD presents with new onset of speech arrest. Mr [**Known lastname 106930**] was with his wife placing a nail in the wall to hang a picture at 11: 45. His wife reports that he he suddenly looked confused and stopped hanging the picture. He was not able to reply when his wife enquired about what was happening to him. He could not follow commands, but remained alert. His wife reports no limb weakness, but she thinks he could have had a facial droop (though she cannot recall in which side). He had no other focal deficits per history. She reports he had a headache earlier in the day, but is unable to determine whether it was of throbbing or pressure quality, for how long it lasted, or any other features. According to his wife, he had never experienced this type of event. He has no previous history of intracranial bleed or recent surgery or trauma. She called EMS, who brought him to [**Hospital1 18**] ED: Afebrile, 160/ 95. 90 bpm. RR 18 SO2 100% in RA. FSG 149. ROS: No fever, no diarrhea, no cough, no chest pain. The rest of ROS is negative. Past Medical History: HTN HLD s/p TURP GERD Nephrolithiasis Inguinal hernia Social History: Lives with his wife and two children. Denies drinking or smoking. No illicit drugs. Owns a cleaning company. Family History: His sister died from breast cancer. Another sister died of stroke at age 40. Physical Exam: Afebrile at 98.3 F, 162/84, 90 bpm; RR 12 with SaO2: 100% in RA Alert. Sclerae anicteric. MMM. No meningismus. No carotid bruits auscultated. Lungs clear bilaterally. Heart regular in rate. Abd soft, nontender, nondistended. Bowel sounds heard throughout. Guaiac negative (per ER team). Neurological exam: Alert. Frustrated, nonverbal. Follows simple commands (i.e. squeeze my hand, raise your arm): preserved comprehension. Verbal perseveration. Nomination impaired. Non-fluent. No apraxia (ideomotor), no agnosia, no field cuts. No extinction. CN Fundi w/ sharp discs. PERRL. VFIC. No ptosis. EOMI. Facial sensation intact. Hearing intact to finger rub. Palate elevates at midline. SCMs intact. Tongue protrudes midline. Motor R UE [**5-22**]. L UE [**5-22**]. R LE [**5-22**]. L LE [**5-22**]. No drift. Tone normal. DTRs: L/R: bic [**2-18**], br [**2-18**], tri [**2-18**]; pat [**3-20**], Ach 2+/2+. Plantars bilaterally flexor. Sensory: Light touch, temp, pinprick and vibration intact Coord/Gait: No dysmetria. No dysdiadochokinesia. Normal FFT. Normal FTN. His NIH stroke score was 5. Hence he received tpa and was transferred to the Unit in CC7 B. As compared to the initial exam in the ER, the patient seems to be more interactive and able to follow commands more easily. His speech impairment has not changed. I discussed the case with Dr. [**Last Name (STitle) 18530**] and also with the nursing team in the unit at CC7. Pertinent Results: CT: no hemorrhage; no signs of early infarction CTA: no major vessel cutoff. Large calcification/plaque in distal L CCA. CTP: Elevated Mean Transient Time with a normal Cerebral Blood Volume in left parietal region; wedge-shaped. MRI CNS w and w/o contrast: Redemonstration of subacute left posterior temporal/occipital infarct. [**2147-9-17**] 12:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2147-9-17**] 12:15PM TSH-0.86 [**2147-9-17**] 12:15PM cTropnT-<0.01 [**2147-9-17**] 12:15PM TOT PROT-7.2 ALBUMIN-4.5 GLOBULIN-2.7 [**2147-9-17**] 12:15PM WBC-6.4 RBC-4.71 HGB-15.1 HCT-41.1 MCV-87 MCH-32.1* MCHC-36.8* RDW-13.3 [**2147-9-17**] 12:15PM ALT(SGPT)-33 AST(SGOT)-29 LD(LDH)-320* CK(CPK)-260* ALK PHOS-81 TOT BILI-1.2 [**2147-9-18**] 07:08AM BLOOD Triglyc-195* HDL-33 CHOL/HD-6.7 LDLcalc-148* TTE:The left atrium is elongated. No thrombus/mass is seen in the body of the left atrium. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. TEE: PFO with left to right shunting, minor descending aortic atheromatous plaque. No thrombus of the left atrium or LAA seen. Brief Hospital Course: Mr [**Known lastname 106931**] speech has improved s/p tpa. He has improved ability to produce phrases in both English and Portugese though his fluency is still sharply decreased. He can name high but not low frequency objects. The patient has difficulty with repetition. He is able to follow crossed body commands. He has shown a complete motor recovery. The left parietal acute infarct may have been due to thrombosis of the left inferior division of the left MCA or possibly embolism. His left internal carotid artery is 40-59% stenosed. This was not considered a high grade enough lesion for him to be a good candidate for CEA or stent. His carotid arteries should be re-examined in six months. TEE showed a PFO with a left to right shunt. This is another possible embolic source, but given his age and the fact that it is a left to right shunt, it is not highly probable. He was started on Plavix 75mg daily. Medications on Admission: Lisinopril, HCTZ, Atenolol, Zocor Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: LEFT MCA stroke. HTN Discharge Condition: Stable. His language exam remains impaired: for low frequency object nomination and repetition. Otherwise, he has shown a complete motor recovery. Discharge Instructions: You have had a stroke. You have recovered after receiving therapy with tpa (a thrombolytic medication) Followup Instructions: You will follow up with Dr. [**Last Name (STitle) **] in the stroke clinic. Please, call to make an appointment at [**Telephone/Fax (1) 2574**].

434,745,401,530,592,550,433

{'Cerebral embolism with cerebral infarction,Ostium secundum type atrial septal defect,Unspecified essential hypertension,Esophageal reflux,Calculus of kidney,Inguinal hernia, without mention of obstruction or gangrene, unilateral or unspecified (not specified as recurrent),Occlusion and stenosis of carotid artery without mention of cerebral infarction'}

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: Speech arrest PRESENT ILLNESS: 65 y/o RH man with a previous medical history significant for HTN and HLD presents with new onset of speech arrest. MEDICAL HISTORY: HTN HLD s/p TURP GERD Nephrolithiasis Inguinal hernia MEDICATION ON ADMISSION: Lisinopril, HCTZ, Atenolol, Zocor ALLERGIES: Aspirin / Motrin PHYSICAL EXAM: Afebrile at 98.3 F, 162/84, 90 bpm; RR 12 with SaO2: 100% in RA FAMILY HISTORY: His sister died from breast cancer. Another sister died of stroke at age 40. SOCIAL HISTORY: Lives with his wife and two children. Denies drinking or smoking. No illicit drugs. Owns a cleaning company. ### Response: {'Cerebral embolism with cerebral infarction,Ostium secundum type atrial septal defect,Unspecified essential hypertension,Esophageal reflux,Calculus of kidney,Inguinal hernia, without mention of obstruction or gangrene, unilateral or unspecified (not specified as recurrent),Occlusion and stenosis of carotid artery without mention of cerebral infarction'}

CHIEF COMPLAINT: Weakness and fatigue x1 wk. PRESENT ILLNESS: 66yo man with hx of afib s/p pacer (no AICD), CAD. DMII, short gut syndrome who presents with fatigue and weakness since wednesday. He noted onset of fatigue and bilateral palmar paresthesias on Wednesday. This was not assoc with any fevers, chills, SOB, chest pain, or palpitations. His sx persisted daily and he had worsened exercise tolerance, reporting difficulty ambulating up three flights of stairs at home. Last night he felt much increasing weakness and fatigue. He awoke at 3am with these complaints. His wife tried taking his BP without any success. She reports that his pulse was "weak and flighty." MEDICAL HISTORY: - diabetes mellitus II; last A1c 5.7 - CAD: no CABG or stent placement. C cath report below. - Afib: originally treated with amio but then underwent AV node ablation and placement of pacer approx 5 yrs ago. - Hypercoagulable state: Seen in [**Hospital **] clinic. On lovenox, complicated by: --deep vein thrombophlebitis of the leg --ischemic gut "short gut syndrome" 15% left of normal gut --CVA [**2121**] --right BKA polycythemia [**Doctor First Name **] Debilitating neuropathic pain non-healing anal fissure, s/p surgery [**8-1**] MEDICATION ON ADMISSION: Captopril 75mg TID Citalopram 60mg daily digoxin 250mcg daily folic acid 2mg daily fosamax 70mg weekly lasix 40-60mg daily Vicodin prn Lidocaine patch prn loperamide 6mg TID Lovenox 60 q12h NPH 14 daily ranitidine 150mg [**Hospital1 **] Toprol XL 12.5mg daily MVI B12 Citracel/Vit D oxycontin [**10-24**] daily neurontin 800mg QID vicodin prn ALLERGIES: Levofloxacin / Cefazolin / Coreg PHYSICAL EXAM: VS: 95.8 HR 72 BP 99/64 RR 12 98% 4L CVP = 25 GEN: Fatigued, arousable to voice Neuro: Alert to person, place, situation, month, year - CN: perrla, face symmetric, tongue midline, shrug appropriate - Strength: [**4-29**] bilat upper. 5/5 strength left lower. left toe downgoing. - reflexes minimal throughout - [**Last Name (un) 36**] intact to light touch HEENT: slight increased facial swelling. PERRLA, EOMI, JVP 6cm. Right IJ in place Cards: RRR, no apprec murmurs. no rubs Lungs: slight crackles at bases. No wheezes, normal effort. Not tachypneic Abd: midline incision. BS+ NT ND. No rebound. No guarding Ext: right BKA. Left foot cool with nonpalp pulses. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. FAMILY HISTORY: Family history is negative for hypercoagulable state, PVD SOCIAL HISTORY: Mr. [**Known lastname 21212**] is a retired systems programmer for a management consulting firm. He is married with no children. He denies alcohol, tobacco or drug use. Prior 3 yrs of tobb abuse

Septicemia due to anaerobes,Acute kidney failure with lesion of tubular necrosis,Intestinal infection due to Clostridium difficile,Acute on chronic systolic heart failure,Paroxysmal ventricular tachycardia,Other and unspecified postsurgical nonabsorption,Primary hypercoagulable state,Ulcer of heel and midfoot,Sepsis,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Esophageal reflux,Polycythemia vera,Coronary atherosclerosis of native coronary artery,Fitting and adjustment of cardiac pacemaker

Anaerobic septicemia,Ac kidny fail, tubr necr,Int inf clstrdium dfcile,Ac on chr syst hrt fail,Parox ventric tachycard,Intest postop nonabsorb,Prim hypercoagulable st,Ulcer of heel & midfoot,Sepsis,DMII wo cmp nt st uncntr,Esophageal reflux,Polycythemia vera,Crnry athrscl natve vssl,Ftng cardiac pacemaker

Admission Date: [**2130-11-25**] Discharge Date: [**2130-12-8**] Date of Birth: [**2064-7-16**] Sex: M Service: MEDICINE Allergies: Levofloxacin / Cefazolin / Coreg Attending:[**First Name3 (LF) 7055**] Chief Complaint: Weakness and fatigue x1 wk. Major Surgical or Invasive Procedure: Ventricular Tachycardia ablation Thoracentesis History of Present Illness: 66yo man with hx of afib s/p pacer (no AICD), CAD. DMII, short gut syndrome who presents with fatigue and weakness since wednesday. He noted onset of fatigue and bilateral palmar paresthesias on Wednesday. This was not assoc with any fevers, chills, SOB, chest pain, or palpitations. His sx persisted daily and he had worsened exercise tolerance, reporting difficulty ambulating up three flights of stairs at home. Last night he felt much increasing weakness and fatigue. He awoke at 3am with these complaints. His wife tried taking his BP without any success. She reports that his pulse was "weak and flighty." . In the ED, SBP 89/56, HR 160. EKG showed wide complex tachycardia. Received amio 150mg IV bolus at 11:07am. Pt became unresponsive at 11:09 so received 200J biphasic cardioversion. He returned to HR of 70 and was V-paced. SBP then 70s-80s. Has two 18g PIVs and received 2L IVF. Amio gtt stopped given persistently low BPs. Lidocaine gtt started at 1mg/min to help prevent recurrent VT. BP remained low so periph neo started at 0.5 mcg/kg/m. Neo increased to 1 mcg/kg/m with SBP to 90. Right IJ CVL placed by ED. Labs returned just prior to transfer and pt was noted to have WBC 35, HCO3 9, and Anion Gap of 18. . Currently, he denies any localizing symptoms: no F/C/NS, URI like sx, cough, abd pain, change in bowels, skin rashes, or urinary complaints. He does describe chronic low back pain. Slightly increased DOE but no CP, no PND, no orthopnea, no increased edema. Past Medical History: - diabetes mellitus II; last A1c 5.7 - CAD: no CABG or stent placement. C cath report below. - Afib: originally treated with amio but then underwent AV node ablation and placement of pacer approx 5 yrs ago. - Hypercoagulable state: Seen in [**Hospital **] clinic. On lovenox, complicated by: --deep vein thrombophlebitis of the leg --ischemic gut "short gut syndrome" 15% left of normal gut --CVA [**2121**] --right BKA polycythemia [**Doctor First Name **] Debilitating neuropathic pain non-healing anal fissure, s/p surgery [**8-1**] Social History: Mr. [**Known lastname 21212**] is a retired systems programmer for a management consulting firm. He is married with no children. He denies alcohol, tobacco or drug use. Prior 3 yrs of tobb abuse Family History: Family history is negative for hypercoagulable state, PVD Physical Exam: VS: 95.8 HR 72 BP 99/64 RR 12 98% 4L CVP = 25 GEN: Fatigued, arousable to voice Neuro: Alert to person, place, situation, month, year - CN: perrla, face symmetric, tongue midline, shrug appropriate - Strength: [**4-29**] bilat upper. 5/5 strength left lower. left toe downgoing. - reflexes minimal throughout - [**Last Name (un) 36**] intact to light touch HEENT: slight increased facial swelling. PERRLA, EOMI, JVP 6cm. Right IJ in place Cards: RRR, no apprec murmurs. no rubs Lungs: slight crackles at bases. No wheezes, normal effort. Not tachypneic Abd: midline incision. BS+ NT ND. No rebound. No guarding Ext: right BKA. Left foot cool with nonpalp pulses. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: EKG [**2130-11-25**] Wide complex regular tachycardia consistent with ventricular tachycardia. Ventricular rate is about 170. Compared to tracing of [**2130-8-15**] ventricular tachycardia is new. Of note, patient was previously ventricularly paced. Clinical correlation is suggested. EKG [**2130-11-27**] Demand ventricular pacing with ventricular premature depolarizations and underlying atrial fibrillation. Compared to previous tracing of [**2130-11-26**] increased ventricular ectopy is now noted. Otherwise, no major change. PLEURAL FLUID- LEFT THORACENTESIS- GRAM STAIN NEGATIVE, CULTURE PENDING UPON DISCHARGE, SENT FOR CYTOLOGY, PENDING UPON DISCHARGE, SENT FOR CHEMISTRIES WHICH REVEAL THIS AS A TRANSUDATIVE EFFUSION BY LIGHTS CRITERIA. LEFT UPPER EXTREMITY [**12-1**]: 1. No evidence of DVT. 2. Non-occlusive thrombus involving the left median antecubital vein, not part of the deep venous system. 3. Left supraclavicular lymphadenopathy. [**12-5**] CHEST X RAY S/P THORACENTESIS ON LEFT: In comparison with the study of [**12-4**], there has been removal of a substantial amount of pleural fluid on the right. Specifically, no evidence of pneumothorax. The left lung remains clear. ECHO [**11-27**]: The left atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is severe regional left ventricular systolic dysfunction with inferior/infero-lateral akinesis (basal to mid infero-lateral wall thinned c/w with prior infarct/scar). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. The right ventricular cavity is moderately dilated. There is moderate global right ventricular free wall hypokinesis. The aortic valve leaflets are moderately thickened. No masses or vegetations are seen on the aortic valve. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Moderate (2+) mitral regurgitation is seen. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. No masses or vegetations are seen on the pulmonic valve, but cannot be fully excluded due to suboptimal image quality. There is a small pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2129-4-28**], the pericardial effusion is new. Otherwise, no significant change. [**2130-11-25**] 09:15PM TYPE-ART PO2-109* PCO2-31* PH-7.24* TOTAL CO2-14* BASE XS--12 [**2130-11-25**] 09:15PM LACTATE-1.4 [**2130-11-25**] 07:53PM GLUCOSE-102 UREA N-54* CREAT-1.7* SODIUM-137 POTASSIUM-4.4 CHLORIDE-110* TOTAL CO2-11* ANION GAP-20 [**2130-11-25**] 07:53PM CK(CPK)-50 [**2130-11-25**] 07:53PM CK-MB-NotDone cTropnT-0.15* [**2130-11-25**] 07:53PM CALCIUM-7.1* PHOSPHATE-4.6* MAGNESIUM-1.7 [**2130-11-25**] 05:42PM URINE HOURS-RANDOM UREA N-482 CREAT-40 SODIUM-52 CHLORIDE-48 [**2130-11-25**] 05:42PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2130-11-25**] 05:42PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2130-11-25**] 05:42PM URINE RBC-[**2-27**]* WBC-[**2-27**] BACTERIA-FEW YEAST-NONE EPI-0-2 TRANS EPI-0-2 [**2130-11-25**] 05:42PM URINE GRANULAR-<1 [**2130-11-25**] 05:42PM URINE AMORPH-OCC [**2130-11-25**] 03:33PM TYPE-[**Last Name (un) **] [**2130-11-25**] 03:33PM O2 SAT-58 [**2130-11-25**] 03:30PM TYPE-ART PO2-89 PCO2-37 PH-7.19* TOTAL CO2-15* BASE XS--13 [**2130-11-25**] 03:30PM LACTATE-1.2 [**2130-11-25**] 03:30PM O2 SAT-93 [**2130-11-25**] 03:30PM freeCa-1.01* [**2130-11-25**] 03:18PM DIGOXIN-0.7* [**2130-11-25**] 03:18PM WBC-44.5* RBC-4.05* HGB-13.7* HCT-41.9 MCV-103* MCH-33.9* MCHC-32.8 RDW-16.8* [**2130-11-25**] 03:18PM PLT COUNT-609*# [**2130-11-25**] 12:35PM WBC-34.7*# RBC-3.97* HGB-13.2* HCT-39.8* MCV-100*# MCH-33.3*# MCHC-33.2 RDW-17.3* [**2130-11-25**] 12:35PM NEUTS-90* BANDS-8* LYMPHS-1* MONOS-0 EOS-0 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 [**2130-11-25**] 12:35PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-1+ MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL BURR-OCCASIONAL BITE-OCCASIONAL [**2130-11-25**] 12:35PM PLT SMR-UNABLE TO [**2130-11-25**] 12:35PM PT-18.0* PTT-34.4 INR(PT)-1.7* [**2130-11-25**] 12:09PM K+-4.0 [**2130-11-25**] 12:00PM GLUCOSE-180* UREA N-58* CREAT-1.7* SODIUM-137 POTASSIUM-3.8 CHLORIDE-110* TOTAL CO2-9* ANION GAP-22* [**2130-11-25**] 12:00PM estGFR-Using this [**2130-11-25**] 12:00PM ALT(SGPT)-14 AST(SGOT)-24 LD(LDH)-385* CK(CPK)-121 ALK PHOS-69 AMYLASE-69 TOT BILI-0.5 [**2130-11-25**] 12:00PM LIPASE-38 [**2130-11-25**] 12:00PM cTropnT-0.12* [**2130-11-25**] 12:00PM CK-MB-7 [**2130-11-25**] 12:00PM ALBUMIN-3.1* CALCIUM-6.7* PHOSPHATE-4.0 [**2130-12-6**] DISCHARGE LABS: WBC 17.7, HCT 34.2, PLT 482 PTT 35.6, INR 1.5 NA 141, K 4.9, CL 107, BICARB 20, BUN 24, CR 1.4, GLUCOSE 127 CALCIUM 7.9, MG 1.7, PHOS 1.7 c diff toxin A POSITIVE BLOOD CULTURES: NO GROWTH TO DATE. URINE CULTURES: NO GROWTH. Brief Hospital Course: VENTRICULAR TACHYCARDIA: patient presented to ER with feelings of fatigue x 1 week. Found to be in V tach and was slightly symptomatic (fatigue, lightheadedness) he was given an amiodarone load of 150mg over 10 minutes IV and became hypotensive (initially thought to be due to amio however the determined that patient was septic). He became unresponsive and was shocked with 200J and regained a normal rhythm. Per the EP service he was started on a lidocaine drip x 24 hours. He was then taken off of the drip as the VT had been related to his ongoing sepsis and when his blood pressure was stabilized and his infection was being treated the thought was his VT would not recur in the immediate sense. Within 3 days his VT returned and he experienced sustained VT, asymptomatic, x 15 hours, refractory to amiodarone load x 2, lidocaine bolus x 2 and lidocaine drip, he converted to with procainadmide but then again reverted back to VT. Eventually he was taken to the EP lab and the VT focus was isolated and ablated and did not return throughout his stay. Given his infection a decision was made by EP not to exchange his pacer for an ICD on this admission and to possibly perform this as an outpatient. Mr [**Known lastname 21212**] can arrange this with his outpatient cardiologist Dr. [**Last Name (STitle) **]. . SEPSIS: noted to be caused by C diff. Initially treated with Vanc/Zosyn but switched to flagyl when C diff returned positive. Stool output eventually began to increase on flagyl and this was switched to PO vancomycin, this was begun on [**12-4**] and this should continue for a 14 day course. . LEUKOCYTOSIS: persistently elevated WBC count, ESR 5, unlikely still related to C diff as C diff is being treated well. peak at 44,000. Discharge WBC at 17,000. Patient also has seen Heme onc inpatient as he has a history of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] and has multiple elevated WBCs in the past. Heme-Onc did not see anything acute but he should follow up with Heme-Onc as an outpatient to further evaluate his leukocytosis. . CHF: given initial sepsis, he was volume resuscitated with 6 liters of normal saline, eventually he was slowly diuresed and had a thoracentesis which relieved 1.5 liters of fluid from his pleural space, transudateive. The pleural fluid culture and cytology are still pending upon discharge, gram stain negative for organisms. . DM- insulin regimen adjusted to NPH 9 qam and 9 qpm with a sliding scale as inpatient, after patient's acute illness fully resolves he may need to go back to his home regimen of NPH 7 qam and 7 qpm with a sliding scale. A1C was 5.7% in [**2130-5-26**]. . HYPERCOAGULABILTY: Patient hypercoagulable, despite coumadin he had spontaneous clots to his SMA and R lower extremity. For this the patient is on lovenox 60mg sc bid. . LOWER L FOOT ULCER: Pt seen by podiatry, they are not concerned for osteomyelitis at this time. Patient needs to follow up with his PCP for this issue. . CHRONIC PAIN: Continued outpatient pain regimen. Gabapentin 800mg QID, oxycodone 20mg [**Hospital1 **], hydrocodone-acetaminophen [**12-27**] tab Q4h. . Follow up: Pt has been instructed to follow up with the following physicians. -Dr. [**Last Name (STitle) **] PCP in the next two weeks. -Dr. [**Last Name (STitle) 2539**] from hematology to follow up your elevated white blood cell count. -Dr. [**Last Name (STitle) 4104**] from cardiology. Medications on Admission: Captopril 75mg TID Citalopram 60mg daily digoxin 250mcg daily folic acid 2mg daily fosamax 70mg weekly lasix 40-60mg daily Vicodin prn Lidocaine patch prn loperamide 6mg TID Lovenox 60 q12h NPH 14 daily ranitidine 150mg [**Hospital1 **] Toprol XL 12.5mg daily MVI B12 Citracel/Vit D oxycontin [**10-24**] daily neurontin 800mg QID vicodin prn Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 4. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Psyllium Packet Sig: Two (2) Packet PO TID (3 times a day) as needed. 8. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 9. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO QID (4 times a day). 10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO QAM (once a day (in the morning)). 12. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO QHS (once a day (at bedtime)). 13. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 16. Collagenase 250 unit/g Ointment Sig: One (1) Appl Topical DAILY (Daily). 17. Cholestyramine-Sucrose 4 gram Packet Sig: One (1) Packet PO BID (2 times a day). 18. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 19. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 11 days. 20. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: as directed units Subcutaneous twice a day: please inject 9 units subcutaneously in the a.m. and at nighttime. In addition use a sliding scale prior to meals. 21. Insulin Glargine 100 unit/mL Solution Sig: sliding scale Subcutaneous three times a day: check blood glucose (BG) prior to breakfast, lunch and dinner. sliding scale, if BG > 150 use 2 units of humalog (glargine), if > 200 use 4 units of humalog, if > 250 units use 6 units of humalog, if > 300 use 8 units of humalog, if > 350 call your doctor or go to the emergency room. 22. Enoxaparin 60 mg/0.6 mL Syringe Sig: as directed Subcutaneous Q12H (every 12 hours): 60mg sc bid . 23. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID (4 times a day) for 10 days. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary Diagnosis Clostridium Difficile Colitis Ventricular Tachycardia Secondary Diagnosis GERD DM II CHF Hypercoagulability BKA R leg Short Gut syndrome Polycythemia [**Doctor First Name **] Acute Renal Failure Discharge Condition: stable, afebrile, with out Ventricular Tachycardia. Discharge Instructions: Mr. [**Known lastname 21212**] you were admitted to the hospital because of weakness, low blood pressure and an abnormal heart rhythm known as ventricular tachycardia. In the emergency room you were given amiodarone and lidocaine medications designed to stop your ventricular tachycardia. In the emergency room you became unresponsive and you were shocked in order to convert your heart into a ventricularly paced rhythm. You were given several liters of fluid and started on medication to keep your blood pressure up. You were noted to have an elevated white blood cell count of 35, anion gap of 18 and a bicarb of 9. You were started initially on the antibiotics Vancomycin and Zosyn for 3 days. It was then noted that you were having large amounts of diarrhea, larger than what normally occurs with your short gut syndrome. Tests confirmed that you had an infection in your colon known as clostridium difficile. You were started on PO flagyl on [**11-27**]. You briefly received IV flagyl and oral vancomycin, then placed back on a PO flagyl regimen. You later developed more severe diarrhea. It was then recommended by the ID doctors that [**Name5 (PTitle) **] receive oral vancomycin to treat your diarrhea. You will need to continue to take this medication at home. During your hospital stay you developed a 15 hour run of ventricular tachycardia. The electrophysiology doctors [**First Name (Titles) 103659**] [**Name5 (PTitle) 103660**] up your pacemaker, tried shocking your heart, and tried giving you a medication called procainamide. None of these things kept you in a normal heart rhythm for very long. You were taken by the electrophysiology team for an ablation of the part of your heart causing the abnormal rhythm known as VT or Vtach. You have not had any runs of VT since your ablation. The EP team discussed whether or not you need a internal defibrillator. They feel that the ablation was successful and that you do not need an ICD placed as an impatient, but they would like for you to follow up as an outpatient. During your care you were also found to have a persistently elevated white blood cell count. You were evaluated by the hematology service who thought that your white blood cell elevation may have been secondary to infection or an abnormality in your specific type of white blood cell. You need to follow this issue up with Dr. [**Last Name (STitle) 2539**] from hematology. You were also noted to have a small ulcer on the largest toe of your L leg. Podiatry was consulted and felt that the infection was superficial and that the infection had not moved into the bone. They want you to follow up with vasular surgery as an outpatient. You were noted to have a large effusion on CXR. It was felt that you would benefit from having this fluid removed from your lungs. You had 1.5 liters removed from your lungs. The preliminary results showed no bacterial infection in your pleural fluid. The fluid was sent to look for any type of abnormal cells. Dr. [**Last Name (STitle) **] will have access to this information in the future and you can discuss the final results with him. During your stay you developed some impaired renal function this was likely due to your dehydration in the setting of your infection. Your renal function improved during your hospital stay. You developed an infection in your left eye. You should cover this eye with wet warm wash cloths 4-6 times per day and erythomycin ointment twice a day. Please take all of your medications as directed. Please keep all of your medical appointments. If you develop chest pain, weakness, shortness of breath, worsening diarrhea, fever, chills, palpitations, weakness or any other worsening of your condition please call your doctor and go to the emergency room immediately. Followup Instructions: Please call [**Telephone/Fax (1) 250**] and make a follow up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in the next two weeks. Please call and schedule an appointment with Dr. [**Last Name (STitle) 2539**] from hematology to follow up your elevated white blood cell count. The phone number to Dr.[**Name (NI) 44536**] office is [**Telephone/Fax (1) 49151**]. Please call and make a follow up appointment to see your cardiologist Dr.[**Last Name (STitle) 4104**] within 10 days of your discharge. The phone number to Dr.[**Name (NI) 103661**] office is ([**Telephone/Fax (1) 10085**]. He can help you set up plans for a defibrillator in the future. Please follow up with Dr. [**Last Name (STitle) 60679**] from electrophysiology his phone number is [**Telephone/Fax (1) 2934**]. You have an appointment with him Wed [**1-10**] at 1pm, on the [**Location (un) 436**] of the [**Hospital Ward Name 23**] building [**Hospital1 18**] [**Hospital Ward Name **]. Please follow up with vascular surgery, you already have an appointment to see them as an outpatient.

038,584,008,428,427,579,289,707,995,250,530,238,414,V533

{'Septicemia due to anaerobes,Acute kidney failure with lesion of tubular necrosis,Intestinal infection due to Clostridium difficile,Acute on chronic systolic heart failure,Paroxysmal ventricular tachycardia,Other and unspecified postsurgical nonabsorption,Primary hypercoagulable state,Ulcer of heel and midfoot,Sepsis,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Esophageal reflux,Polycythemia vera,Coronary atherosclerosis of native coronary artery,Fitting and adjustment of cardiac pacemaker'}

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: Weakness and fatigue x1 wk. PRESENT ILLNESS: 66yo man with hx of afib s/p pacer (no AICD), CAD. DMII, short gut syndrome who presents with fatigue and weakness since wednesday. He noted onset of fatigue and bilateral palmar paresthesias on Wednesday. This was not assoc with any fevers, chills, SOB, chest pain, or palpitations. His sx persisted daily and he had worsened exercise tolerance, reporting difficulty ambulating up three flights of stairs at home. Last night he felt much increasing weakness and fatigue. He awoke at 3am with these complaints. His wife tried taking his BP without any success. She reports that his pulse was "weak and flighty." MEDICAL HISTORY: - diabetes mellitus II; last A1c 5.7 - CAD: no CABG or stent placement. C cath report below. - Afib: originally treated with amio but then underwent AV node ablation and placement of pacer approx 5 yrs ago. - Hypercoagulable state: Seen in [**Hospital **] clinic. On lovenox, complicated by: --deep vein thrombophlebitis of the leg --ischemic gut "short gut syndrome" 15% left of normal gut --CVA [**2121**] --right BKA polycythemia [**Doctor First Name **] Debilitating neuropathic pain non-healing anal fissure, s/p surgery [**8-1**] MEDICATION ON ADMISSION: Captopril 75mg TID Citalopram 60mg daily digoxin 250mcg daily folic acid 2mg daily fosamax 70mg weekly lasix 40-60mg daily Vicodin prn Lidocaine patch prn loperamide 6mg TID Lovenox 60 q12h NPH 14 daily ranitidine 150mg [**Hospital1 **] Toprol XL 12.5mg daily MVI B12 Citracel/Vit D oxycontin [**10-24**] daily neurontin 800mg QID vicodin prn ALLERGIES: Levofloxacin / Cefazolin / Coreg PHYSICAL EXAM: VS: 95.8 HR 72 BP 99/64 RR 12 98% 4L CVP = 25 GEN: Fatigued, arousable to voice Neuro: Alert to person, place, situation, month, year - CN: perrla, face symmetric, tongue midline, shrug appropriate - Strength: [**4-29**] bilat upper. 5/5 strength left lower. left toe downgoing. - reflexes minimal throughout - [**Last Name (un) 36**] intact to light touch HEENT: slight increased facial swelling. PERRLA, EOMI, JVP 6cm. Right IJ in place Cards: RRR, no apprec murmurs. no rubs Lungs: slight crackles at bases. No wheezes, normal effort. Not tachypneic Abd: midline incision. BS+ NT ND. No rebound. No guarding Ext: right BKA. Left foot cool with nonpalp pulses. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. FAMILY HISTORY: Family history is negative for hypercoagulable state, PVD SOCIAL HISTORY: Mr. [**Known lastname 21212**] is a retired systems programmer for a management consulting firm. He is married with no children. He denies alcohol, tobacco or drug use. Prior 3 yrs of tobb abuse ### Response: {'Septicemia due to anaerobes,Acute kidney failure with lesion of tubular necrosis,Intestinal infection due to Clostridium difficile,Acute on chronic systolic heart failure,Paroxysmal ventricular tachycardia,Other and unspecified postsurgical nonabsorption,Primary hypercoagulable state,Ulcer of heel and midfoot,Sepsis,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Esophageal reflux,Polycythemia vera,Coronary atherosclerosis of native coronary artery,Fitting and adjustment of cardiac pacemaker'}

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is a 65-year-old woman recently admitted in [**2137-11-18**] after a fall at home and found to have an acute left subdural hematoma with an emergent evacuation. Her course was complicated by Pseudomonas sepsis, as well as E. coli sepsis. She was trach'd and pegged, and discharged to rehab on [**2137-12-27**]. MEDICAL HISTORY: MEDICATION ON ADMISSION: ALLERGIES: PHYSICAL EXAM: Her temp was 97, BP 162/75, respiratory rate 24, heart rate 61, sats 94% on room air. In general, the patient was lying in bed and in no acute distress. She had trach and PEG in place. HEENT: Pupils equal, round and reactive to light. LUNGS: Clear to auscultation. CARDIOVASCULAR: Regular rate and rhythm. ABDOMEN: Soft, nontender, PEG tube in place. EXTREMITIES: No clubbing, cyanosis or edema. NEURO: Awake, alert, oriented to hospital, nods yes appropriately with questions, no spontaneous speech, sticks out tongue to command, has a right exotropia. EOMS are full. Tongue midline. Face appears symmetric. She has no pronator drift on the left. Her right upper extremity is flaccid. She withdraws to pain briskly in her lower extremities. Her right foot is externally rotated. Deep tendon reflexes are 2+ throughout. FAMILY HISTORY: SOCIAL HISTORY:

Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Other convulsions,Chronic hepatitis C without mention of hepatic coma,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Late effects of cerebrovascular disease, hemiplegia affecting dominant side,Unspecified essential hypertension,Accidental fall from wheelchair,Tracheostomy status,Depressive disorder, not elsewhere classified

Subdural hem w/o coma,Convulsions NEC,Chrnc hpt C wo hpat coma,DMII wo cmp nt st uncntr,Late ef-hemplga dom side,Hypertension NOS,Fall from wheelchair,Tracheostomy status,Depressive disorder NEC

Admission Date: [**2138-1-31**] Discharge Date: [**2138-2-4**] Date of Birth: [**2072-2-1**] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old woman recently admitted in [**2137-11-18**] after a fall at home and found to have an acute left subdural hematoma with an emergent evacuation. Her course was complicated by Pseudomonas sepsis, as well as E. coli sepsis. She was trach'd and pegged, and discharged to rehab on [**2137-12-27**]. She had a witnessed fall from a wheelchair in the nursing home, hitting her forehead with a small amount of blood from her trach site, hematoma on the forehead, was alert throughout. She was sent to [**Hospital1 **] ER for a head CT which showed an old left subdural hematoma in the frontal region with small subdural more near the midline in the frontal area which was new. The patient was admitted to the ICU for observation. PHYSICAL EXAM: Her temp was 97, BP 162/75, respiratory rate 24, heart rate 61, sats 94% on room air. In general, the patient was lying in bed and in no acute distress. She had trach and PEG in place. HEENT: Pupils equal, round and reactive to light. LUNGS: Clear to auscultation. CARDIOVASCULAR: Regular rate and rhythm. ABDOMEN: Soft, nontender, PEG tube in place. EXTREMITIES: No clubbing, cyanosis or edema. NEURO: Awake, alert, oriented to hospital, nods yes appropriately with questions, no spontaneous speech, sticks out tongue to command, has a right exotropia. EOMS are full. Tongue midline. Face appears symmetric. She has no pronator drift on the left. Her right upper extremity is flaccid. She withdraws to pain briskly in her lower extremities. Her right foot is externally rotated. Deep tendon reflexes are 2+ throughout. HOSPITAL COURSE: She was admitted for close observation. She had a repeat head CT which showed no further bleeding or extension of subdural hematoma, and she was transferred to the regular floor on [**2138-2-1**]. She remains neurologically stable with stable vital signs, neurologically nodding to questions. Her gaze is conjugate. She has right hemiparesis. Withdraws her lower extremities. She is stable and ready for transfer back to rehab. DISCHARGE MEDICATIONS: 1. Insulin per sliding scale and fixed dose. 2. Dilantin Infatab 50 mg po bid. 3. Lansoprazole 30 mg NG qd. 4. Hydralazine 50 mg po q 6 h--hold for SBP less than 100. 5. Metoprolol 75 mg po tid--hold for SBP less than 100. 6. Tylenol 650 po q 4 h prn. CONDITION AT DISCHARGE: Stable. FOLLOW-UP: She will follow-up with Dr. [**Last Name (STitle) 739**] in 1 month with a repeat head CT. [**Doctor First Name 742**] [**Doctor Last Name **], 14.AAA Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2138-2-3**] 09:41 T: [**2138-2-3**] 09:58 JOB#: [**Job Number 11500**]

852,780,070,250,438,401,E884,V440,311

{'Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Other convulsions,Chronic hepatitis C without mention of hepatic coma,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Late effects of cerebrovascular disease, hemiplegia affecting dominant side,Unspecified essential hypertension,Accidental fall from wheelchair,Tracheostomy status,Depressive disorder, not elsewhere classified'}

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 65-year-old woman recently admitted in [**2137-11-18**] after a fall at home and found to have an acute left subdural hematoma with an emergent evacuation. Her course was complicated by Pseudomonas sepsis, as well as E. coli sepsis. She was trach'd and pegged, and discharged to rehab on [**2137-12-27**]. MEDICAL HISTORY: MEDICATION ON ADMISSION: ALLERGIES: PHYSICAL EXAM: Her temp was 97, BP 162/75, respiratory rate 24, heart rate 61, sats 94% on room air. In general, the patient was lying in bed and in no acute distress. She had trach and PEG in place. HEENT: Pupils equal, round and reactive to light. LUNGS: Clear to auscultation. CARDIOVASCULAR: Regular rate and rhythm. ABDOMEN: Soft, nontender, PEG tube in place. EXTREMITIES: No clubbing, cyanosis or edema. NEURO: Awake, alert, oriented to hospital, nods yes appropriately with questions, no spontaneous speech, sticks out tongue to command, has a right exotropia. EOMS are full. Tongue midline. Face appears symmetric. She has no pronator drift on the left. Her right upper extremity is flaccid. She withdraws to pain briskly in her lower extremities. Her right foot is externally rotated. Deep tendon reflexes are 2+ throughout. FAMILY HISTORY: SOCIAL HISTORY: ### Response: {'Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Other convulsions,Chronic hepatitis C without mention of hepatic coma,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Late effects of cerebrovascular disease, hemiplegia affecting dominant side,Unspecified essential hypertension,Accidental fall from wheelchair,Tracheostomy status,Depressive disorder, not elsewhere classified'}

CHIEF COMPLAINT: Transfer from outside hospital for subarchnoid hemorrhage. PRESENT ILLNESS: 88 yo female found down unwitnessed fall where she hit her head [**Female First Name (un) **] chair, was lying in blood with L temporal laceration on scalp, unknown duration. Patient was brought in to outside hospital where her GCS was reportedly 15. She had a CT done at the outside hospital which showed a small amount of subarachnoid blood b/l in sulci. She was up and talking with ED and having her scalp laceration sutured when her speech suddenly became dysarthric and she became more disoriented. She then became unresponsive and was intubated for airway protection. She was transferred to [**Hospital1 **] for additional care. MEDICAL HISTORY: Hypertension Hyperlipidemia Macular Degeneration diabetes Glaucoma Cataracts dementia (mild?) MEDICATION ON ADMISSION: Amlodipine Lisinopril Zocor Neurontin Actos Timolol (likely eye drops) Prednisolone Vit D ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Vitals: BP 130/47 P 94 R 16 O2 100% (on vent 450/20/5/50%) FAMILY HISTORY: Mother with strokes and an MI. Father with an MI. Brothers with heart disease. SOCIAL HISTORY: Lives with son in semi-independent state. Cooks and does laundry and makes her bad. Can dress herself. She gets around with a walker. With regards to habits- light cigarette smoking 30 years ago but nothing recent, no ETOH use, no illict drug use.

Subarachnoid hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Encephalopathy, unspecified,Pulmonary collapse,Ventilator associated pneumonia,Accidental fall from chair,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Macular degeneration (senile), unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified glaucoma,Unspecified hereditary and idiopathic peripheral neuropathy,Anemia, unspecified,Chronic maxillary sinusitis

Subarachnoid hem-no coma,Encephalopathy NOS,Pulmonary collapse,Ventltr assoc pneumonia,Fall from chair,Hypertension NOS,Hyperlipidemia NEC/NOS,Macular degeneration NOS,DMII wo cmp nt st uncntr,Glaucoma NOS,Idio periph neurpthy NOS,Anemia NOS,Chr maxillary sinusitis

Admission Date: [**2133-11-7**] Discharge Date: [**2133-11-13**] Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 1838**] Chief Complaint: Transfer from outside hospital for subarchnoid hemorrhage. Major Surgical or Invasive Procedure: intubation History of Present Illness: 88 yo female found down unwitnessed fall where she hit her head [**Female First Name (un) **] chair, was lying in blood with L temporal laceration on scalp, unknown duration. Patient was brought in to outside hospital where her GCS was reportedly 15. She had a CT done at the outside hospital which showed a small amount of subarachnoid blood b/l in sulci. She was up and talking with ED and having her scalp laceration sutured when her speech suddenly became dysarthric and she became more disoriented. She then became unresponsive and was intubated for airway protection. She was transferred to [**Hospital1 **] for additional care. Past Medical History: Hypertension Hyperlipidemia Macular Degeneration diabetes Glaucoma Cataracts dementia (mild?) Social History: Lives with son in semi-independent state. Cooks and does laundry and makes her bad. Can dress herself. She gets around with a walker. With regards to habits- light cigarette smoking 30 years ago but nothing recent, no ETOH use, no illict drug use. Family History: Mother with strokes and an MI. Father with an MI. Brothers with heart disease. Physical Exam: Vitals: BP 130/47 P 94 R 16 O2 100% (on vent 450/20/5/50%) general: intubated, sedated, no response to voice initially but seemd to be able to slightly open eyes when asked to at end of exam. no spontaneous eye opening. chest: lcta b/l CVS: RRR, S1S2, no murmurs abd: soft, NT/ND, +BS ext: no LE edema Neuro: mental status: intubated, no eye opening cranial nerves: PERRL (2-->1 b/l), no response to confrontation, unable to elicit Doll's eyes but this was made difficult with the C-collar. Corneal reflex intact. Face appears symmeric. motor: spontaneously moving all 4 extremities equally, normal tone. reflexes: UE reflexes 2+ b/l. Unable to elicit patellar or ankle jerks. Babinski- downgoing on L, mute on R. DISCHARGE NEUROLOGIC EXAM: Mental status- alert and oriented to hospital, "[**2033**]" and knows president. Speech intact. CN- mild R nasolabial fold flattening likely baseline Motor exam full strength throughout Sensation decreased at distal lower extremities c/w peripheral neuropathy Gait unsteady with retropulsion Pertinent Results: [**2133-11-6**] 11:10PM BLOOD WBC-14.8* RBC-3.67* Hgb-11.0* Hct-32.7* MCV-89 MCH-29.9 MCHC-33.5 RDW-14.2 Plt Ct-194 [**2133-11-12**] 04:20AM BLOOD WBC-4.9 RBC-3.54* Hgb-10.5* Hct-31.2* MCV-88 MCH-29.6 MCHC-33.5 RDW-15.2 Plt Ct-152 [**2133-11-6**] 11:10PM BLOOD Neuts-89.8* Lymphs-7.2* Monos-2.7 Eos-0.2 Baso-0.1 [**2133-11-6**] 11:10PM BLOOD PT-12.7 PTT-22.4 INR(PT)-1.1 [**2133-11-6**] 11:10PM BLOOD Glucose-195* UreaN-20 Creat-0.7 Na-143 K-3.5 Cl-107 HCO3-20* AnGap-20 [**2133-11-12**] 04:20AM BLOOD Glucose-95 UreaN-8 Creat-0.6 Na-146* K-3.5 Cl-112* HCO3-25 AnGap-13 [**2133-11-6**] 11:10PM BLOOD Calcium-8.5 Phos-3.5 Mg-1.9 [**2133-11-10**] 03:15AM BLOOD %HbA1c-6.1* eAG-128* [**2133-11-10**] 03:15AM BLOOD HDL-46 CHOL/HD-2.7 [**2133-11-8**] 01:36AM BLOOD Phenyto-26.5* [**2133-11-8**] 10:57AM BLOOD Phenyto-29.0* [**2133-11-8**] 05:50PM BLOOD Phenyto-26.4* [**2133-11-9**] 02:51AM BLOOD Phenyto-26.0* [**2133-11-10**] 03:15AM BLOOD Phenyto-20.2* [**2133-11-11**] 04:30AM BLOOD Phenyto-13.3 [**2133-11-7**] 09:46AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2133-11-7**] 10:11AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]->1.050* [**2133-11-7**] 10:11AM URINE Blood-MOD Nitrite-NEG Protein-TR Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [**2133-11-7**] 12:53PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG IMAGING: CT HEAD 1. Stable bifrontal subarachnoid hemorrhage. No new hemorrhage. No new acute findings. 2. Chronic atrophy and small vessel disease. 3. Extensive sinus opacification on the left as described. Single locule of air in the left frontal soft tissues, correlate with site of injury. CTA HEAD Mild subarachnoid hemorrhage, unchanged from previous CT. CTA demonstrates no evidence of vascular occlusion, stenosis or an aneurysm greater than 3 mm in size. Changes of chronic sinusitis, left maxillary sinus. CT C-SPINE 1. No acute traumatic cervical spine fracture or displacement. 2. Multilevel cervical degenerative disease as described. If there is concern for ligamentous or soft tissue injury, MRI is more sensitive. ECHO Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Increased PCWP. Mild aortic regurgitation. No structural cardiac cause of syncope identified. EEG- PRELIM READ slowing c/w encephalopathy, L>R slowing c/w SAH. Brief Hospital Course: 88 yo RHW presents after fall, head trauma, with subarachoid hemorrhage. NEURO: Patient initially presented to OSH where SAH was discovered on imaging. Patient was then loaded with Dilatin for seizure prophylaxis, and received Ativan. She was reportedly talking and alert before this, but after medications became somnolent and was intubated for airway protection. She was then transferred to [**Hospital1 18**]. She was loaded with Dilantin again. Head CT here confirmed small bifrontal SAH. Given there was not substantial head trauma with fall, she had a CTA to rule out underlying aneurysm to explain the SAH. This was negative. Patient was monitored closely with repeat head CTs which showed stable SAH. EEG showed L>R slowing but no e/o seizures or focal spikes. Dilantin level was initially high above 30, and it was monitored daily until it trended down below the normal range. Patients mental status improved correlating with the decrease in her Dilantin level, and she was extubated. Patient was transferred to the neurology floor, where she remained stable. Mental status at discharge fluctuated between different times of day. For example, if she did not sleep, the following morning she was lethargic and kept repeating herself, with no following commands. However, when awake, she was oriented and appropriate. Patient does not require AEDs given small amount of subarachnoid blood and 2 EEGs which did not show focal spikes or epileptiform changes. Patient will follow up in stroke clinic. She should resume taking ASA 81 mg in 9 days (2 weeks from admission). ID: Patient had fever while intubated. CXR showed bibasilar atelectasis, cannot rule out PNA, so treated for VAP with vanco and zosyn. She then remained afebrile. Upon floor transfer, she had no respiratory symptoms and CXR was not convincing for PNA, so vanco/zosyn were D/Ced. She did have extensive sinusitis on head CT, likely due to intubation and NGT placement, so was continued on Augmentin to complete a total 10 day course of antibiotics (additional 5 days post-discharge). CV: No events on telemetry, TTE showed 1+ MR [**First Name (Titles) **] [**Last Name (Titles) **] LV filling pressures. There was no etiology for syncope identified. RENAL: Cr stable, no issues. GI: Seen by speech/swallow, cleared for soft solids, thin liquids and meds crushed whole in thin liquids. No e/o aspiration. DIABETES: Patient continued on oral hypoglycemics and HISS. Patient was discharged to rehab. Medications on Admission: Amlodipine Lisinopril Zocor Neurontin Actos Timolol (likely eye drops) Prednisolone Vit D Discharge Medications: 1. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime) as needed for pain. 5. Pioglitazone 15 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 5 days. 7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 10. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 11. Prednisolone Acetate 0.12 % Drops, Suspension Sig: One (1) Drop Ophthalmic QOD (). Discharge Disposition: Extended Care Facility: [**Hospital6 **] Hospital at [**Location (un) 4047**] Discharge Diagnosis: subarachnoid hemorrhage Discharge Condition: Neuro status: nonfocal exam, peripheral neuropathy Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Mental Status: Confused - sometimes. Discharge Instructions: You were admitted after falling and hitting your head. You had a small amount of bleeding around your brain, for which you recevied antiseizure medication. You did not have any seizures. You should wait 9 days before taking any aspirin. Followup Instructions: You should follow up with Dr. [**First Name (STitle) **] in the stroke clinic. Call [**Telephone/Fax (1) 1694**] for an appointment.

852,348,518,997,E884,401,272,362,250,365,356,285,473

{'Subarachnoid hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Encephalopathy, unspecified,Pulmonary collapse,Ventilator associated pneumonia,Accidental fall from chair,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Macular degeneration (senile), unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified glaucoma,Unspecified hereditary and idiopathic peripheral neuropathy,Anemia, unspecified,Chronic maxillary sinusitis'}

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: Transfer from outside hospital for subarchnoid hemorrhage. PRESENT ILLNESS: 88 yo female found down unwitnessed fall where she hit her head [**Female First Name (un) **] chair, was lying in blood with L temporal laceration on scalp, unknown duration. Patient was brought in to outside hospital where her GCS was reportedly 15. She had a CT done at the outside hospital which showed a small amount of subarachnoid blood b/l in sulci. She was up and talking with ED and having her scalp laceration sutured when her speech suddenly became dysarthric and she became more disoriented. She then became unresponsive and was intubated for airway protection. She was transferred to [**Hospital1 **] for additional care. MEDICAL HISTORY: Hypertension Hyperlipidemia Macular Degeneration diabetes Glaucoma Cataracts dementia (mild?) MEDICATION ON ADMISSION: Amlodipine Lisinopril Zocor Neurontin Actos Timolol (likely eye drops) Prednisolone Vit D ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Vitals: BP 130/47 P 94 R 16 O2 100% (on vent 450/20/5/50%) FAMILY HISTORY: Mother with strokes and an MI. Father with an MI. Brothers with heart disease. SOCIAL HISTORY: Lives with son in semi-independent state. Cooks and does laundry and makes her bad. Can dress herself. She gets around with a walker. With regards to habits- light cigarette smoking 30 years ago but nothing recent, no ETOH use, no illict drug use. ### Response: {'Subarachnoid hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Encephalopathy, unspecified,Pulmonary collapse,Ventilator associated pneumonia,Accidental fall from chair,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Macular degeneration (senile), unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified glaucoma,Unspecified hereditary and idiopathic peripheral neuropathy,Anemia, unspecified,Chronic maxillary sinusitis'}

CHIEF COMPLAINT: Elective Ultrafiltration PRESENT ILLNESS: Pt is a 84 year old Russian speaking male with hx CAD s/p CABG '[**37**] and re-do '[**51**] (LIMA --> LAD; SVG -->OM1; SVG -->PDA), ischemic DCM with EF 25%, severe MR [**First Name (Titles) **] [**Last Name (Titles) **], and chronic AF now s/p atrio-ventricular junctional ablation with BiV-pacemaker who now presents for elective admission for ultrafiltration for volume overload secondary to CHF. The pt has a history of recalcitrant NYHA stage 4 CHF with numerous protracted previous hospital courses requiring lasix drips, nesiritide and intubations. He currently has [**1-27**] pillow orthopnea, denies CP or anginal equivalents, and notes indolent bilateral lower extremity swelling. MEDICAL HISTORY: 1. CAD status post CABG in [**2137**]. 2. Status post MI x2. 3. CHF, dilated ischemic cardiomyopathy with systolic/diastolic heart failure, EF 30 percent, 1 plus AR, 2 plus TR, 2 plus MR in [**10-28**]. 4. Paroxysmal atrial fibrillation. 5. Low back pain status post laminectomy/fusion. 6. Peripheral neuropathy. 7. Chronic renal insufficiency. 8. Benign prostatic hypertrophy. 9. Dementia 10. DM 11. Depression MEDICATION ON ADMISSION: tamsulosin 0.4mg po daily donepazil 10mg po dialy coumadin 5mg po daily finestaride 5mg po dialy toprol XL 25 mg po daily tiagabine 12mg po nightly oxycodone sustained release 10 mg po BID lipitor 20 mg po dialy asprin 81 mg daily lisinopril 5mg po dialy toresmide 80 mg po dialy ALLERGIES: Neurontin / Topamax / Aldactone / Dicloxacillin / Amiodarone PHYSICAL EXAM: 97.3 82 96/52 18 98% RA FAMILY HISTORY: non-contributory SOCIAL HISTORY: Patient lives with wife. [**Name (NI) **] and daughter are very involved in medical care. Denies tobacco or EtOHuse.

Congestive heart failure, unspecified,Methicillin susceptible Staphylococcus aureus septicemia,Pyogenic arthritis, forearm,Other primary cardiomyopathies,Urinary tract infection, site not specified,Acute kidney failure, unspecified,Atrial fibrillation,Hyperosmolality and/or hypernatremia,Mechanical complication of other vascular device, implant, and graft,Infection with microorganisms resistant to penicillins,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Herpes simplex without mention of complication,Fitting and adjustment of cardiac pacemaker,Other iatrogenic hypotension,Constipation, unspecified,Other tenosynovitis of hand and wrist,Venous (peripheral) insufficiency, unspecified

CHF NOS,Meth susc Staph aur sept,Pyogen arthritis-forearm,Prim cardiomyopathy NEC,Urin tract infection NOS,Acute kidney failure NOS,Atrial fibrillation,Hyperosmolality,Malfunc vasc device/graf,Inf mcrg rstn pncllins,Pseudomonas infect NOS,Herpes simplex NOS,Ftng cardiac pacemaker,Iatrogenc hypotnsion NEC,Constipation NOS,Tenosynov hand/wrist NEC,Venous insufficiency NOS

Admission Date: [**2161-10-12**] Discharge Date: [**2161-10-30**] Service: [**Hospital Unit Name 196**] Allergies: Neurontin / Topamax / Aldactone / Dicloxacillin / Amiodarone Attending:[**First Name3 (LF) 9554**] Chief Complaint: Elective Ultrafiltration Major Surgical or Invasive Procedure: Ultrafiltration by CHF solutions History of Present Illness: Pt is a 84 year old Russian speaking male with hx CAD s/p CABG '[**37**] and re-do '[**51**] (LIMA --> LAD; SVG -->OM1; SVG -->PDA), ischemic DCM with EF 25%, severe MR [**First Name (Titles) **] [**Last Name (Titles) **], and chronic AF now s/p atrio-ventricular junctional ablation with BiV-pacemaker who now presents for elective admission for ultrafiltration for volume overload secondary to CHF. The pt has a history of recalcitrant NYHA stage 4 CHF with numerous protracted previous hospital courses requiring lasix drips, nesiritide and intubations. He currently has [**1-27**] pillow orthopnea, denies CP or anginal equivalents, and notes indolent bilateral lower extremity swelling. Past Medical History: 1. CAD status post CABG in [**2137**]. 2. Status post MI x2. 3. CHF, dilated ischemic cardiomyopathy with systolic/diastolic heart failure, EF 30 percent, 1 plus AR, 2 plus TR, 2 plus MR in [**10-28**]. 4. Paroxysmal atrial fibrillation. 5. Low back pain status post laminectomy/fusion. 6. Peripheral neuropathy. 7. Chronic renal insufficiency. 8. Benign prostatic hypertrophy. 9. Dementia 10. DM 11. Depression Social History: Patient lives with wife. [**Name (NI) **] and daughter are very involved in medical care. Denies tobacco or EtOHuse. Family History: non-contributory Physical Exam: 97.3 82 96/52 18 98% RA Gen: NAD, good spirits, alert gentleman Heent: EOMI, PEERL, MMM Neck: 7-9 cm JVP, brisk carotid upstrokes, Heart: regular rate, increased S2, 1/6 SEM Lungs: clear, no wheezes or rales Abd: soft, nt/nd. NABS Ext: 1+ bilateral lower extremity edema with overlying erythematous, warm skin Neuro: non-focal, difficult to assess [**1-26**] language barrier Pertinent Results: [**2161-10-12**] 03:57PM WBC-6.3 RBC-3.45* HGB-8.8* HCT-28.1* MCV-81* MCH-25.6* MCHC-31.5 RDW-20.5* [**2161-10-12**] 03:57PM NEUTS-76.6* LYMPHS-12.5* MONOS-8.1 EOS-2.5 BASOS-0.3 [**2161-10-12**] 03:57PM PLT COUNT-194 [**2161-10-12**] 03:57PM PT-16.1* PTT-32.2 INR(PT)-1.6 . [**2161-10-12**] 03:57PM GLUCOSE-114* UREA N-56* CREAT-2.9* SODIUM-134 POTASSIUM-5.4* CHLORIDE-97 TOTAL CO2-24 ANION GAP-18 [**2161-10-12**] 03:57PM TOT PROT-6.9 ALBUMIN-3.2* GLOBULIN-3.7 CALCIUM-8.4 PHOSPHATE-4.9*# MAGNESIUM-2.6 . [**2161-10-12**] 03:58PM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.011 [**2161-10-12**] 03:58PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [**2161-10-12**] 03:58PM URINE RBC-[**11-14**]* WBC->50 BACTERIA-MANY YEAST-NONE EPI-0 [**2161-10-12**] 03:58PM URINE OSMOLAL-360 [**2161-10-12**] 03:58PM URINE HOURS-RANDOM UREA N-629 CREAT-59 SODIUM-LESS THAN . [**2161-10-18**] 04:18AM BLOOD ESR-55* [**2161-10-18**] 04:18AM BLOOD CRP-27.76* [**2161-10-13**] 04:00AM BLOOD Hapto-69 . [**10-12**] CXR: The heart is enlarged consistent with cardiomegaly. There is a left chest wall biventricular pacemaker with the leads in good position on this single projection. There is interval placement of a right IJ central line with the tip in the right atrium. If the position desired is the SVC, recommend pulling back approximately 4 cm. There is no evidence of pneumothorax. There is perihilar haziness and bilateral small pleural effusions, findings consistent with CHF. The patient is status post median sternotomy and CABG. The aorta is tortuous. . IMPRESSION: 1. Interval placement of right IJ central line with the tip in the right atrium. 2. Findings consistent with congestive heart failure and pulmonary edema. 3. Bilateral pleural effusions. . [**2161-10-17**]: CT Abdomen/pelvis: IMPRESSION: 1. Moderate bilateral pleural effusions. 2. No bowel wall thickening or abscess is detected. 3. Colon diffusely distended with air and stool. 4. Cholelithiasis. . [**2161-10-17**]: portable abominal x-ray FINDINGS: There is gaseous distention of the entire colon. There is gas and feces visualized in the right and the left colon and the rectum. There are no evidence of mechanical obstruction of the small or large bowel. On the upright film there is no evidence of free intraperitoneal air. . IMPRESSION: Gaseous distention of the colon. No evidence of bowel obstruction. No evidence of free air. . [**2161-10-19**]: left upper extremity ultrasound UNILATERAL UPPER EXTREMITY VENOUS ULTRASOUND, LEFT: Both [**Doctor Last Name 352**] scale and color Doppler ultrasound was used for this evaluation. There is normal compressibility of the left cephalic, basilic, paired brachial, axillary, and jugular veins. There is normal respiratory variation in the left jugular, subclavian, axillary, paired brachial, basilic, and cephalic veins. No intraluminal filling defect identified. No deep venous thrombosis. . IMPRESSION: No deep venous thrombosis. . [**2161-10-19**] TTE: GENERAL COMMENTS: Suboptimal image quality - poor echo windows. . Conclusions: 1. The left atrium is dilated. 2. The left ventricular cavity is mildly dilated. There is severe global left ventricular hypokinesis. Overall left ventricular systolic function is severely depressed. 3. The aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic regurgitation is seen. 4. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. 5. Moderate to severe [3+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. 6. No evidence of endocarditis seen.. 7. Compared with the findings of the prior report (tape unavailable for review) of [**2161-9-17**], the mitral regurgitation is less. . [**10-21**] chest ultrasound: REASON FOR THIS EXAMINATION: ? abscess/infected pacer pocket INDICATION: Pacer, septic. Limited ultrasound of the chest wall was performed around the pacer demonstrating no fluid collections. No evidence of abscess. . [**10-24**] Left wrist x-ray There is mild diffuse osteopenia. There is severe narrowing of the radiocarpal joint with essentially complete loss of the joint space. There is a large relatively well circumscribed (15 mm) lucency in the subchondral portion of the distal radius, abutting the distal radioulnar joint. There is moderate degenerative narrowing of the first CMC joint. There is also slight narrowing of the triscaphe joint. There is ill-definition of the distal corner of the scaphoid radially -- ? subtle erosion. Incidental note is made of an ossicle adjacent to the ulnar styloid. There is diffuse soft tissue edema with faint vascular calcification. . IMPRESSION: 1. Soft tissue edema about the wrist. 2. Marked degenerative narrowing of the radiocarpal joint and to a lesser extent the first CMC joint. 3. Subchondral lucency in the distal radius medially. Because it is relatively well circumscribed, this most likely represents a large degenerative subchondral cyst (geode). 4. Faint chondrocalcinosis over triangular fibrocartilage. This can be seen in CPPD, hyperparathyroidism, or hemochromatosis. 5. Ill-definition of the scaphoid -- this is not well seen on the oblique view and may be an artifact due to a small spur. 6. Otherwise, no findings specific for osteomyelitis. . [**2161-10-25**] CXR: Since the previous radiograph, the patient has been intubated with endotracheal tube terminating at the thoracic inlet level. A right subclavian vascular catheter has been placed and has an unusual midline location with respect to the mediastinum. A nasogastric tube courses below the diaphragm. No pneumothorax is identified. The cardiac silhouette is enlarged. Pulmonary vascularity is within normal limits for supine technique. No definite areas of consolidation are observed in either lung. There is subcutaneous emphysema in the right chest wall. . IMPRESSION: 1) Unusual midline position of central venous catheter. This appears much more medial than anticipated for the superior vena cava, and an arterial location should be considered. This finding has been communicated with the clinical service caring for the patient on the morning of [**2161-10-26**] when the radiograph was available for interpretation. 2) Nasogastric tube in satisfactory position. . Left wrist, tenosynovium: ([**2161-10-25**]; pathology specimen) Granulation tissue with acute and chronic inflammation and fibrinopurulent exudate. . [**2161-10-26**] CXR: FINDINGS: There has been interval removal of the right sided subclavian catheter. No evidence of mediastinal hematoma, and hematoma at catheter placement site cannot be assessed by chest x-ray. The tip of of the endotracheal tube remains 5 cm above the carina. Enteric tube remains present. Pace maker and leads remain unchanged. Sternotomy sutures are intact. The extreme left costophrenic angle has been coned from this study. Cardiac and mediastinal silhouettes remain stable. No evidence of mediastinal hematoma. No evidence of pneumothorax or pneumonia. Note is made of a slight haziness of the right lower lung fields, which has been seen on prior examinations. It is unclear whether this represents a small pleural effusion or minimal atelectasis. . IMPRESSION: Interval removal of right subclavian catheter. No other significant change. . [**2161-10-26**] TEE: IMPRESSION: Mildly thickened mitral, aortic and tricuspid valves but without discrete vegetation. Mild aortic regurgitation. Moderate mitral regurgitation. Moderate tricuspid regurgitation. No vegetations identified. . Brief Hospital Course: 1. Dilated Cardiomyopathy: Pt was admitted for elective ultrafiltration with CHF solutions with the goal of rapid removal of volume and restoration of euvolemia. He was obviously volume overloaded on admission, and his MAP's were in the low 70's. Mr.[**Known lastname 11300**] was maintained on his [**Hospital 3782**] medical regimen, minus the beta-blocker and ace-inhibitor for the chance of hypotension during ultrafiltration. He was placed on a heparin drip to prevent clotting of the ultrafiltration machine. He diuresed 12L using ultrafiltration. During ultrafiltration, his pressures transiently dropped and he did require low-levels of dopamine (3-5mic/kg/min) for this problem. Interestingly, the pt's creatinine decreased from admission level of 2.7 down to 1.8 on [**2161-10-16**] (likely from increased renal perfusion from improvement of his Frank-Starling equilibrium and better forward flow). After discontinuation of ultrafiltration, diuresis was continued with IV lasix. Low dose ACE and beta-blocker were re-started. While pt was septic with MRSA bacteremia, ACE, beta-blocker were held. Lasix transiently discontinued but for the most part continued for further diuresis, as pt was volume overloaded. Pt continued to diurese well. His creatinine decreased steadily down to normal and stabilized around 1.2. on [**10-24**], pt was found to be hypernatremic with sodium of 150. Pt was found to have a free water deficit of 4.5 liters. He was started on D5W and continued on this for a few days with resolution of hypernatremia. D5W was discontinued. At this point, pt appeared to be intravascularly depleted, but with total body volume overload. Pt was restarted on diuresis to help mobilize fluid. It was noted at pt's albumin was 1.9. . 2. CAD: From a CAD standpoint, pt remained stable. He was chest pain free and had no ischemic changes on EKG throughout this hospitalization. Pt was maintained on asprin, and a statin. His BB and ACE-inhibitor was held during ultrafiltration and briefly re-started after the discontinuation of ultrafiltration. Beta-blocker and ACE were held while patient was septic with MRSA bacteremia. Statin was held when pt was started on Daptomycin for treatment of MRSA bacteremia. Low-dose ACE and beta-blocker were restarted after pt recovered from sepsis. Pt was discharged on Lisinopril 5mg and Toprol XL 12.5mg qd. These medications should be titrated up to his home dosages of Lisinopril 5mg and Toprol XL 25mg qd. In addition, Lipitor 20mg qd should be restarted after he completes his course of Daptomycin on [**10-31**]. . 3. Rhythm: Pt does have chronic AF, but he is s/p AV junction ablation and BiV pacemaker placement [**8-29**] (last hospitalization). His pacemaker was working correctly and mainly revealed a paced rhythms at 80bpm with a non-specific intraventricular delay pattern on surface EKG. His coumadin was held during this hospitalization and he was maintained on heparin. Anticoagulation was discontinued on [**10-17**] after an extensive discussion with the family who stated that they felt that the pt was at great risk of falls (per family, pt has several recent falls at home) and they did not wish for him to be anticoagulated. They were explained the increased risk of stroke off anticoagulation. EP interrogated the pt's pacer and found that the pt had an underlying AV nodal rhythm. The pacer was stopped. Pt had an underlying rhythm which was at a rate of 90-110 in atrial fibrillation. They recommended removal of the pacer since the pt didn't appear to need it. After extensive discussion between the EP and ID services, it was decided not to remove the pacemaker, since it appeared that the source of persistent infection was the septic left wrist joint. Prior to discharge, the pacer was restarted. . 4. Infection: During the beginning of the hospital course, pt had an enterococcal UTI which was treated with Levoquin. Pt was also noted to have bilateral warm, erythematous, painful lower extremities worrisome for cellulitis complicating chronic venous insufficiency. He was treated for this with clindamycin from [**Date range (1) 11301**] and these symptoms subsequently resolved. On [**2161-10-17**] (24 hours after central line removal), pt spiked a temperature of 101.4. He was pancultured. CXR was negative for pneumonia. Pt complained of abdominal pain and an abdominal CT was obtained to look for an acute abdominal process. CT Abd/pelvis was negative and only found dilated loops of large bowel with lots of stool, but no obstruction or air-fluid levels. On [**2161-10-18**], pt had [**3-29**] positive blood cultures for gram positive cocci. He was started on empiric antibiotics of vancomycin, levo, flagyl. At the time, pt had several possible sources of infection including recent central line, UTI, sacral ulcer, GI tract, endocarditis, pacemaker infection, hardware for spinal fusion. The central line was most likely the portal of entry of the bacteria. Pt was provided supportive care and daily blood cultures were drawn. From [**Date range (1) 4359**], the pt grew out 13/14 positive blood cultures, all with coag positive staph aureus, which was found to be high grade MRSA bacteremia. On [**10-18**], pt's left upper extremity was noted to be swollen; this was thought to be secondary to IV infiltration. An ultrasound of the Left upper extremity was found to be negative for DVT. Infectious disease was [**Month/Year (2) 4221**] on [**10-19**] who agreed with vanco and stated that vanco levels needed to be dosed daily using vanco trough levels, with goal trough level of 15-20. A TEE on [**10-19**] showed no evidence of endocarditis. On [**10-20**], pt was found unresponsive and rigoring; BP 89/50 and ABG 7.48, pCO2 28, pO2 190. Antihypertensives and diurestics were held during this time. On [**2161-10-20**], pt was started on Daptomycin; daily CK levels were checked and statin was discontinued. On [**2161-10-21**], ultrasound of the pacer pocket was negative for abscess or infection. EP interrogated the pt's pacer and found that the pt had an underlying AV nodal rhythm. They recommended removal of the pacer since the pt didn't appear to need it. Pt appeared to be improving clinically and remained afebrile. However, he continued to grow out new positive blood cultures from [**10-23**], [**10-24**]. On [**10-24**], it was noted that pt's left and hand and wrist looked warm with an area of fluctuance on the dorsum of the hand and decreasd range of motion of the wrist along with severe pain. Ortho was [**Month/Year (2) 4221**]. Left hand films showed possible erosion of scaphoid bone. They performed a bedside tap of the wrist joint and removed 1cc of purulent fluid and diagnosed left septic wrist joint. On [**10-25**], the pt was taken to the OR for wash out of the left wrist joint. They performed open irrigation and debridement of the radiocarpal joint, radioulnar joint, extensor sheaths, and extensive tenosynovium. The patient was electively intubated for the I&D and started on pressors during the procedure. The pt was left intubated and extubated for planned pacer removal on [**10-26**]. On [**10-25**], pt was noted to have lesions on his right buttocks suggestive of zoster and was started on acyclovir. TEE was performed on [**10-26**] and was negative for endocarditis. After extensive discussion between the EP and ID services, it was decided not to remove the pacemaker, since it appeared that the source of persistent infection was the septic left wrist joint. It was also felt that the pacemaker leads were most likely endothelialized by this point and unlikely to be infected. Pt was successfully extubated and weaned off pressors. On [**10-27**], a sample from the suspected zoster lesions were diagnosed as Herpes Simplex virus type 2. Acyclovir was discontinued. In total, pt has had 20/36 blood cultures positive for MRSA, the last positive set was from [**10-25**] which is the date of the left wrist I&D. He has received a 14 day course of Vanco and 11 day course of dapto. ID recommended giving a total of 4 weeks of vanco from [**10-25**]; pt's last day of vanco should be [**11-21**]. However, he should follow-up with [**Hospital **] clinic prior to discontinuing vanco. Pt should receive one week of Daptomycin from [**10-25**], last day is [**10-31**]. Pt should follow-up with Dr. [**Last Name (STitle) 6173**] in [**Hospital **] clinic ([**Telephone/Fax (1) 457**]) . 5. Renal Failure: Pt had an elevated Cr of 2.7 on admission. He diuresed 900 cc after foley placement, and conitnued to diurese likely from post-obstructive diuresis. His Cr decreased to 1.8 on discharge, close to his baseline of 1.5-1.7. This improvement in GFR is likely due to a combination of both post-renal and pre-renal azotemia. The improvement is due to decompression of obstruction and improved forward flow, respectively. Pt continued to diurese well during his infection both on and off diuretics. Pt creatinine progressively decreased and stabilized around 1.2. . 5. GI: Pt was noted to be contipated on [**2161-10-17**]. He was started on an aggressive bowel regimen which included Senna, lactulose, bisacodyl, Docusate, and daily saline enemas. From that point on, the goal was for daily bowel movements. . 6. Pulm: Pt was briefly intubated and easily extubated perioperative during after the left septic wrist I&D. . 7. BPH: The pt diuresed 900cc cloudy urine when a foley was placed on admission. He has severe BPH and he was maintained on his outpt regimen for this issue. He did have a Pseudomonal UTI and likely he experienced a post-obstructive diuresis from this. He was emperically treated with levaquin since his previous Pseudomonal UTI was pan-sensitive, including levaquin. Foley was removed when pt was transferred to the floor, where he got [**Hospital1 **] straight caths. Foley was replaced when pt returned to the CCU with sepsis. . 8. Access: On [**2161-10-25**], a right subclavian central line was attempted. CXR found the line to be located in the subclavian artery. The line was removed. Vascular surgery was [**Date Range 4221**] who felt that the patient appeared stable post-procedure without further complications. Femoral venous access was obtained. On day of discharge, a PICC line was placed by IR and the femoral line was removed. Medications on Admission: tamsulosin 0.4mg po daily donepazil 10mg po dialy coumadin 5mg po daily finestaride 5mg po dialy toprol XL 25 mg po daily tiagabine 12mg po nightly oxycodone sustained release 10 mg po BID lipitor 20 mg po dialy asprin 81 mg daily lisinopril 5mg po dialy toresmide 80 mg po dialy Discharge Medications: 1. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 2. Donepezil Hydrochloride 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO QD (). 4. Oxycodone HCl 10 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO Q12H (every 12 hours). 5. Quetiapine Fumarate 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 6. Tiagabine HCl 4 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection [**Hospital1 **] (2 times a day). 9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) 15 ml PO BID (2 times a day). 12. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q4H (every 4 hours) as needed. 13. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 14. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 15. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 16. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Morphine Sulfate 2 mg/mL Syringe Sig: 1-2 mg Injection Q4H (every 4 hours) as needed for pain. 18. Daptomycin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours) for 2 days: 400 mg QD not 500 mg. 19. Vancomycin HCl 10 g Recon Soln Sig: One (1) 1000 mg Intravenous Q24H (every 24 hours) for 4 weeks: goal level 15-20- check daily troughs. 20. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day: please give [**12-26**] tab Qd and titrate up as tolerated. 21. Torsemide 20 mg Tablet Sig: Three (3) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: NYHA Class 4 heart failure- EF 20% secondary to ischemia cardiomyopathy MRSA septicemia Left wrist septic joint- MRSA CRI BPH hypercholesterolemia CAD s/p MI x 2, s/p CABG Discharge Condition: Improved and stable on cardiac meds Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 2L Followup Instructions: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**], [**Name Initial (NameIs) **].D. Where: [**Hospital6 29**] NEUROLOGY Phone:[**Telephone/Fax (1) 541**] Date/Time:[**2161-11-9**] 1:00 Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 5500**], M.D. Where: [**Hospital6 29**] ORTHOPEDICS Phone:[**Telephone/Fax (1) 1113**] Date/Time:[**2161-11-11**] 9:45 Provider: [**Name10 (NameIs) 1947**],[**Name11 (NameIs) 5446**] [**Hospital 1947**] CLINIC Where: CC-2 [**Hospital 1947**] UNIT Phone:[**Telephone/Fax (1) 3153**] Date/Time:[**2161-11-25**] 3:40 Provider: [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 2031**] [**Telephone/Fax (1) 3512**] Follow-up appointment should be in 1 month Infectious Disease clinic will contact patient about appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6173**] in [**12-26**] weeks. Device Clinic- [**12-7**] at 3 pm, [**Hospital Ward Name 23**] 7 Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 284**] [**12-7**] at 3:30 pm- [**Hospital Ward Name 23**] 7 [**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2139**]

428,038,711,425,599,584,427,276,996,V090,041,054,V533,458,564,727,459

{'Congestive heart failure, unspecified,Methicillin susceptible Staphylococcus aureus septicemia,Pyogenic arthritis, forearm,Other primary cardiomyopathies,Urinary tract infection, site not specified,Acute kidney failure, unspecified,Atrial fibrillation,Hyperosmolality and/or hypernatremia,Mechanical complication of other vascular device, implant, and graft,Infection with microorganisms resistant to penicillins,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Herpes simplex without mention of complication,Fitting and adjustment of cardiac pacemaker,Other iatrogenic hypotension,Constipation, unspecified,Other tenosynovitis of hand and wrist,Venous (peripheral) insufficiency, 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: Elective Ultrafiltration PRESENT ILLNESS: Pt is a 84 year old Russian speaking male with hx CAD s/p CABG '[**37**] and re-do '[**51**] (LIMA --> LAD; SVG -->OM1; SVG -->PDA), ischemic DCM with EF 25%, severe MR [**First Name (Titles) **] [**Last Name (Titles) **], and chronic AF now s/p atrio-ventricular junctional ablation with BiV-pacemaker who now presents for elective admission for ultrafiltration for volume overload secondary to CHF. The pt has a history of recalcitrant NYHA stage 4 CHF with numerous protracted previous hospital courses requiring lasix drips, nesiritide and intubations. He currently has [**1-27**] pillow orthopnea, denies CP or anginal equivalents, and notes indolent bilateral lower extremity swelling. MEDICAL HISTORY: 1. CAD status post CABG in [**2137**]. 2. Status post MI x2. 3. CHF, dilated ischemic cardiomyopathy with systolic/diastolic heart failure, EF 30 percent, 1 plus AR, 2 plus TR, 2 plus MR in [**10-28**]. 4. Paroxysmal atrial fibrillation. 5. Low back pain status post laminectomy/fusion. 6. Peripheral neuropathy. 7. Chronic renal insufficiency. 8. Benign prostatic hypertrophy. 9. Dementia 10. DM 11. Depression MEDICATION ON ADMISSION: tamsulosin 0.4mg po daily donepazil 10mg po dialy coumadin 5mg po daily finestaride 5mg po dialy toprol XL 25 mg po daily tiagabine 12mg po nightly oxycodone sustained release 10 mg po BID lipitor 20 mg po dialy asprin 81 mg daily lisinopril 5mg po dialy toresmide 80 mg po dialy ALLERGIES: Neurontin / Topamax / Aldactone / Dicloxacillin / Amiodarone PHYSICAL EXAM: 97.3 82 96/52 18 98% RA FAMILY HISTORY: non-contributory SOCIAL HISTORY: Patient lives with wife. [**Name (NI) **] and daughter are very involved in medical care. Denies tobacco or EtOHuse. ### Response: {'Congestive heart failure, unspecified,Methicillin susceptible Staphylococcus aureus septicemia,Pyogenic arthritis, forearm,Other primary cardiomyopathies,Urinary tract infection, site not specified,Acute kidney failure, unspecified,Atrial fibrillation,Hyperosmolality and/or hypernatremia,Mechanical complication of other vascular device, implant, and graft,Infection with microorganisms resistant to penicillins,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Herpes simplex without mention of complication,Fitting and adjustment of cardiac pacemaker,Other iatrogenic hypotension,Constipation, unspecified,Other tenosynovitis of hand and wrist,Venous (peripheral) insufficiency, unspecified'}

CHIEF COMPLAINT: Bad headache PRESENT ILLNESS: 79 y.o. F h/o Coumadin for A fib in the past, and h/o previous admission/discharge on [**2114-1-8**] - [**2114-1-10**] for left subacute subdural hematoma. Does not recall falls/ trauma. Reports headache never diminished; and today she developed severe headache, and was taken to [**Hospital3 **] by family. CT head at [**Hospital3 **] shows worsening of L SDH, after which was transferred to [**Hospital1 18**]. Patient denies any vision changes, no weakness, no tingling, she vomited once in ED. MEDICAL HISTORY: A Fib on coumadin for 22years, bradycardic in 40s, HTN, hypercholesterolemia, hypothyroidism; bilateral cataract surgery; denied cardiac surgery. MEDICATION ON ADMISSION: Percocet 10/325 mg 1 tab q 4-6 h prn Phenytoin 100 mg tid Colace 100 mg 1 [**Hospital1 **] Zetia 10 mg 1 QHS Fosamax 70 mg Q Wednesday Synthroid 100 MCG 1 tab QD Verapamil HCL 120 mg 1 QHS Toprol XL 25 mg 1 QAM Digoxin 0.25 mg 1 QAM Vitamin D 400 1 QD Multivitamin 1 tab QD ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: PHYSICAL EXAM ON ADMISSION: O: T: BP:126/55 HR:50 R 15 O2 Sats 96 RA Gen: WD/WN, appears in NAD. HEENT: Pupils: PERLA bilaterally EOMs Full Neck: Supple. Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [**2-18**] objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. FAMILY HISTORY: non contributory SOCIAL HISTORY: Patient lives at home alone, nonsmoker, ETOH [**3-20**] glasses of wine/week.

Subdural hemorrhage,Other pulmonary embolism and infarction,Urinary tract infection, site not specified,Atrial fibrillation,Unspecified essential hypertension,Pure hypercholesterolemia,Unspecified acquired hypothyroidism

Subdural hemorrhage,Pulm embol/infarct NEC,Urin tract infection NOS,Atrial fibrillation,Hypertension NOS,Pure hypercholesterolem,Hypothyroidism NOS

Admission Date: [**2114-1-14**] Discharge Date: [**2114-2-3**] Date of Birth: [**2034-8-25**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 78**] Chief Complaint: Bad headache Major Surgical or Invasive Procedure: Left sided craniotomy X 2 for evacuation of subdural hematoma IVC filter History of Present Illness: 79 y.o. F h/o Coumadin for A fib in the past, and h/o previous admission/discharge on [**2114-1-8**] - [**2114-1-10**] for left subacute subdural hematoma. Does not recall falls/ trauma. Reports headache never diminished; and today she developed severe headache, and was taken to [**Hospital3 **] by family. CT head at [**Hospital3 **] shows worsening of L SDH, after which was transferred to [**Hospital1 18**]. Patient denies any vision changes, no weakness, no tingling, she vomited once in ED. Past Medical History: A Fib on coumadin for 22years, bradycardic in 40s, HTN, hypercholesterolemia, hypothyroidism; bilateral cataract surgery; denied cardiac surgery. Social History: Patient lives at home alone, nonsmoker, ETOH [**3-20**] glasses of wine/week. Family History: non contributory Physical Exam: PHYSICAL EXAM ON ADMISSION: O: T: BP:126/55 HR:50 R 15 O2 Sats 96 RA Gen: WD/WN, appears in NAD. HEENT: Pupils: PERLA bilaterally EOMs Full Neck: Supple. Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [**2-18**] objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: II: Pupils equally round and reactive to light, 3 to 1 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**5-21**] throughout. No pronator drift Sensation: Intact to light touch, proprioception bilaterally. Reflexes: B T Br Pa Ac Right 1+ 1+ 1+ 1 1 Left 1+ 1+ 1+ 1 1 Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin Pertinent Results: [**2114-1-28**] 05:30AM BLOOD WBC-6.1 RBC-3.05* Hgb-9.5* Hct-28.1* MCV-92 MCH-31.3 MCHC-33.9 RDW-13.4 Plt Ct-490* [**2114-1-27**] 07:05AM BLOOD WBC-5.7 RBC-3.02* Hgb-9.5* Hct-28.0* MCV-93 MCH-31.3 MCHC-33.7 RDW-13.4 Plt Ct-418 [**2114-1-26**] 06:58AM BLOOD WBC-5.5 RBC-2.89* Hgb-9.1* Hct-26.7* MCV-93 MCH-31.4 MCHC-33.9 RDW-13.5 Plt Ct-361 [**2114-1-18**] 02:54AM BLOOD Neuts-89.1* Lymphs-6.4* Monos-3.6 Eos-0.9 Baso-0.1 [**2114-1-14**] 05:00PM BLOOD Neuts-88.2* Lymphs-8.7* Monos-2.3 Eos-0.2 Baso-0.5 [**2114-1-28**] 04:55PM BLOOD Plt Ct-644* [**2114-1-28**] 04:55PM BLOOD PT-12.9 PTT-37.5* INR(PT)-1.1 [**2114-1-28**] 05:30AM BLOOD Plt Ct-490* [**2114-1-28**] 05:30AM BLOOD PT-12.9 PTT-38.6* INR(PT)-1.1 [**2114-1-27**] 07:05AM BLOOD Glucose-91 UreaN-6 Creat-0.5 Na-140 K-3.9 Cl-106 HCO3-27 AnGap-11 [**2114-1-26**] 06:58AM BLOOD Glucose-89 UreaN-6 Creat-0.5 Na-139 K-3.9 Cl-103 HCO3-29 AnGap-11 [**2114-1-25**] 12:40AM BLOOD Glucose-94 UreaN-9 Creat-0.5 Na-139 K-3.6 Cl-104 HCO3-28 AnGap-11 [**2114-1-18**] 11:31PM BLOOD CK(CPK)-197* [**2114-1-18**] 03:55PM BLOOD CK(CPK)-195* [**2114-1-18**] 08:33AM BLOOD CK(CPK)-57 [**2114-1-18**] 11:31PM BLOOD CK-MB-5 [**2114-1-18**] 03:55PM BLOOD CK-MB-6 [**2114-1-27**] 07:05AM BLOOD Calcium-8.2* Phos-3.9 Mg-2.3 [**2114-1-25**] 12:40AM BLOOD Albumin-2.8* Calcium-8.0* Phos-3.3 Mg-2.2 [**2114-1-24**] 03:16PM BLOOD Digoxin-0.9 [**2114-1-23**] 03:24AM BLOOD Digoxin-0.6* [**2114-1-25**] 12:40AM BLOOD Phenyto-8.3* [**2114-1-23**] 03:24AM BLOOD Phenyto-10.6 [**2114-1-20**] 10:38AM BLOOD Type-ART Temp-36.7 pO2-417* pCO2-37 pH-7.46* calTCO2-27 Base XS-3 Intubat-NOT INTUBA [**2114-1-18**] 03:07AM BLOOD Type-ART pO2-158* pCO2-43 pH-7.41 calTCO2-28 Base XS-2 [**2114-1-19**] 06:37AM BLOOD K-3.4* [**2114-1-18**] 03:07AM BLOOD Glucose-122* Lactate-0.9 Na-137 K-4.3 Cl-105 [**2114-1-17**] 03:05PM BLOOD Hgb-9.8* calcHCT-29 [**2114-1-15**] 11:40AM BLOOD Hgb-13.0 calcHCT-39 [**2114-1-18**] 03:07AM BLOOD freeCa-1.21 [**2114-1-17**] 03:05PM BLOOD freeCa-1.07* CT HEAD W/O CONTRAST [**2114-1-25**] 10:57 AM IMPRESSION: Minimal decrease in size of left hemispheric mixed density extra-axial fluid collection status post craniotomy with less midline shift than before. CT HEAD W/O CONTRAST [**2114-1-23**] 4:09 PM IMPRESSION: No significant change since [**2114-1-21**] in mixed density left frontal subdural hematoma causing minimal left to right midline shift. UNILAT UP EXT VEINS US BILAT [**2114-1-22**] 3:50 PM IMPRESSION: Complete venous occlusion involving a portion of the left basilic, as well as the length of the right and left cephalic veins. CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2114-1-20**] 10:57 AM IMPRESSION: 1. Bilateral segmental pulmonary embolism with a heavy clot burden. This finding was called to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at 12:37 p.m. on the date of the examination. 2. Minimal hazy opacity in the left upper lobe of uncertain significance. FEMORAL VASCULAR US RIGHT [**2114-1-20**] 2:30 PM IMPRESSION: 1. No evidence of DVT in the bilateral common femoral and greater saphenous veins. FEMORAL VASCULAR US LEFT [**2114-1-20**] 2:30 PM IMPRESSION: 1. No evidence of DVT in the bilateral common femoral and greater saphenous veins. CT HEAD W/O CONTRAST [**2114-1-14**] 5:18 PM IMPRESSION: Acute-on-chronic left-sided subdural hematoma, with persistant significant rightward subfalcine herniation. Effacement of the suprasellar cistern, concerning for downward transtentorial herniation. Discussed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at 9:20pm [**2114-1-4**]. Brief Hospital Course: 79F with HPI as above was evaluated in the ED by the neurosurgery team on [**2114-1-14**]. She was given a Dilantin bolus dose and admitted to the SICU by the neurosurgery service for subacute on chronic SDH. She was taken to the operating room on [**2114-1-15**] for a left frontoparietal craniotomy and evacuation of subdural hematoma. For details, please see the operative note. She tolerated the procedure well, was extubated and transferred to the PACU and back to the SICU in stable condition. She had a subdural drain in place and no complaints of headache and was neurologically intact at post op check. She had a head CT scan post op which showed interval decrease of the L SDH. She had post op EKG changes/ST depression and cardiac enzymes were cycled and were negative. Cardiology was consulted and recommended an echo. She was continued on dilantin for seizure prophylaxis. The subdural drain was removed on [**2114-1-16**] and a post pull CT was stable. It was noted that the patient may be sundowning at night, she was still oriented, but not as alert and had full strength all 4 when cooperative. A CT head on [**1-17**] showed reaccumulation of SDH and she was taken back to the OR for evacuation and had 3 drains placed (2 subdural, 1 subgaleal). Post-op CT showed decreased shift. Her dilantin level was 5.9 and a dilantin bolus was given. An echocardiogram was done on [**1-18**] which showed mild pulmonary hypertension. A repeat head CT on [**1-19**] was stable, she received 2units packed RBCs for decreased hematocrit and was transferred to the floor. She was evaluated by speech and swallow team and the pt was not found to have any overt signs of aspiration and recommended a PO diet of thin liquids and soft solids. On [**1-20**], the patient felt weak and fainted while walking with physical therapy. Her O2 saturation decreased to the 70s on room air. Her EKG had no acute changes and a CTA chest was done which showed bilateral segmental pulmonary emboli, ultrasound of the lower extremities showed no evidence of DVT. She was transferred to the SICU and was taken to the OR for IVC filter placement. She was started on aspirin post procedure and a CT head was done on [**1-21**] which showed minimal increase in the SDH. On [**1-22**], her mental status was improved and she had bilateral upper extremity ultrasounds showed thrombosis in the left basilic vein and bilateral cephalic veins. A CT head on [**1-23**] was stable and she was started on a heparin drip with a goal PTT of 40-60. The patient continued to work with physical therapy and was noted to desat to 80% with any exertion. She was started on Coumadin 5mg on [**1-24**] and continued on the heparin drip. She was seen by hematology for ? hypercoagulability work up and it was recommended that the patient would benefit from long term anticoagulation given her history of atrial fibrillation and hemodynamically unstable PE. She was transferred to the floor on [**1-26**] and was continued on heparin drip and coumadin with a goal INR of [**2-18**]. Her coumadin dose was increased over the next several days with minimal increase in her INR and she was continued on the heparin drip. The dilantin was changed to keppra on [**1-29**] and hematology saw the patient for increased platelets, which is most likely reactive. On [**1-30**] she had a 30-60 second episode of not being able to speak during a shower. She had full recovery and was neurologically stable with no intervention. A head CT was done which showed no new hemorrhage and the neurology stroke service was consulted. It was felt that this episode may have been a seizure and she was given a bolus dose of dilantin and continued on dilantin until [**2-1**]. A carotid duplex was done which showed less than 40% stenosis within bilateral internal carotid arteries and antegrade flow in both vertebral arteries. Her INR was 1.8 [**2114-2-3**] and her heparin was stopped. She should continu with her coumadin and INR checked daily until therapeutic range 2.0 to 3.0 is maintained. Medications on Admission: Percocet 10/325 mg 1 tab q 4-6 h prn Phenytoin 100 mg tid Colace 100 mg 1 [**Hospital1 **] Zetia 10 mg 1 QHS Fosamax 70 mg Q Wednesday Synthroid 100 MCG 1 tab QD Verapamil HCL 120 mg 1 QHS Toprol XL 25 mg 1 QAM Digoxin 0.25 mg 1 QAM Vitamin D 400 1 QD Multivitamin 1 tab QD Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QWED (every Wednesday). 10. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Powder in Packet Sig: One (1) Powder in Packet PO TID (3 times a day). 11. Verapamil 120 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 12. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed. 13. Warfarin 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) for 1 doses: Monitor INR daily until therapautic level 2.0 to 3.0 maintained. 14. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 15. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 18. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital 169**] Center Elmhurst Discharge Diagnosis: Left sided subdural hematoma Bilateral Segmental PEs Discharge Condition: Neurologically stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY ?????? Have a family member check your incision daily for signs of infection ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? You may wash your hair only after sutures and/or staples have been removed ?????? You may shower before this time with assistance and use of a shower cap ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered ?????? Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F Followup Instructions: Follow up with Dr [**First Name (STitle) **] in 4 weeks with a head CT Completed by:[**2114-2-3**]

432,415,599,427,401,272,244

{'Subdural hemorrhage,Other pulmonary embolism and infarction,Urinary tract infection, site not specified,Atrial fibrillation,Unspecified essential hypertension,Pure hypercholesterolemia,Unspecified acquired hypothyroidism'}

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: Bad headache PRESENT ILLNESS: 79 y.o. F h/o Coumadin for A fib in the past, and h/o previous admission/discharge on [**2114-1-8**] - [**2114-1-10**] for left subacute subdural hematoma. Does not recall falls/ trauma. Reports headache never diminished; and today she developed severe headache, and was taken to [**Hospital3 **] by family. CT head at [**Hospital3 **] shows worsening of L SDH, after which was transferred to [**Hospital1 18**]. Patient denies any vision changes, no weakness, no tingling, she vomited once in ED. MEDICAL HISTORY: A Fib on coumadin for 22years, bradycardic in 40s, HTN, hypercholesterolemia, hypothyroidism; bilateral cataract surgery; denied cardiac surgery. MEDICATION ON ADMISSION: Percocet 10/325 mg 1 tab q 4-6 h prn Phenytoin 100 mg tid Colace 100 mg 1 [**Hospital1 **] Zetia 10 mg 1 QHS Fosamax 70 mg Q Wednesday Synthroid 100 MCG 1 tab QD Verapamil HCL 120 mg 1 QHS Toprol XL 25 mg 1 QAM Digoxin 0.25 mg 1 QAM Vitamin D 400 1 QD Multivitamin 1 tab QD ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: PHYSICAL EXAM ON ADMISSION: O: T: BP:126/55 HR:50 R 15 O2 Sats 96 RA Gen: WD/WN, appears in NAD. HEENT: Pupils: PERLA bilaterally EOMs Full Neck: Supple. Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [**2-18**] objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. FAMILY HISTORY: non contributory SOCIAL HISTORY: Patient lives at home alone, nonsmoker, ETOH [**3-20**] glasses of wine/week. ### Response: {'Subdural hemorrhage,Other pulmonary embolism and infarction,Urinary tract infection, site not specified,Atrial fibrillation,Unspecified essential hypertension,Pure hypercholesterolemia,Unspecified acquired hypothyroidism'}

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is a 77 year old woman with a history of coronary artery disease status post myocardial infarction in [**2136**], status post recent left anterior descending stent with an ejection fraction of 25%, hypertension, known carotid stenosis, who was admitted to Trauma Surgical Intensive Care Unit on [**5-5**], after falling after a blackout and hitting her head. The patient had trauma to the head and face. The patient had one to two minutes of loss of consciousness. MEDICAL HISTORY: 1. Coronary artery disease status post myocardial infarction in [**2129**]. On [**2143-5-8**], the patient had a percutaneous transluminal coronary angioplasty stent of a 70% mid left anterior descending and was started on Plavix for nine months and Coumadin for a low ejection fraction, and questionable inferior apical aneurysm. 2. Hypertension. 3. Hypercholesterolemia. 4. History of breast cancer. 5. History of cerebrovascular accident. 6. Hypothyroidism. 7. Lumbar stenosis. 8. Status post total abdominal hysterectomy. 9. Carotid stenosis. 10. Status post appendectomy. 11. History of glaucoma surgery. 12. Likely posterior circulation hypoperfusion. 13. Chronic renal insufficiency. 14. Doppler done in [**3-/2143**], showed left common carotid stenosis between 60 to 70% and a right subclavian stenosis between 70 and 80%. MEDICATION ON ADMISSION: 1. Synthroid 25 micrograms p.o. q. day. 2. Coumadin. 3. Aspirin 325 mg q. day. 4. Atenolol 25 mg twice a day. 5. Elavil 25 mg q. h.s. 6. Fioricet p.r.n. 7. Lipitor 20 mg q. h.s. 8. Lisinopril 10 mg twice a day. 9. Multivitamin. 10. Valium 1 mg q. day. 11. Plavix 75 mg q. day. ALLERGIES: The patient has no known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

Other and unspecified intracranial hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Mitral valve disorders,Unspecified fall,Syncope and collapse,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Pure hypercholesterolemia,Unspecified acquired hypothyroidism,Swelling, mass, or lump in chest

Brain hem NEC w/o coma,Mitral valve disorder,Fall NOS,Syncope and collapse,Crnry athrscl natve vssl,Hypertension NOS,Pure hypercholesterolem,Hypothyroidism NOS,Chest swelling/mass/lump

Admission Date: [**2143-5-5**] Discharge Date: [**2143-5-9**] Date of Birth: [**2065-5-14**] Sex: F Service: MEDICINE HISTORY OF PRESENT ILLNESS: The patient is a 77 year old woman with a history of coronary artery disease status post myocardial infarction in [**2136**], status post recent left anterior descending stent with an ejection fraction of 25%, hypertension, known carotid stenosis, who was admitted to Trauma Surgical Intensive Care Unit on [**5-5**], after falling after a blackout and hitting her head. The patient had trauma to the head and face. The patient had one to two minutes of loss of consciousness. The patient denies preceding chest pain, shortness of breath, lightheadedness, dizziness, diaphoresis, visual loss and vertigo. She has no history of syncope or loss of consciousness although she had an episode of transient visual loss in the setting of taking sublingual Nitroglycerin on last admission. The patient had no post-ictal confusion. in the Emergency Department, a head CT scan was done which showed an intraparenchymal bleed on the medial portion of the right frontal lobe. A CT scan of the spine showed no fracture of subluxation. The patient was discharged recently on Coumadin. On admission, her INR was found to be 1.1. On last admission, the patient was evaluated by the Neurological Service after a transient visual loss. The patient was discharged with scheduled follow-up with Neurology, with results of the MRI and MRA still pending. PAST MEDICAL HISTORY: 1. Coronary artery disease status post myocardial infarction in [**2129**]. On [**2143-5-8**], the patient had a percutaneous transluminal coronary angioplasty stent of a 70% mid left anterior descending and was started on Plavix for nine months and Coumadin for a low ejection fraction, and questionable inferior apical aneurysm. 2. Hypertension. 3. Hypercholesterolemia. 4. History of breast cancer. 5. History of cerebrovascular accident. 6. Hypothyroidism. 7. Lumbar stenosis. 8. Status post total abdominal hysterectomy. 9. Carotid stenosis. 10. Status post appendectomy. 11. History of glaucoma surgery. 12. Likely posterior circulation hypoperfusion. 13. Chronic renal insufficiency. 14. Doppler done in [**3-/2143**], showed left common carotid stenosis between 60 to 70% and a right subclavian stenosis between 70 and 80%. MEDICATIONS ON ADMISSION: 1. Synthroid 25 micrograms p.o. q. day. 2. Coumadin. 3. Aspirin 325 mg q. day. 4. Atenolol 25 mg twice a day. 5. Elavil 25 mg q. h.s. 6. Fioricet p.r.n. 7. Lipitor 20 mg q. h.s. 8. Lisinopril 10 mg twice a day. 9. Multivitamin. 10. Valium 1 mg q. day. 11. Plavix 75 mg q. day. ALLERGIES: The patient has no known drug allergies. PHYSICAL EXAMINATION: On physical examination, the patient was alert and oriented. She had swelling over the right eye and forehead. The patient was able to follow commands. Pupils were symmetric and reactive. Cranial nerves II through XII intact. Strength of five out of five throughout. Sensation intact. No pronator drift. Neck had a cervical collar on. Lungs were clear to auscultation bilaterally. Heart was regular rate and rhythm, S1, S2. Abdomen soft, nontender, nondistended. Extremities with no edema. She had ecchymosis and abrasions of her shins bilaterally. Rectal: The patient had normal tone, heme negative. Back with no tenderness or deformities. LABORATORY: On admission, white blood cell count 5.9, hematocrit 32.2, platelets 169. Sodium 138, potassium 4.8, chloride 103, bicarbonate 28, BUN 35, creatinine 1.2, glucose 113. PT 12.9, INR 1.1, PTT 24.8, CK 143, MB 3, troponin less than 0.3. Electrocardiogram unchanged from prior. HOSPITAL COURSE: The patient was admitted to Trauma Surgical Intensive Care Unit for observation. Coumadin, aspirin and Plavix were held. The patient was felt stable and was transferred to Medicine. In terms of the syncopal work-up, it was unclear whether this was related to cardiac versus neurologic. Cardiology was consulted and recommended an electrophysiology study. Additionally, the patient was ruled out for a myocardial infarction. She had an electrophysiology study performed which showed normal sinus, no sinus dysfunction, normal per kg conduction, no inducible ventricular tachycardia. The patient was followed by Neurosurgery and Neurology. It was felt that her intracranial bleed was small. The patient initially had aspirin, Plavix and Coumadin withheld; then she was started on aspirin since her intracranial bleed seemed small and the patient had no neurological deficits. It was agreed upon between Neurology and Cardiology that she could be restarted back on Plavix, however, it is felt that restarting Coumadin is too risky at this time. During the hospital course, the patient had episodes of chest pain. There were no [**Year (4 digits) **] changes. The patient was ruled out for a myocardial infarction. It was felt that the patient's syncopal episode was not due to neurovascular causes, however, the MRI / MRA revealed a left CCA stenosis and no left vertebral artery was seen. Furthermore, a left subclavian stenosis was also noted. Due to these findings, it was felt that the patient should maintain a blood pressure of greater than 130 to maintain adequate perfusion to her brain. The syncopal event is most likely from vasovagal or orthostatic hypotension, however, if it recurs, further evaluation is warranted. The patient was noted to have a mass in the right upper lung on CT scan, however, this was seen on prior CT scans and the patient says it is related to radiation therapy from her radiation therapy when she had breast cancer. It was felt that further evaluation of this mass would not be followed up as an inpatient and will be deferred to outpatient management. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSES: 1. Syncope, most like vasovagal versus orthostatic hypotension. 2. Small intracranial hemorrhage. 3. Electrophysiology study with no evidence of inducible ventricular tachycardia, sinus dysfunction or conduction abnormalities. 4. Coronary artery disease, ruled out for myocardial infarction. 5. Carotid disease. 6. Hypertension. DISCHARGE INSTRUCTIONS: 1. The patient should follow-up with her Cardiologist. 2. The patient should follow-up with her Neurologist. 3. The patient should also follow-up with her primary care physician as scheduled as before. DISCHARGE MEDICATIONS: 1. Atenolol 50 mg twice a day. 2. Elavil 25 mg q. h.s. 3. Lisinopril 10 mg twice a day. 4. Lipitor 20 mg q. day. 5. Plavix 25 mg q. day. 6. Aspirin 325 mg q. day. 7. Levoxyl 25 micrograms q. day. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**] Dictated By:[**Name8 (MD) 101638**] MEDQUIST36 D: [**2143-5-10**] 15:15 T: [**2143-5-10**] 16:19 JOB#: [**Job Number 101639**]

853,424,E888,780,414,401,272,244,786

{'Other and unspecified intracranial hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Mitral valve disorders,Unspecified fall,Syncope and collapse,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Pure hypercholesterolemia,Unspecified acquired hypothyroidism,Swelling, mass, or lump in chest'}

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 77 year old woman with a history of coronary artery disease status post myocardial infarction in [**2136**], status post recent left anterior descending stent with an ejection fraction of 25%, hypertension, known carotid stenosis, who was admitted to Trauma Surgical Intensive Care Unit on [**5-5**], after falling after a blackout and hitting her head. The patient had trauma to the head and face. The patient had one to two minutes of loss of consciousness. MEDICAL HISTORY: 1. Coronary artery disease status post myocardial infarction in [**2129**]. On [**2143-5-8**], the patient had a percutaneous transluminal coronary angioplasty stent of a 70% mid left anterior descending and was started on Plavix for nine months and Coumadin for a low ejection fraction, and questionable inferior apical aneurysm. 2. Hypertension. 3. Hypercholesterolemia. 4. History of breast cancer. 5. History of cerebrovascular accident. 6. Hypothyroidism. 7. Lumbar stenosis. 8. Status post total abdominal hysterectomy. 9. Carotid stenosis. 10. Status post appendectomy. 11. History of glaucoma surgery. 12. Likely posterior circulation hypoperfusion. 13. Chronic renal insufficiency. 14. Doppler done in [**3-/2143**], showed left common carotid stenosis between 60 to 70% and a right subclavian stenosis between 70 and 80%. MEDICATION ON ADMISSION: 1. Synthroid 25 micrograms p.o. q. day. 2. Coumadin. 3. Aspirin 325 mg q. day. 4. Atenolol 25 mg twice a day. 5. Elavil 25 mg q. h.s. 6. Fioricet p.r.n. 7. Lipitor 20 mg q. h.s. 8. Lisinopril 10 mg twice a day. 9. Multivitamin. 10. Valium 1 mg q. day. 11. Plavix 75 mg q. day. ALLERGIES: The patient has no known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: ### Response: {'Other and unspecified intracranial hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Mitral valve disorders,Unspecified fall,Syncope and collapse,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Pure hypercholesterolemia,Unspecified acquired hypothyroidism,Swelling, mass, or lump in chest'}

CHIEF COMPLAINT: Chest pain. PRESENT ILLNESS: This is a 73 year old female with cardiac risk factors of hypertension, hypercholesterolemia, tobacco use, who presents to the Emergency Department with nausea, vomiting, chest pain, shortness of breath, diaphoresis, bradycardia, with a heart rate in the 40's. Electrocardiogram on admission was notable for four to five mm ST elevation in leads 2, 3, AVF and three to four mm ST depressions in leads L-D, V2 and 1 to [**Street Address(2) 1766**] depressions in leads V4 through V6. Electrocardiogram was also notable for Mobitz type I heart block. MEDICAL HISTORY: Hypertension. Hyperchylomicronemia. Peptic ulcer disease, status post subtotal gastrectomy 30 years ago. Gastroesophageal reflux disease. Anemia. Status post appendectomy. Tobacco use. Abdominal aortic aneurysm, four cms in [**2167-9-17**], infrarenal, partially thrombosed lumen. MEDICATION ON ADMISSION: ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: Notable for cancer on the patient's mother's side, unknown type. SOCIAL HISTORY: The patient is a 50 pack year smoker, no alcohol use. The patient lives in [**Location 1268**] with her son and husband.

Acute myocardial infarction of inferoposterior wall, initial episode of care,Cardiac complications, not elsewhere classified,Ventricular fibrillation,Urinary tract infection, site not specified,Mitral valve insufficiency and aortic valve insufficiency,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Esophageal reflux,Tobacco use disorder

AMI inferopost, initial,Surg compl-heart,Ventricular fibrillation,Urin tract infection NOS,Mitral/aortic val insuff,Crnry athrscl natve vssl,Hypertension NOS,Esophageal reflux,Tobacco use disorder

Admission Date: [**2168-7-18**] Discharge Date: [**2168-7-19**] Date of Birth: [**2095-1-10**] Sex: F Service: CHIEF COMPLAINT: Chest pain. HISTORY OF PRESENT ILLNESS: This is a 73 year old female with cardiac risk factors of hypertension, hypercholesterolemia, tobacco use, who presents to the Emergency Department with nausea, vomiting, chest pain, shortness of breath, diaphoresis, bradycardia, with a heart rate in the 40's. Electrocardiogram on admission was notable for four to five mm ST elevation in leads 2, 3, AVF and three to four mm ST depressions in leads L-D, V2 and 1 to [**Street Address(2) 1766**] depressions in leads V4 through V6. Electrocardiogram was also notable for Mobitz type I heart block. In the Emergency Department, the patient was given aspirin, started on Heparin and Integrolin. The patient subsequently became bradycardiac, down to the 50's to 60's. However, she was maintaining her blood pressure. The patient went to catheterization, was found to have total occlusion of the right coronary artery, was stented times two. Unfortunately, there was no reflow with stent opening. The patient subsequently dropped her blood pressure, became more bradycardiac and had four episodes of ventricular fibrillation, for each of which she was shocked. The patient was intubated and Swanned. An intra-aortic balloon pump was placed. The patient's RV pressure was 34 over 9; PA pressure was 30 over 15 and pulmonary capillary wedge pressure was 17. The patient's cardiac index was 2.77. During the catheterization, the patient received Atropine and Amiodarone. PAST MEDICAL HISTORY: Hypertension. Hyperchylomicronemia. Peptic ulcer disease, status post subtotal gastrectomy 30 years ago. Gastroesophageal reflux disease. Anemia. Status post appendectomy. Tobacco use. Abdominal aortic aneurysm, four cms in [**2167-9-17**], infrarenal, partially thrombosed lumen. MEDICATIONS: Aspirin 325 mg p.o. q. day. Lipitor 10 mg p.o. q. day. Prevacid. Atenolol. Hydrochlorothiazide/Triamterene. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient is a 50 pack year smoker, no alcohol use. The patient lives in [**Location 1268**] with her son and husband. FAMILY HISTORY: Notable for cancer on the patient's mother's side, unknown type. PHYSICAL EXAMINATION: Vital signs: Temperature 99.4; pulse 94; blood pressure 122/76; respirations 14; oxygen saturation 97%. In general, the patient is sedated. Lungs are clear to auscultation bilaterally anteriorly. Cardiovascular: Distant heart sounds; no murmurs; regular rate and rhythm. Abdomen: Soft, nontender, nondistended. Normoactive bowel sounds. Extremities: Cool, thready pulses. [**Name (NI) **] PT pulses bilaterally. LABORATORY DATA: White count 11.5; hematocrit of 43.4; platelets 291; PT 13.1; PTT 30.2; INR 1.1. CK 169. Chest x-ray shows no cardiopulmonary disease. Cardiac catheterization from [**2168-7-17**] shows right dominant; total occlusion of proximal right coronary artery; status post stent times two; 0% residual with transient, severe no reflow. However, eventual 0% residual stenosis. Left main coronary artery is normal. Left anterior descending shows mild disease. Left circumflex shows small disease. Cardiac index of 2.77. Post catheterization electrocardiogram shows normal sinus rhythm at 86 beats per minute; borderline PR prolongation at 240 milliseconds; Q waves in leads 2, 3 and AVF. Good R wave progression. HOSPITAL COURSE: In short, this is a 73 year old female with significant cardiac risk factors of hypertension, hypercholesterolemia, tobacco use, who presents to the Emergency Department with chest pain. Electrocardiogram was notable for ST elevations in the inferior leads and ST depressions in the precordial leads, consistent with inferior myocardial infarction involving the inferior left ventricle and possibly RV territory, status post Right coronary artery stenting. Cardiac catheterization complicated by ventricular fibrillation arrest times four; status post shock. 1.) Coronary artery disease, as already noted. The patient suffered ST elevation inferior myocardial infarction. Her CK peaked at 5,065 with MB of 519; MB index of 10.2 and a treponin greater than 50. The patient was placed on a cardiac regimen including aspirin, Plavix and 20 mg p.o. q. day of Lipitor. She received a total of 18 hours of Integrolin. Beta blocker was held secondary to the fear of RV involvement and potential hypotension. 2.) Pump. The patient had a cardiac index catheterization of 2.77. She also had an intra-aortic balloon pump in place, augmenting her diastole by 25 to 30 mms. On [**2168-7-21**], the cardiology fellow noted a murmur that hadn't been heard by the rest of the team specifically holosystolic, heard best at the left lower sternal border. For this reason, an echo was obtained. The patient was found to have an ejection fraction of 55 to 60%. The left atrium was mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Left ventricular systolic function is mildly depressed with mild basal inferior hypokinesis. There is 1+ aortic regurgitation, 2+ mitral regurgitation. 3.) Rhythm. The patient presented with bradycardia, likely ischemic related, status post Atropine. The patient's ventricular fibrillation was likely secondary to reperfusion injury. For this, she received Amiodarone. On coming to the CCU, the patient was in normal sinus rhythm. The patient had a pacer wire in place and was set to pace at 50. It was felt that the patient was unlikely to redevelop ventricular fibrillation now that the Right coronary artery was open and she was reperfused. Indeed, she had no further ectopy. She did not require any further Amiodarone. The patient's bradycardia had also resolved. The pacer wire was removed. 4.) Blood pressure. The patient was initially transferred to the CCU from the catheterization laboratory, intubated and on Dopamine. This was quickly titrated, signaling that the right ventricular involvement was likely minimal. 5.) Hematology. The patient had a femoral hematoma post catheterization. Her hematocrit remained stable. 6.) Communication. The patient and her daughter had a lot of trouble coming to terms with this myocardial infarction. They were especially concerned that the myocardial infarction occurred just months after she had initiated therapy to lower her cholesterol and make a daily habit of using aspirin. The patient was seen by social work. 7.) Infectious disease. The patient was found to have a urinary tract infection by her urinalysis. She was prescribed a three day course of Levafloxacin. The patient was never symptomatic. CONDITION ON DISCHARGE: Good. DISCHARGE MEDICATIONS: Aspirin 325 mg p.o. q. day. Plavix 75 mg p.o. q. day times 30 days. Lipitor 10 mg p.o. q h.s. Oxycodone one tablet q. four to six hours prn, number of tablets 15. Levofloxacin 500 mg p.o. q. day times five days total. Lisinopril 5 mg p.o. q. day. Prevacid 30 mg p.o. q. day. DISCHARGE INSTRUCTIONS: The patient is discharged to home with services. She was warned to see her doctor if she developed any worsening chest pain, shortness of breath, dizziness, sweating, nausea or vomiting. The patient has an appointment on [**7-27**] with her primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Of note, I have forgotten to mention that the patient's PR interval was still prolonged, even several days post myocardial infarction and catheterization. For this reason, a beta blocker was not restarted. An electrocardiogram should be rechecked on [**2168-7-27**] to see if the PR interval is still elevated. If not, she should be started on beta blocker at low dose. DISCHARGE DIAGNOSES: Inferior myocardial infarction. Ventricular fibrillatory arrest, status post shock times four. Urinary tract infection. Hypertension. Abdominal aortic aneurysm. This will need to be monitored. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**] Dictated By:[**Name8 (MD) 4990**] MEDQUIST36 D: [**2168-7-27**] 03:26 T: [**2168-7-27**] 03:58 JOB#: [**Job Number 102260**]

410,997,427,599,396,414,401,530,305

{'Acute myocardial infarction of inferoposterior wall, initial episode of care,Cardiac complications, not elsewhere classified,Ventricular fibrillation,Urinary tract infection, site not specified,Mitral valve insufficiency and aortic valve insufficiency,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Esophageal reflux,Tobacco use disorder'}

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: Chest pain. PRESENT ILLNESS: This is a 73 year old female with cardiac risk factors of hypertension, hypercholesterolemia, tobacco use, who presents to the Emergency Department with nausea, vomiting, chest pain, shortness of breath, diaphoresis, bradycardia, with a heart rate in the 40's. Electrocardiogram on admission was notable for four to five mm ST elevation in leads 2, 3, AVF and three to four mm ST depressions in leads L-D, V2 and 1 to [**Street Address(2) 1766**] depressions in leads V4 through V6. Electrocardiogram was also notable for Mobitz type I heart block. MEDICAL HISTORY: Hypertension. Hyperchylomicronemia. Peptic ulcer disease, status post subtotal gastrectomy 30 years ago. Gastroesophageal reflux disease. Anemia. Status post appendectomy. Tobacco use. Abdominal aortic aneurysm, four cms in [**2167-9-17**], infrarenal, partially thrombosed lumen. MEDICATION ON ADMISSION: ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: Notable for cancer on the patient's mother's side, unknown type. SOCIAL HISTORY: The patient is a 50 pack year smoker, no alcohol use. The patient lives in [**Location 1268**] with her son and husband. ### Response: {'Acute myocardial infarction of inferoposterior wall, initial episode of care,Cardiac complications, not elsewhere classified,Ventricular fibrillation,Urinary tract infection, site not specified,Mitral valve insufficiency and aortic valve insufficiency,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Esophageal reflux,Tobacco use disorder'}

CHIEF COMPLAINT: chest and back pain PRESENT ILLNESS: 52M with a history of thoracic aortic aneurysm presents to the [**Hospital1 18**] ER with a 3 hour history of a tearing chest pain that radiated to his back. He states the pain began during the day, however was a lower grade pain and around 11PM the pain became sharp, severe and constant. The pain intensity did not subside therefore he decided to be evaluated in the ER. He also reports he had a similar episode 2 weeks ago where he was evaluated at [**Hospital1 2025**] and was told he had a thoracic aneurysm. He was evaluated by a surgeon who suggestive operative repair, however the patient was unable to go to his follow up appointments. MEDICAL HISTORY: Hep C, type A aortic dissection (caused by htn/drug use per pt) MEDICATION ON ADMISSION: [**Last Name (STitle) 197**] 5', Folic Acid 1', ISMN ER 30', Nifedical XL 30', Carvediolol 12.5'' ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: bp 106/62 HR 56 reg RR 12 FAMILY HISTORY: denies hx of aortic aneurysms, dissections or valvular disease SOCIAL HISTORY: Lives with son, recently moved to [**State 350**], on disability, drink 3 40oz beers a day along with 2-3 shots of liquor, smokes [**1-19**] cigarettes/day, smokes occasional marijuana

Dissection of aorta, thoracoabdominal,Other primary cardiomyopathies,Chronic systolic heart failure,Heart valve replaced by other means,Aortocoronary bypass status,Other and unspecified alcohol dependence, continuous,Bipolar disorder, unspecified,Unspecified essential hypertension,Precordial pain,Long-term (current) use of anticoagulants,Coronary atherosclerosis of unspecified type of vessel, native or graft,Old myocardial infarction,Atherosclerosis of native arteries of the extremities, unspecified,Unspecified viral hepatitis C without hepatic coma,Personal history of noncompliance with medical treatment, presenting hazards to health,Tobacco use disorder,Amphetamine and other psychostimulant dependence, in remission

Dsct of thoracoabd aorta,Prim cardiomyopathy NEC,Chr systolic hrt failure,Heart valve replac NEC,Aortocoronary bypass,Alcoh dep NEC/NOS-contin,Bipolar disorder NOS,Hypertension NOS,Precordial pain,Long-term use anticoagul,Cor ath unsp vsl ntv/gft,Old myocardial infarct,Athscl extrm ntv art NOS,Hpt C w/o hepat coma NOS,Hx of past noncompliance,Tobacco use disorder,Amphetamin depend-remiss

Admission Date: [**2149-12-13**] Discharge Date: [**2149-12-17**] Date of Birth: [**2097-5-8**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2777**] Chief Complaint: chest and back pain Major Surgical or Invasive Procedure: [**2149-12-16**]: Cardiac Catheterization History of Present Illness: 52M with a history of thoracic aortic aneurysm presents to the [**Hospital1 18**] ER with a 3 hour history of a tearing chest pain that radiated to his back. He states the pain began during the day, however was a lower grade pain and around 11PM the pain became sharp, severe and constant. The pain intensity did not subside therefore he decided to be evaluated in the ER. He also reports he had a similar episode 2 weeks ago where he was evaluated at [**Hospital1 2025**] and was told he had a thoracic aneurysm. He was evaluated by a surgeon who suggestive operative repair, however the patient was unable to go to his follow up appointments. Past Medical History: Hep C, type A aortic dissection (caused by htn/drug use per pt) PSH: Bentall with mechanical AVR, L THR x 3, removal of hardware Social History: Lives with son, recently moved to [**State 350**], on disability, drink 3 40oz beers a day along with 2-3 shots of liquor, smokes [**1-19**] cigarettes/day, smokes occasional marijuana Does not work Family History: denies hx of aortic aneurysms, dissections or valvular disease Physical Exam: bp 106/62 HR 56 reg RR 12 Gen: 52yom lying in bed in NAD. Alert and oriented CV: RRR, audible click from mechanical aortic valve Lungs: CTA bilat Abd: Soft no m/t/o Extremities: Warm, well perfused, palpable lower extremity pulses bilat Wound: groin puncture c/d/i Pertinent Results: Admission labs: [**2149-12-13**] 03:19AM BLOOD WBC-4.0 RBC-3.84* Hgb-12.2* Hct-35.9* MCV-93 MCH-31.7 MCHC-33.9 RDW-13.6 Plt Ct-268 [**2149-12-13**] 03:19AM BLOOD PT-15.0* PTT-27.2 INR(PT)-1.3* [**2149-12-13**] 07:23AM BLOOD Glucose-98 UreaN-11 Creat-0.8 Na-139 K-4.0 Cl-108 HCO3-23 AnGap-12 [**2149-12-13**] 07:23AM BLOOD ALT-22 AST-29 CK(CPK)-55 AlkPhos-73 TotBili-0.8 [**2149-12-13**] 03:19AM BLOOD Lipase-17 [**2149-12-13**] 07:23AM BLOOD CK-MB-1 cTropnT-<0.01 [**2149-12-13**] 07:23AM BLOOD Albumin-3.7 Calcium-8.4 Phos-3.4 Mg-1.6 Discharge: [**2149-12-17**] 10:00AM BLOOD WBC-2.7* RBC-3.86* Hgb-12.3* Hct-36.7* MCV-95 MCH-32.0 MCHC-33.6 RDW-13.6 Plt Ct-194 [**2149-12-17**] 10:00AM BLOOD Glucose-126* UreaN-7 Creat-0.9 Na-136 K-4.1 Cl-100 HCO3-24 AnGap-16 [**2149-12-17**] 10:00AM BLOOD Calcium-9.5 Phos-4.2 Mg-1.8 Cardiac Enzymes: [**2149-12-13**] 07:23AM BLOOD CK-MB-1 cTropnT-<0.01 [**2149-12-13**] 01:32PM BLOOD CK-MB-1 cTropnT-<0.01 [**2149-12-15**] 01:30PM BLOOD cTropnT-<0.01 Brief Hospital Course: Pt admitted from ED with Type B aortic dissection, uncontrolled hypertension and pain. He was admitted to the CVICU and placed on nipride/esmolol drips for blood pressure control. His INR was sub-therapeutic and he was started on a heparin gtt for his mechanical avr. Given his heavy ETOH history, the pt was placed on withdrawl precautions and a ciwa scale. He was evaluated by the cardiology service who made recommendations for oral blood pressure meds. His drips were weaned off and his BP was controlled with oral agents. Once off the drips he was transfered to the VICU where he continued to be monitored closely. His pain and blood pressure were well controlled. He was seen by addiction medicine and social work and followed throughout his stay. CT scan showed:"thoracic aorta dissection most consistent with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 11916**] type B dissection. The dissection starts just distal to the left subclavian artery and ends just proximal to the bilateral renal arteries. The dissection extends into the proximal SMA. The visualized vessels are patent." Cardiac surgery was consulted and evaluated the patient. They determined that he would need an open repair and asked for a cardiac catheterization prior to surgery. On [**12-16**] the patient went for a cardiac cath, which showed no coronary artery disease. He remained in the VICU through [**12-17**] at which time it was determined he was stable for discharge home. His pain and blood pressure were well controlled. He will return in a few weeks for open surgical repair of his dissection with Dr. [**Last Name (STitle) 914**] and Dr. [**Last Name (STitle) **]. We reviewed the seriousness of his condition, including the importance of medication compliance, blood pressure control and refraining from any drugs. Medications on Admission: [**Last Name (STitle) 197**] 5', Folic Acid 1', ISMN ER 30', Nifedical XL 30', Carvediolol 12.5'' Discharge Medications: 1. enoxaparin 80 mg/0.8 mL Syringe Sig: 70 mg Subcutaneous [**Hospital1 **] (2 times a day): 70mg or 0.7mL . Disp:*20 * Refills:*0* 2. warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. Disp:*90 Tablet(s)* Refills:*0* 3. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for hr <55, sbp<100. 4. nifedipine 30 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO BID (2 times a day). Disp:*60 Tablet Extended Release(s)* Refills:*1* 5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 8. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Type B Aortic Dissection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You have an aortic dissection and will need surgery to repair it. You must keep your blood pressure under good control until your follow up and surgery with the cardiac surgery division. You should not lift anything >10 lbs. Do not drive while taking narcotic pain medication. You have a mechanical aortic valve replacement and must be anticoagulated for this. You have been started on Lovenox (short term blood thinner) and restarted on [**Hospital1 197**] (long term blood thinner). Contine both and have your blood level (INR) checked at least 2x week. When your INR is >2, you will stop the Lovenox injections but continue on [**Hospital1 197**]. Do not change your dose or discontiue either medication without your PCP's instruction. Discharge Instructions: Taking [**Hospital1 197**] (Warfarin) Your doctor [**First Name (Titles) 2875**] [**Last Name (Titles) 197**] (warfarin) for you. Be sure to take it as directed. Because [**Last Name (Titles) 197**] helps keep your blood from clotting, you also need to protect yourself from injury, which could lead to excessive bleeding. Guidelines for Medication Use Follow the fact sheet that came with your medication. It tells you when and how to take your medication. Ask for a sheet if you didn??????t get one. Do not take [**Last Name (Titles) 197**] during pregnancy because it can cause birth defects. Talk to your doctor about the risks of taking [**Last Name (Titles) 197**] while pregnant. Take [**Last Name (Titles) 197**] at the same time each day. If you miss a dose, take it as soon as you remember??????unless it??????s almost time for your next dose. In that case, skip the dose you missed. [**Male First Name (un) **]??????t take a double dose. Keep appointments for blood (protime/INR) tests as often as directed. [**Male First Name (un) **]??????t take any other medications without checking with your doctor first. This includes over-the-counter medications and any herbal remedies. Other Precautions Tell all your healthcare providers that you take [**Male First Name (un) 197**]. It??????s also a good idea to carry a medical identification card or wear a medical ID bracelet. Use a soft toothbrush and an electric razor. [**Male First Name (un) **]??????t go barefoot. [**Male First Name (un) **]??????t trim corns or calluses yourself. Keep Your Diet Steady Keep your diet pretty much the same each day. That??????s because many foods contain vitamin K. Vitamin K helps your blood clot. So eating foods that contain vitamin K can affect the way [**Male First Name (un) 197**] works. You [**Male First Name (un) **]??????t need to avoid foods that have vitamin K. But you do need to keep the amount of them you eat steady (about the same day to day). If you change your diet for any reason, such as due to illness or to lose weight, be sure to tell your doctor. Examples of foods high in vitamin K are asparagus, avocado, broccoli, and cabbage. Oils, such as soybean, canola, and olive oils are also high in vitamin K. Alcohol affects how your body uses [**Male First Name (un) 197**]. Talk to your doctor about whether you should avoid alcohol while you??????re using [**Male First Name (un) 197**]. Herbal teas that contain sweet clover, sweet [**Location (un) **], or tonka beans can interact with [**Location (un) 197**]. Keep the amount of herbal tea you use steady. Possible Side Effects Tell your doctor if you have any of these side effects, but [**Male First Name (un) **]??????t stop taking the medication until your doctor tells you to. Mild side effects include the following: More gas (flatulence) than usual Bloating Diarrhea Nausea Vomiting Hair loss Decreased appetite Weight loss When to Call Your Doctor Call your doctor immediately if you have any of the following: Trouble breathing Swollen lips, tongue, throat, or face Hives or painful rash Black, bloody, or tarry stools Blood in your urine Vomiting or coughing up blood Bleeding gums or sores in your mouth Urinating less than usual Yellowing of the skin or eyes (jaundice) Dizziness Severe headache Easy bleeding or bruising Purple discoloration of your toes or fingers Sudden leg or foot pain Any chest pain Lovenox/Enoxaparin injection What is enoxaparin injection? ENOXAPARIN (Lovenox??????) is commonly used after knee, hip, or abdominal surgeries to prevent blood clotting. Enoxaparin is also used to treat existing blood clots in the lungs or in the veins. Enoxaparin is similar to heparin. Enoxaparin is known as an anticoagulant, and is sometimes called a blood thinner. However, enoxaparin does not actually thin the blood, but decreases the ability of blood to form clots. Generic enoxaparin injections are not yet available. What should my health care professional know before I receive enoxaparin? They need to know if you have any of these conditions: bleeding disorders, hemorrhage, or hemophilia brain tumor or aneurysm decreased kidney function diabetes high blood pressure infection of the heart or heart valves receiving injections of medications or vitamins liver disease previous stroke prosthetic heart valve recent surgery or delivery of a baby ulcer in the stomach or intestine, diverticulitis, or other bowel disease undergoing treatments for cancer an unusual or allergic reaction to enoxaparin, heparin, pork or pork products, other medicines, foods, dyes, or preservatives pregnant or trying to get pregnant breast-feeding How should I use this medicine? Enoxaparin is for injection under the skin. It is usually given by a health-care professional, or you or a family member may be trained on how to give the injections. If you are to give yourself injections, make sure you understand how to use the syringe, measure the dose if necessary, and give the injection, and how to dispose of used syringes and needles. Use the syringes only once, and throw away syringes and needles in a closed container to prevent accidental needle sticks. Use exactly as directed. Do not exceed the [**Male First Name (un) 2875**] dose, and try not to miss doses. To avoid bruising, do not rub the site where enoxaparin has been injected. What if I miss a dose? It is important to administer enoxaparin at regular intervals as [**Male First Name (un) 2875**] by your health care professional. Depending on your condition, enoxaparin is usually given either once daily (every 24 hours) or twice daily (every 12 hours). If you have been instructed to use enoxaparin on a regular schedule, use missed doses as soon as you remember, unless it is almost time for the next dose. Do not use double doses. What drug(s) may interact with enoxaparin? antiinflammatory drugs such as ibuprofen (Motrin??????), naproxen (Aleve??????), or ketoprofen (Orudis-KT??????) clopidogrel dipyridamole fish oil (omega-3 fatty acids) supplements herbal products containing feverfew, garlic, ginger, gingko, or horse chestnut ticlopidine Tell your prescriber or health care professional about all other medicines you are taking, including non-prescription medicines, nutritional supplements, or herbal products. Also tell your prescriber or health care professional if you are a frequent user of drinks with caffeine or alcohol, if you smoke, or if you use illegal drugs. These may affect the way your medicine works. Check with your health care professional before stopping or starting any of your medicines. What should I watch for while taking enoxaparin? In case of an accident or emergency, it is recommended that you place a notification in your wallet that you are receiving enoxaparin. Your condition will be monitored carefully while you are receiving enoxaparin. Notify your prescriber or health care professional and seek emergency treatment if you develop increased difficulty in breathing, chest pain, dizziness, shortness of breath, swelling in the legs or arms, abdominal pain, decreased vision, pain when walking, or pain and warmth of the arms or legs. These can be signs that your condition has worsened. Monitor your skin closely for easy bruising or red spots, which can indicate bleeding. If you notice easy bruising or minor bleeding from the nose, gums/teeth, in your urine, or stool, contact your prescriber or health care professional immediately, these are indications that your medication needs adjustment or evaluation. Keep scheduled appointments with your prescriber or health care professional to check on your condition. If you are going to have surgery, tell your prescriber or health care professional that you have received enoxaparin. Be careful to avoid injury while you are using enoxaparin. Take special care brushing or flossing your teeth, shaving, cutting your fingernails or toenails, or when using sharp objects. Report any injuries to your prescriber or health care professional. What side effects might I notice from receiving enoxaparin? Side effects that you should report to your prescriber or health care professional as soon as possible: Rare or uncommon: signs and symptoms of bleeding such as back or stomach pain, black, tarry stools, blood in the urine, or coughing up blood difficulty breathing dizziness or fainting spells More frequent: bleeding from the injection site fever unusual bruising or bleeding: bleeding gums, red spots on the skin, nosebleeds Side effects that usually do not require medical attention (report to your prescriber or health care professional if they continue or are bothersome): pain or irritation at the injection site skin rash, itching Where can I keep my medicine? Keep out of the reach of children. Store at room temperature below 25 degrees C (77 degrees F); do not freeze. If your injections have been specially prepared, you may need to store them in the refrigerator - ask your pharmacist. Throw away any unused medicine after the expiration date. Make sure you receive a puncture-resistant container to dispose of the needles and syringes once you have finished with them. Do not reuse these items. Return the container to your prescriber or health care professional for proper disposal Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 85918**], MD Phone:[**Telephone/Fax (1) 3070**] Date/Time:[**2149-12-19**] 11:20. This is for INR follow-up. [**Street Address(2) 91381**], [**Location (un) **] MASS. [**Telephone/Fax (1) 3070**] *** do not miss [**First Name (Titles) **] [**Last Name (Titles) **]t*** [**Doctor Last Name **] [**Doctor Last Name **] DAMN, WEND [**1668-12-30**] HRS. [**Street Address(2) **], [**Location (un) **] MASS. [**Telephone/Fax (1) 3070**]. NEW PCP Your surgery will be scheduled sometime in the next several weeks. Dr.[**Name (NI) 9379**] (cardiac surgeon) office will call you with your surgery date. His number is ([**Telephone/Fax (1) 1504**] Completed by:[**2149-12-17**]

441,425,428,V433,V458,303,296,401,786,V586,414,412,440,070,V158,305,304

{'Dissection of aorta, thoracoabdominal,Other primary cardiomyopathies,Chronic systolic heart failure,Heart valve replaced by other means,Aortocoronary bypass status,Other and unspecified alcohol dependence, continuous,Bipolar disorder, unspecified,Unspecified essential hypertension,Precordial pain,Long-term (current) use of anticoagulants,Coronary atherosclerosis of unspecified type of vessel, native or graft,Old myocardial infarction,Atherosclerosis of native arteries of the extremities, unspecified,Unspecified viral hepatitis C without hepatic coma,Personal history of noncompliance with medical treatment, presenting hazards to health,Tobacco use disorder,Amphetamine and other psychostimulant dependence, in remission'}

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: chest and back pain PRESENT ILLNESS: 52M with a history of thoracic aortic aneurysm presents to the [**Hospital1 18**] ER with a 3 hour history of a tearing chest pain that radiated to his back. He states the pain began during the day, however was a lower grade pain and around 11PM the pain became sharp, severe and constant. The pain intensity did not subside therefore he decided to be evaluated in the ER. He also reports he had a similar episode 2 weeks ago where he was evaluated at [**Hospital1 2025**] and was told he had a thoracic aneurysm. He was evaluated by a surgeon who suggestive operative repair, however the patient was unable to go to his follow up appointments. MEDICAL HISTORY: Hep C, type A aortic dissection (caused by htn/drug use per pt) MEDICATION ON ADMISSION: [**Last Name (STitle) 197**] 5', Folic Acid 1', ISMN ER 30', Nifedical XL 30', Carvediolol 12.5'' ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: bp 106/62 HR 56 reg RR 12 FAMILY HISTORY: denies hx of aortic aneurysms, dissections or valvular disease SOCIAL HISTORY: Lives with son, recently moved to [**State 350**], on disability, drink 3 40oz beers a day along with 2-3 shots of liquor, smokes [**1-19**] cigarettes/day, smokes occasional marijuana ### Response: {'Dissection of aorta, thoracoabdominal,Other primary cardiomyopathies,Chronic systolic heart failure,Heart valve replaced by other means,Aortocoronary bypass status,Other and unspecified alcohol dependence, continuous,Bipolar disorder, unspecified,Unspecified essential hypertension,Precordial pain,Long-term (current) use of anticoagulants,Coronary atherosclerosis of unspecified type of vessel, native or graft,Old myocardial infarction,Atherosclerosis of native arteries of the extremities, unspecified,Unspecified viral hepatitis C without hepatic coma,Personal history of noncompliance with medical treatment, presenting hazards to health,Tobacco use disorder,Amphetamine and other psychostimulant dependence, in remission'}

CHIEF COMPLAINT: PRESENT ILLNESS: Mrs. [**Known lastname 1637**] is a 69 year old female with a history of coronary artery disease status post coronary artery bypass graft following a non-ST elevation myocardial infarction in [**2124-1-1**], and also history of type I diabetes, presenting with unstable angina. The patient had done well from coronary artery bypass graft until [**2124-10-30**] when she began to experience angina again. She was taken to the catheterization laboratory at that point where she was found to have left anterior descending lesions which were not amenable to intervention at that time and the case was complicated by two dissections. Following that the patient had an escalated pattern of angina until 2 days prior to admission when the patient experienced angina at rest. Her angina is experienced as a chest heaviness with pain radiating to the left arm. MEDICAL HISTORY: 1. Coronary artery disease status post coronary artery bypass graft in [**2123**] wit saphenous vein graft to patent ductus arteriosus and saphenous vein graft to left anterior descending, left internal mammary artery to diagonal, saphenous vein graft to an OM. Catheterization on [**11-2**] showed stump occlusion of saphenous vein graft to the left anterior descending with failed intervention, stump occlusion saphenous vein graft to the patent ductus arteriosus, patent left internal mammary artery to the diagonal and patent saphenous vein graft to the OM. 2. Type 1 diabetes mellitus. 3. IgG Monoclonal gammopathy. 4. Osteoporosis. 5. Status post TH for leiomyoma. 6. Hypertension. MEDICATION ON ADMISSION: ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: She lives alone in [**Location (un) 3307**]. No tobacco, alcohol or drug use.

Coronary atherosclerosis of native coronary artery,Congestive heart failure, unspecified,Mitral valve disorders,Cardiogenic shock,Diabetes with ketoacidosis, type I [juvenile type], not stated as uncontrolled,Acidosis,Cardiac complications, not elsewhere classified,Acute myocardial infarction of unspecified site, initial episode of care,Paroxysmal ventricular tachycardia

Crnry athrscl natve vssl,CHF NOS,Mitral valve disorder,Cardiogenic shock,DMI keto nt st uncntrld,Acidosis,Surg compl-heart,AMI NOS, initial,Parox ventric tachycard

Admission Date: [**2125-1-20**] Discharge Date: [**2125-1-29**] Date of Birth: [**2055-11-6**] Sex: F Service: HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 1637**] is a 69 year old female with a history of coronary artery disease status post coronary artery bypass graft following a non-ST elevation myocardial infarction in [**2124-1-1**], and also history of type I diabetes, presenting with unstable angina. The patient had done well from coronary artery bypass graft until [**2124-10-30**] when she began to experience angina again. She was taken to the catheterization laboratory at that point where she was found to have left anterior descending lesions which were not amenable to intervention at that time and the case was complicated by two dissections. Following that the patient had an escalated pattern of angina until 2 days prior to admission when the patient experienced angina at rest. Her angina is experienced as a chest heaviness with pain radiating to the left arm. PAST MEDICAL HISTORY: 1. Coronary artery disease status post coronary artery bypass graft in [**2123**] wit saphenous vein graft to patent ductus arteriosus and saphenous vein graft to left anterior descending, left internal mammary artery to diagonal, saphenous vein graft to an OM. Catheterization on [**11-2**] showed stump occlusion of saphenous vein graft to the left anterior descending with failed intervention, stump occlusion saphenous vein graft to the patent ductus arteriosus, patent left internal mammary artery to the diagonal and patent saphenous vein graft to the OM. 2. Type 1 diabetes mellitus. 3. IgG Monoclonal gammopathy. 4. Osteoporosis. 5. Status post TH for leiomyoma. 6. Hypertension. MEDICATIONS: 1. Actonel 35 mg po q week. 2. Aspirin 81 mg po once daily. 3. Insulin NPH 18 units in the morning and 8 units in the evening. Regular insulin 8 units in the morning and 2 units at dinner. 4. Imdur 30 mg three times a day. 5. Lipitor 10 mg po once daily. 6. Lisinopril 40 mg po once daily. 7. Metformin 500 mg po twice a day 8. Plavix 75 mg po once daily 9. Toprol-XL 50 mg po once daily ALLERGIES: No known drug allergies. SOCIAL HISTORY: She lives alone in [**Location (un) 3307**]. No tobacco, alcohol or drug use. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.9, blood pressure 94/33, pulse 60, respiratory rate 16, saturating at 99 percent on room air. LUNGS: Clear. HEART: Unremarkable without murmurs, rubs, or gallops. EXTREMITY: She had no lower extremity edema. LABORATORY DATA: On admission laboratory data was notable for sodium of 132, glucose of 272, normal creatinine, normal coags, and normal CK with a troponin of 0.02. HOSPITAL COURSE: 1. Cardiovascular: The patient underwent cardiac catheterization on [**1-22**] initially which demonstrated 20 percent left main left anterior descending calcified with 95 percent osteal stenosis in the mid and distal vessel within the distal left anterior descending, circumflex had diffuse disease with 60 percent osteal stenosis and 80 percent long stenosis between the OM2 and OM3, right coronary artery had moderate degree disease and saphenous vein graft to OM2 was widely patent but with severe disease again between the OM2 and OM3. She had a hepico stent deployed in the mid left anterior descending but the distal left anterior descending was small and diffusely diseased and not amenable to stenting. She had following that an episode of nausea, and the next morning had recurrent episode of chest pain radiating to the left arm. Electrocardiogram showed slight ST elevations in V2, V3 with inverted T waves in V4, V5, V6, and the patient was hypotensive to the 70's. The patient had no sign or symptoms of congestive heart failure while in hospital. She was treated with 20 mg of Lasix po once daily and given her orthostasis until the day prior to discharge she had persistent low blood pressure. On the day of discharge her Lasix was discontinued. She was taken back to the cardiac catheterization laboratory where the stent into the left anterior descending was opened but there was again diffuse vessel disease. Another stent was deployed within that previously patent stent. Also the patient was noted to have a decreased cardiac index at 1.98 and to be profoundly acidotic. An intraaortic balloon pump was placed after administration of Dopamine. She was noted to have decreased ejection fraction of approximately 30 percent. The patient was transferred to the CCU where she was found to have ketones and determined to be in diabetic ketoacidosis. The pressors were aptly weaned off. The balloon pump was weaned within 24 hours. The patient was transported back to the floor. Of note the patient had CK pump to the 700s following a second event and repeat echocardiogram demonstrated new ejection fraction of approximately 25 percent. Thereafter the patient remained chest pain free while in house, however her blood pressure remained tenuous and she was orthostatic until the day of discharge. For that reason her beta blocker and ACE inhibitor were decreased to 12.5 mg of atenolol and 2.5 mg of lisinopril. It was felt that there were likely no further interventions possible on this patient given difficulties in the catheterization state. She was continued on aspirin, Plavix, atorvastatin, and Warfarin was initiated for decreased ejection fraction of 25 percent with a target INR of 2. ENDOCRINE: The patient is a type 1 diabetic and the morning following her initial cardiac catheterization she refused her insulin. NOHA staff was notified and the patient subsequently went into diabetic ketoacidosis. She was treated in the Intensive Care Unit with insulin and fluids and electrolytes and the acidosis rapidly resolved and she had no further complications of diabetes during her hospital stay. LABORATORY STUDIES: In addition to the cardiac catheterization as mentioned previously the patient had several echocardiograms, the last of which was done on [**1-26**], which was 3 days after her second cardiac catheterization. This demonstrated moderately dilated left ventricular cavity. Severe global left ventricular hypokinesis with basal inferolateral akinesis, mid inferolateral akinesis, and lateral apex was akinetic without an effusion. 1+ mitral regurgitation and normal RV function. The patient had a peak CK of 765 on [**1-24**] and chest x-ray on [**1-25**], showed mild cardiomegaly and minimal perihilar haziness in upper lobe redistribution. DISCHARGE CONDITION: Good. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSIS: 1. Coronary artery disease, likely not amenable to further intervention status post left anterior descending stents x 2. 2. Congestive heart failure with ejection fraction 25 percent. 3. Type 1 diabetes mellitus. 4. Hypertension. 5. Anticoagulation for low ejection fraction. DISCHARGE MEDICATIONS: 1. Atorvastatin 10 mg po once daily 2. Plavix 25 mg po once daily 3. Pantoprazole 40 mg po once daily 4. Aspirin 325 mg po once daily 5. Metoprolol XL 12.5 6. Warfarin 5 mg qhs [**1-29**] and [**1-30**] and then 2 mg thereafter to have an INR checked on [**2125-2-1**], targeting an INR of 2.0. 7. Insulin NPH 18 units in the morning and 8 units in the evening, Regular insulin sliding scale 8. Lisinopril 2.5 mg po once daily. FOLLOW UP APPOINTMENTS: The patient has follow up appointment with Dr. [**Last Name (STitle) **] on [**2-2**] and he should call her usual cardiologist for an appointment within one to two weeks. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], M.D. Dictated By:[**Last Name (NamePattern1) 11801**] MEDQUIST36 D: [**2125-1-30**] 10:31 T: [**2125-2-1**] 21:02 JOB#: [**Job Number 31075**]

414,428,424,785,250,276,997,410,427

{'Coronary atherosclerosis of native coronary artery,Congestive heart failure, unspecified,Mitral valve disorders,Cardiogenic shock,Diabetes with ketoacidosis, type I [juvenile type], not stated as uncontrolled,Acidosis,Cardiac complications, not elsewhere classified,Acute myocardial infarction of unspecified site, initial episode of care,Paroxysmal ventricular tachycardia'}

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: Mrs. [**Known lastname 1637**] is a 69 year old female with a history of coronary artery disease status post coronary artery bypass graft following a non-ST elevation myocardial infarction in [**2124-1-1**], and also history of type I diabetes, presenting with unstable angina. The patient had done well from coronary artery bypass graft until [**2124-10-30**] when she began to experience angina again. She was taken to the catheterization laboratory at that point where she was found to have left anterior descending lesions which were not amenable to intervention at that time and the case was complicated by two dissections. Following that the patient had an escalated pattern of angina until 2 days prior to admission when the patient experienced angina at rest. Her angina is experienced as a chest heaviness with pain radiating to the left arm. MEDICAL HISTORY: 1. Coronary artery disease status post coronary artery bypass graft in [**2123**] wit saphenous vein graft to patent ductus arteriosus and saphenous vein graft to left anterior descending, left internal mammary artery to diagonal, saphenous vein graft to an OM. Catheterization on [**11-2**] showed stump occlusion of saphenous vein graft to the left anterior descending with failed intervention, stump occlusion saphenous vein graft to the patent ductus arteriosus, patent left internal mammary artery to the diagonal and patent saphenous vein graft to the OM. 2. Type 1 diabetes mellitus. 3. IgG Monoclonal gammopathy. 4. Osteoporosis. 5. Status post TH for leiomyoma. 6. Hypertension. MEDICATION ON ADMISSION: ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: She lives alone in [**Location (un) 3307**]. No tobacco, alcohol or drug use. ### Response: {'Coronary atherosclerosis of native coronary artery,Congestive heart failure, unspecified,Mitral valve disorders,Cardiogenic shock,Diabetes with ketoacidosis, type I [juvenile type], not stated as uncontrolled,Acidosis,Cardiac complications, not elsewhere classified,Acute myocardial infarction of unspecified site, initial episode of care,Paroxysmal ventricular tachycardia'}

CHIEF COMPLAINT: Nausea, vomiting, hypertension. PRESENT ILLNESS: This is a 33-year-old male with a history of uncontrolled hypertension, type 1 diabetes, and severe gastroparesis. He was recently admitted from [**2182-1-3**] through [**2182-1-7**] for hypertensive crisis as well as exacerbation of gastroparesis. He returned to be admitted to the CCU on [**2182-1-10**] for hypertension, hypertensive crisis with systolic blood pressures in the 200s, with diastolic pressures in the 100s. The patient was treated with nitroprusside drip until systolic blood pressure stayed in the 180s, before transfer to the medical floor. MEDICAL HISTORY: 1. Type 1 diabetes mellitus since [**00**] years of age. History of diabetic ketoacidosis. 2. History of hypertensive urgency. 3. Severe gastroparesis. 4. Hemorrhagic gastritis. 5. History of esophageal ulcer. 6. Coronary artery disease (please see discharge summary from [**2182-1-7**] for more details). MEDICATION ON ADMISSION: ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: Positive for type 1 diabetes, gastroparesis, hypertension (please see previous discharge summary from [**2182-1-7**]). SOCIAL HISTORY: The patient denies alcohol, cocaine and tobacco use. He has a girl friend.

Malignant essential hypertension,Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled,Urinary tract infection, site not specified,Gastroparesis,Neurogenic bladder NOS,Orthostatic hypotension

Malignant hypertension,DMI neuro nt st uncntrld,Urin tract infection NOS,Gastroparesis,Neurogenic bladder NOS,Orthostatic hypotension

Admission Date: [**2182-1-10**] Discharge Date: [**2182-1-17**] Date of Birth: [**2148-4-23**] Sex: M Service: MEDICINE CHIEF COMPLAINT: Nausea, vomiting, hypertension. HISTORY OF PRESENT ILLNESS: This is a 33-year-old male with a history of uncontrolled hypertension, type 1 diabetes, and severe gastroparesis. He was recently admitted from [**2182-1-3**] through [**2182-1-7**] for hypertensive crisis as well as exacerbation of gastroparesis. He returned to be admitted to the CCU on [**2182-1-10**] for hypertension, hypertensive crisis with systolic blood pressures in the 200s, with diastolic pressures in the 100s. The patient was treated with nitroprusside drip until systolic blood pressure stayed in the 180s, before transfer to the medical floor. On [**2182-1-10**] admission to the CCU, the patient had nausea, vomiting, blurry vision, diarrhea, myalgias, but denied chest pain, headaches, shortness of breath and cough. Prior to the transfer to the floor, his clonidine patch was increased from 0.1 mg to 0.2 mg. The patient states that the morning of this admission, he had a fatty meal. PAST MEDICAL HISTORY: 1. Type 1 diabetes mellitus since [**00**] years of age. History of diabetic ketoacidosis. 2. History of hypertensive urgency. 3. Severe gastroparesis. 4. Hemorrhagic gastritis. 5. History of esophageal ulcer. 6. Coronary artery disease (please see discharge summary from [**2182-1-7**] for more details). MEDICINES ON ADMISSION: 1. Lisinopril 10 mg p.o. q.d. 2. Clonidine 0.1 mg transdermal patch, to be replaced on Fridays. 3. NPH insulin 12 units q.a.m. and 12 units q.p.m. 4. Regular insulin, sliding scale, per Joclyn (see previous discharge summary discharge medications from [**2182-1-7**]). 5. Reglan 10 mg p.o. q.d. 6. Protonix 40 mg p.o. q.d. 7. Micronase 5 mg p.o. q.d. MEDICINES ON TRANSFER FROM THE CCU: 1. Reglan 10 mg I.V. q.i.d. 2. Lisinopril 2.5 mg q.d. 3. Clonidine 0.2 mg q.week patch. 4. Florinef 0.1 mg q.d. 5. Labetalol 400 mg b.i.d. 6. Levofloxacin 250 mg q.d. 7. Ativan 0.5 mg q.4-6h. p.r.n. 8. Zofran 2 mg q.6h. p.r.n. 9. Regular insulin, sliding scale. 10. Protonix 40 mg q.d. 11. Maalox p.r.n. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient denies alcohol, cocaine and tobacco use. He has a girl friend. FAMILY HISTORY: Positive for type 1 diabetes, gastroparesis, hypertension (please see previous discharge summary from [**2182-1-7**]). PHYSICAL EXAM ON TRANSFER TO THE FLOOR: Blood pressure 177/70, heart rate 108, respirations 14, temperature 98.6??????, O2 sat 98% on room air. GENERAL: Patient shaking and unable to talk. HEENT: Anicteric. Eyes - pupils are equally round, reactive to light. Mucous membranes are dry. NECK: Supple without lymphadenopathy. CV: Tachycardic. Regular rate and rhythm, normal S1 and S2. CHEST: Clear to auscultation bilaterally. ABDOMEN: Diffusely tender to palpation, decreased bowel sounds. EXTREMITIES: No cyanosis, clubbing or edema. LABS: WBC 11.1, hematocrit 28.7, platelets 225, sodium 137, potassium 3.9, chloride 107, bicarb 22, BUN 25, creatinine 1.7, glucose 190, calcium 8.6, phosphorus 3.7, magnesium 1.5. ASSESSMENT: This is a 33-year-old male with type 1 diabetes who returns approximately two days after being discharged to the CCU with hypertensive urgency, nausea, vomiting, abdominal pain. HOSPITAL COURSE: After transfer from the CCU: 1. Hypertension: The patient's systolic blood pressures remained under 170 - 180 on the floor while the patient was supine. The patient had marked orthostatic hypotension (lying down usually 150 - 170, sitting up decreased to around 120s, and standing up systolic blood pressures in the 90s). This was completely asymptomatic. He denied dizziness, lightheadedness, nausea, or headache. Because of this, his clonidine patch was decreased back down to 0.1 mg q.week and his lisinopril was titrated up to 20 mg q.day. The labetalol remained at 400 mg b.i.d. Florinef was restarted upon discharge from the CCU, however it was discontinued after one day on the floor. It was decided that the Florinef was not a good idea in this patient who not only has orthostatic hypotension but has very markedly elevated blood pressures as well. This was discontinued on the last admission, and we agree with that assessment on this admission as well. A tox-screen, as it always has been, was negative. The patient has a digital blood pressure cuff at home, with which he will be measuring a.m. blood pressure. The endocrine also set him up for ambulatory blood pressure monitoring in their clinic. 2. GI: Again, the patient was made NPO and treated with I.V. Protonix, I.V. Reglan, and I.V. antiemetics. This improved in approximately three to four days, and then he was tolerating p.o. Nutrition was consulted to help the patient understand the importance of dietary compliance. 3. Type 1 diabetes: The patient was seen by [**Hospital1 756**] endocrine fellow (Dr. [**Last Name (STitle) 60745**] as well as with the endocrine attending on service. The insulin regimen that the patient was currently on with NPH was changed to a standing Humalog before meals, as well as Lantus at night. He was continued on his fingersticks q.i.d. as well as Humalog sliding scale. The regimen was increased while the patient was in-house to try to maintain blood sugars in the 100s to low 200s. Mr. [**Known lastname **] knows how to contact Dr. [**Last Name (STitle) 60745**] with his blood sugars for the next couple of days while he is an outpatient for help with management. 4. Endocrine: Of note, Mr. [**Known lastname **] had a previously high 24-hour urine cortisol. However, since this was done in a high-stress setting in the ICU, it is likely an artifact but will need to be checked again in order to rule out [**Location (un) 3484**] disease. Mr. [**Known lastname **] has a prescription to recheck this as an outpatient in the [**Hospital 1800**] Clinic. At that time, he will also have an aldosterone and a plasma renin activity level checked as well. 5. Renal: The Renal Team followed Mr. [**Known lastname **] for his chronic renal insufficiency. To manage his blood pressure, they preferred an ACE inhibitor instead of hydralazine. However, when the patient had extremely high blood pressures, he did respond to I.V. hydralazine in the acute setting. They recommended watching the dose of the ACE inhibitor, however, secondary to his chronic renal insufficiency. 6. Recurrent UTIs: On admission to the CCU, the patient had a urinary tract infection, this time with pyuria (he has had several in the past without pyuria), which was asymptomatic, however cultures grew coag-negative Staph. aureus that was resistant to penicillin and Levaquin. Therefore, the Levaquin that was started empirically was changed to I.V. oxacillin. The patient has had several UTIs notable for a coag-negative Staph. Occasionally with white blood cells in the urine and leukocyte esterase and other times without, most but not all in the setting of a Foley. Infectious disease was consulted and thought that this was likely colonization, was asymptomatic, and therefore antibiotics were not necessary. Urology was consulted and recommended renal ultrasound that showed bilateral echogenic kidneys consistent with parenchymal disease. It also revealed an increased post-void residual volume of approximately 129 cc. On the floor, the patient had post-void residual measured which only showed 20 cc, and this residual urine was sent for UA and culture after he had been on the oxacillin for four to five days. This culture did come back as no growth. Urology recommended finishing a 7-day course of p.o. Keflex at 500 mg q.i.d. and then switching to a suppressive dose of 250 mg of Keflex b.i.d. The elevated post-void residual and frequent UTIs (note that a prostate ultrasound was checked and was negative on this admission) do support the possibility of a neurogenic bladder secondary to type 1 diabetes with severe autonomic dysfunction. CONDITION AT DISCHARGE: Good. DISCHARGE STATUS: The patient was discharged to home and was given explicit instructions about his followup and recent change in medications. He was again instructed to eat low-fat meals, at least four times a day, that were of small volume, that would help not exacerbate his gastroparesis. DISCHARGE MEDICATIONS: 1. Lantus 18 units q.h.s. 2. Humalog 4 units immediately before breakfast, 6 units immediately before lunch, 6 units immediately before dinner. 3. Keflex 500 mg q.i.d. to finish up a 7-day course and then 250 mg b.i.d. 4. Micronase 5 mg q.d. 5. Protonix 40 mg q.d. 6. Reglan 10 mg q.i.d. 7. Clonidine 0.1 mg patch - a new patch was recently placed on Thursday, [**2182-1-17**], to be changed once a week. 8. Lisinopril 20 mg q.d. 9. Labetalol 400 mg b.i.d. DISCHARGE DIAGNOSES: 1. Type 1 diabetes with autonomic dysregulation. 2. Hypertensive urgency. 3. Asymptomatic orthostatic hypotension. 4. Gastroparesis. 5. Recurrent Staph. coag-negative UTIs. FOLLOWUP APPOINTMENTS: 1. [**Hospital 1800**] clinic, [**2182-1-18**], 3:00 pm, [**Street Address(2) 93185**] (Dr. [**Last Name (STitle) 60745**] - to be set up for ambulatory blood pressure monitoring, to rule out elevated aldosterone, to check plasma renin activity as well as to collect urine collection bottle to measure 24-hour cortisol). 2. ................... PCP at [**Name9 (PRE) 191**] [**Name9 (PRE) 479**] on Monday, [**2182-1-21**] at 1:30. 3. Dr. [**Last Name (STitle) 9125**] in Urology, [**2182-2-14**], Thursday at 1:00 pm at [**Hospital1 9384**] in the [**Hospital 1426**] Medical Building on the [**Location (un) 448**]. 4. [**Hospital 2793**] clinic with Dr. [**Last Name (STitle) **] [**Name (STitle) 1860**] on [**2182-2-21**], Thursday, at 1:00 pm. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) 736**] Dictated By:[**Name8 (MD) 210**] MEDQUIST36 D: [**2182-1-19**] 19:06 T: [**2182-1-19**] 19:29 JOB#: [**Job Number **]

401,250,599,536,596,458

{'Malignant essential hypertension,Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled,Urinary tract infection, site not specified,Gastroparesis,Neurogenic bladder NOS,Orthostatic hypotension'}

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: Nausea, vomiting, hypertension. PRESENT ILLNESS: This is a 33-year-old male with a history of uncontrolled hypertension, type 1 diabetes, and severe gastroparesis. He was recently admitted from [**2182-1-3**] through [**2182-1-7**] for hypertensive crisis as well as exacerbation of gastroparesis. He returned to be admitted to the CCU on [**2182-1-10**] for hypertension, hypertensive crisis with systolic blood pressures in the 200s, with diastolic pressures in the 100s. The patient was treated with nitroprusside drip until systolic blood pressure stayed in the 180s, before transfer to the medical floor. MEDICAL HISTORY: 1. Type 1 diabetes mellitus since [**00**] years of age. History of diabetic ketoacidosis. 2. History of hypertensive urgency. 3. Severe gastroparesis. 4. Hemorrhagic gastritis. 5. History of esophageal ulcer. 6. Coronary artery disease (please see discharge summary from [**2182-1-7**] for more details). MEDICATION ON ADMISSION: ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: Positive for type 1 diabetes, gastroparesis, hypertension (please see previous discharge summary from [**2182-1-7**]). SOCIAL HISTORY: The patient denies alcohol, cocaine and tobacco use. He has a girl friend. ### Response: {'Malignant essential hypertension,Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled,Urinary tract infection, site not specified,Gastroparesis,Neurogenic bladder NOS,Orthostatic hypotension'}

CHIEF COMPLAINT: Acetaminophen and aspirin overdose PRESENT ILLNESS: Patient is a 19 year old female with Hx of several past suicide attempts transferred from [**Hospital 1562**] Hospital with an aspirin and tylenol overdose after 24hours s/p ingestion with Tylenol level at that time was well within parameters for probable hepatic toxicity per the Rumack-[**Doctor First Name **] nomogram. Reportedly day prior to admission to OSH, at 1 pm, pt took 70 pills each of ASA and tylenol (around 30 g). She subsequently vomited, including pill fragments yesterday. She did have some tinnitus. Otherwise was doing well but decided to call 911 the subsequent morning and was brought to ED at the OSH. In the ED, the pt was asymptomatic. Pt. Was given her inital dose of PO Mucomyst 7 grams. About an hour and a half later she vomited the initial dose. She denies taking any other substances. Initial Tylenol level at approximately 24 H was 31 with initial AST/ALT 62/63 increase to 411/332. Pt was transferred from OSH for liver transplant evaluation if her liver function worsened. On admission to the MICU, the patient denied any Suicidal ideations/homocidal ideations. She denied any fever/chills, chest pain, shortness of breath, abdominal pain, BRBPR, hematemesis, diarrhea. She did report some nausea, but no emesis. The patient did report life stressors but did not wish to endorse further. . Patient was admitted with plan to give IV N-aceytlcysteine loading (150mg/kg over 15min, then 50mg/kg over 4 hours, then 100mg/kg over 16hours) and plans to monitor LFTs and INR. The liver team was consulted who recommended the patient finish the course of mucomyst 70mg/kg and recommended no vitamin K be given so as to trend the patient's INR as a marker of hepatic function. They also recommended continuing PPI and dolasteron for nausea associated with overdose. On admission, the patient's LFTs were AST = 543 and ALT = 648 with INR of 1.4. These peaked at 1076 and 1075 respictively, now trending downward with values of 374/830 today and INR of 1.2. The patient has no evidence of hepatic necrosis and will likely recover full hepatic function. She is currently awaiting placement for inpatient psychiatric hospitilization and is being admitted to the medical service for continued observation while awaiting placement. MEDICAL HISTORY: 1. Suicide Attempts x4- using different methods. One last year, landed her in a coma in [**Hospital3 **] hospital x3 days. She has been intubated for those events in the past. 2. Psychiatric History: very complex including chart diagnoses of bipolar disorder, ADHD, schizoaffective disorder, and OCD. Currently not taking any meds except zyprexa, but has taken depakote and lithium in the past. MEDICATION ON ADMISSION: Zyprexa but does not know the dose No herbals/vitamin supplements ALLERGIES: Penicillins PHYSICAL EXAM: 97.6 125/54 82 18 98%RA NAD, AAOx3, lying in bed, speaking in full sentences, has nail polish, sleeping with a pink [**Male First Name (un) **] bear. MMM, OP-clear, nose ring, neck FROM, PERRL, anicteric CTA-B RR without murmur soft, NT/ND, +BS, no HSM, keloid above belly button. No C/C/E, warm, no rashes No asterixis FAMILY HISTORY: Adopted from [**Country 10181**] SOCIAL HISTORY: Obtained her GED from High School. Currently single but sexually active. EtOH 1-3 beers ever couple nights. Denies cocaine, heroin, canabis, ecstasy. Currently lost her job a few weeks ago. Her boyfriend recently got out of jail.

Poisoning by aromatic analgesics, not elsewhere classified,Schizoaffective disorder, unspecified,Hepatitis, unspecified,Suicide and self-inflicted poisoning by analgesics, antipyretics, and antirheumatics,Unspecified nonpsychotic mental disorder,Bipolar I disorder, most recent episode (or current) unspecified,Borderline personality disorder,Attention deficit disorder with hyperactivity

Pois-arom analgesics NEC,Schizoaffective dis NOS,Hepatitis NOS,Poison-analgesics,Nonpsychotic disord NOS,Bipolor I current NOS,Borderline personality,Attn deficit w hyperact

Admission Date: [**2156-9-26**] Discharge Date: [**2156-9-29**] Date of Birth: [**2136-9-29**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 348**] Chief Complaint: Acetaminophen and aspirin overdose Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a 19 year old female with Hx of several past suicide attempts transferred from [**Hospital 1562**] Hospital with an aspirin and tylenol overdose after 24hours s/p ingestion with Tylenol level at that time was well within parameters for probable hepatic toxicity per the Rumack-[**Doctor First Name **] nomogram. Reportedly day prior to admission to OSH, at 1 pm, pt took 70 pills each of ASA and tylenol (around 30 g). She subsequently vomited, including pill fragments yesterday. She did have some tinnitus. Otherwise was doing well but decided to call 911 the subsequent morning and was brought to ED at the OSH. In the ED, the pt was asymptomatic. Pt. Was given her inital dose of PO Mucomyst 7 grams. About an hour and a half later she vomited the initial dose. She denies taking any other substances. Initial Tylenol level at approximately 24 H was 31 with initial AST/ALT 62/63 increase to 411/332. Pt was transferred from OSH for liver transplant evaluation if her liver function worsened. On admission to the MICU, the patient denied any Suicidal ideations/homocidal ideations. She denied any fever/chills, chest pain, shortness of breath, abdominal pain, BRBPR, hematemesis, diarrhea. She did report some nausea, but no emesis. The patient did report life stressors but did not wish to endorse further. . Patient was admitted with plan to give IV N-aceytlcysteine loading (150mg/kg over 15min, then 50mg/kg over 4 hours, then 100mg/kg over 16hours) and plans to monitor LFTs and INR. The liver team was consulted who recommended the patient finish the course of mucomyst 70mg/kg and recommended no vitamin K be given so as to trend the patient's INR as a marker of hepatic function. They also recommended continuing PPI and dolasteron for nausea associated with overdose. On admission, the patient's LFTs were AST = 543 and ALT = 648 with INR of 1.4. These peaked at 1076 and 1075 respictively, now trending downward with values of 374/830 today and INR of 1.2. The patient has no evidence of hepatic necrosis and will likely recover full hepatic function. She is currently awaiting placement for inpatient psychiatric hospitilization and is being admitted to the medical service for continued observation while awaiting placement. Past Medical History: 1. Suicide Attempts x4- using different methods. One last year, landed her in a coma in [**Hospital3 **] hospital x3 days. She has been intubated for those events in the past. 2. Psychiatric History: very complex including chart diagnoses of bipolar disorder, ADHD, schizoaffective disorder, and OCD. Currently not taking any meds except zyprexa, but has taken depakote and lithium in the past. Social History: Obtained her GED from High School. Currently single but sexually active. EtOH 1-3 beers ever couple nights. Denies cocaine, heroin, canabis, ecstasy. Currently lost her job a few weeks ago. Her boyfriend recently got out of jail. Family History: Adopted from [**Country 10181**] Physical Exam: 97.6 125/54 82 18 98%RA NAD, AAOx3, lying in bed, speaking in full sentences, has nail polish, sleeping with a pink [**Male First Name (un) **] bear. MMM, OP-clear, nose ring, neck FROM, PERRL, anicteric CTA-B RR without murmur soft, NT/ND, +BS, no HSM, keloid above belly button. No C/C/E, warm, no rashes No asterixis Pertinent Results: Admission Labs: [**2156-9-26**] CBC: WBC-8.9 RBC-4.12* HGB-12.8 HCT-36.8 MCV-90 MCH-31.1 MCHC-34.8 RDW-12.4 CHEM: GLUCOSE-127* UREA N-5* CREAT-0.7 SODIUM-141 POTASSIUM-3.9 CHLORIDE-109* TOTAL CO2-23 ANION GAP-13 LFTs: ALT(SGPT)-543* AST(SGOT)-648* LD(LDH)-589* ALK PHOS-74 TOT BILI-0.3 LIPASE-22 AMYLASE-35 Coags: PT-14.2* PTT-34.5 INR(PT)-1.4 Additional labs/studies . AST: 648 -> 1056 -> 1076 -> 825 -> 614 -> 374 -> 120 ALT: 543 -> 899 -> 1075 -> 1069 -> 979 -> 830 -> 588 INR: 1.4 -> 1.4 -> 1.3 -> 1.3 -> 1.4 -> 1.2 -> 1.1 . [**2156-9-27**]: ABG pO2-139* pCO2-28* pH-7.43 calHCO3-19* Base XS--3 [**2156-9-27**]: Lactate-1.5 Discharge Labs: [**2156-9-29**] CBC: WBC-4.5 RBC-3.88* Hgb-12.1 Hct-35.5* MCV-91 MCH-31.3 MCHC-34.2 RDW-12.8 Plt Ct-228 Chem: Glucose-89 UreaN-7 Creat-0.5 Na-140 K-3.7 Cl-106 HCO3-25 Calcium-9.3 Phos-3.3 Mg-2.0 LFTs: ALT-588* AST-120* AlkPhos-80 TotBili-0.4 DirBili-0.1 IndBili-0.3 Brief Hospital Course: A/P: Patient is a 19 year old female with multiple psyciatric diagnoses including bipolar disorder, Borderline personality disorder, schizoaffective disorder, ADHD admitted s/p suicide attempt by Tylenol and aspirin. . 1. Tylenol overdose - Patient was transferred from outside hospital with tylenol ingestion with levels in range of probable hepatotoxicity. She was started on IV mucomyst at OSH and transferred to [**Hospital1 18**] for further care and possible assesssment for transplant if need be. Upon admission to the intensive care unit, the patient was given a loading dose of mucomyst and additionally received remainded of acetylcysteine doses per protocol. The patient LFTS on admission were remarkable for AST = 648 and ALT = 543 which continued to rise initially on admission, peaking the day after admission at AST = 1076 and ALT = 1069. Since that time, the patient's LFTs have continued to resolve, msot recent upon discharge AST = 120 and ALT = 588. The patient's INR was mildly elevated on admission to 1.4. The patient did not receive Vitamin K as per GI's request so as to be able to chart the patient's hepatic function reliably. The patient's INR corrected spontaneously, now 1.1 on discharge without any events of bleeding during the patient's admission. The patient's synthetic function is currently completely restored and the patient is expected to recover fully from this insult. . 2. Psych - The psychiatry team was immediately part of the patient's care. Upon initial evaluation, given the patient's hepatotoxicity, the recommendation was made that all psych meds should be held. The patient carries multiple psychiatric diagnoses including Borderline PD, Bipolar, ADHD, and schizoaffective disorder with multiple suicide attempts. Given the patient's recent suicide attempt, she was kept with a 1:1 sitter while in the hospital. The patient was assessed daily for safety and endorsed to the team each day that she was not having and suicidal or homicidal ideation and denied throughout her hospital course any visual or auditory hallucinations. The patient is being discharged without any medications with expected assessment and appropriate treatment as necessary at the inpatient psych unit. The patient was discharged to the care of [**Hospital1 **] 4. . 3. FEN- The patient was on a house diet with repletion of electrolytes as needed Medications on Admission: Zyprexa but does not know the dose No herbals/vitamin supplements Discharge Medications: None Discharge Disposition: Extended Care Discharge Diagnosis: 1. Acetaminophen overdose 2. Suicide attempt 3. Bipolar disorder Discharge Condition: Good. Patient is with normal hepatic function, resolving transaminitis, without pain. Patient afebrile, hemodynamically stable Discharge Instructions: 1. Please take all medications as instructed 2. Please keep all outpatient appointments upon discharge 3. Please return to hospital for medical care if onset of severe abdominal pain, nausea/vomiting, bleeding or any other concerning symptoms. Followup Instructions: 1. Patient to be transferred to inpatient psychiatric facility 2. Please follow up with your psychiatrist upon discharge 3. Please follow up with your primary care physician upon discharge

965,295,573,E950,300,296,301,314

{'Poisoning by aromatic analgesics, not elsewhere classified,Schizoaffective disorder, unspecified,Hepatitis, unspecified,Suicide and self-inflicted poisoning by analgesics, antipyretics, and antirheumatics,Unspecified nonpsychotic mental disorder,Bipolar I disorder, most recent episode (or current) unspecified,Borderline personality disorder,Attention deficit disorder with hyperactivity'}

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: Acetaminophen and aspirin overdose PRESENT ILLNESS: Patient is a 19 year old female with Hx of several past suicide attempts transferred from [**Hospital 1562**] Hospital with an aspirin and tylenol overdose after 24hours s/p ingestion with Tylenol level at that time was well within parameters for probable hepatic toxicity per the Rumack-[**Doctor First Name **] nomogram. Reportedly day prior to admission to OSH, at 1 pm, pt took 70 pills each of ASA and tylenol (around 30 g). She subsequently vomited, including pill fragments yesterday. She did have some tinnitus. Otherwise was doing well but decided to call 911 the subsequent morning and was brought to ED at the OSH. In the ED, the pt was asymptomatic. Pt. Was given her inital dose of PO Mucomyst 7 grams. About an hour and a half later she vomited the initial dose. She denies taking any other substances. Initial Tylenol level at approximately 24 H was 31 with initial AST/ALT 62/63 increase to 411/332. Pt was transferred from OSH for liver transplant evaluation if her liver function worsened. On admission to the MICU, the patient denied any Suicidal ideations/homocidal ideations. She denied any fever/chills, chest pain, shortness of breath, abdominal pain, BRBPR, hematemesis, diarrhea. She did report some nausea, but no emesis. The patient did report life stressors but did not wish to endorse further. . Patient was admitted with plan to give IV N-aceytlcysteine loading (150mg/kg over 15min, then 50mg/kg over 4 hours, then 100mg/kg over 16hours) and plans to monitor LFTs and INR. The liver team was consulted who recommended the patient finish the course of mucomyst 70mg/kg and recommended no vitamin K be given so as to trend the patient's INR as a marker of hepatic function. They also recommended continuing PPI and dolasteron for nausea associated with overdose. On admission, the patient's LFTs were AST = 543 and ALT = 648 with INR of 1.4. These peaked at 1076 and 1075 respictively, now trending downward with values of 374/830 today and INR of 1.2. The patient has no evidence of hepatic necrosis and will likely recover full hepatic function. She is currently awaiting placement for inpatient psychiatric hospitilization and is being admitted to the medical service for continued observation while awaiting placement. MEDICAL HISTORY: 1. Suicide Attempts x4- using different methods. One last year, landed her in a coma in [**Hospital3 **] hospital x3 days. She has been intubated for those events in the past. 2. Psychiatric History: very complex including chart diagnoses of bipolar disorder, ADHD, schizoaffective disorder, and OCD. Currently not taking any meds except zyprexa, but has taken depakote and lithium in the past. MEDICATION ON ADMISSION: Zyprexa but does not know the dose No herbals/vitamin supplements ALLERGIES: Penicillins PHYSICAL EXAM: 97.6 125/54 82 18 98%RA NAD, AAOx3, lying in bed, speaking in full sentences, has nail polish, sleeping with a pink [**Male First Name (un) **] bear. MMM, OP-clear, nose ring, neck FROM, PERRL, anicteric CTA-B RR without murmur soft, NT/ND, +BS, no HSM, keloid above belly button. No C/C/E, warm, no rashes No asterixis FAMILY HISTORY: Adopted from [**Country 10181**] SOCIAL HISTORY: Obtained her GED from High School. Currently single but sexually active. EtOH 1-3 beers ever couple nights. Denies cocaine, heroin, canabis, ecstasy. Currently lost her job a few weeks ago. Her boyfriend recently got out of jail. ### Response: {'Poisoning by aromatic analgesics, not elsewhere classified,Schizoaffective disorder, unspecified,Hepatitis, unspecified,Suicide and self-inflicted poisoning by analgesics, antipyretics, and antirheumatics,Unspecified nonpsychotic mental disorder,Bipolar I disorder, most recent episode (or current) unspecified,Borderline personality disorder,Attention deficit disorder with hyperactivity'}

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is a 73-year-old man with a history of CAD, status post CABG times two vessels, LIMA to LAD, SVG to RCA in [**2178**], hypertension, type 2 diabetes, cholangiocarcinoma status post Roux-en-Y, hepaticojejunostomy, status post cholecystectomy and common bile duct incisions in [**1-25**] complicated by GI bleeds secondary to gastric telangiectasias, status post multiple Argon laser ablations who presents for elective catheterization. The patient described shortness of breath for several weeks and chest pain with exertion. The patient had a recent admission at [**Hospital 2725**] Hospital where he presented with a small MI. He was transfused 2 units there. The patient was admitted there for seven days. He says that he has had no chest pain since discharge from [**Location (un) 2725**]. MEDICAL HISTORY: 1. CAD, status post CABG in [**2178**] with LIMA to LAD, SVG to RCA, status post a non-Q wave MI in [**10-27**] with an ETT MIBI that showed a questionable ischemia. 2. Hypertension. 3. Type 2 diabetes. 4. BPH. 5. Cholangiocarcinoma. 6. Klatskin's tumor, status post cholecystectomy and bile duct excision and Roux-en-Y hepaticojejunostomy and PTC drain placement. 7. CHF with an EF of 25%. 8. Chronic renal insufficiency with baseline elevated creatinine. 9. GI bleed secondary to gastric AVMs treated with Argon laser ablation. 10. Anemia of chronic disease with transfusion requirements. 11. History of encephalopathy. MEDICATION ON ADMISSION: ALLERGIES: Indocin causes anaphylaxis. PHYSICAL EXAM: FAMILY HISTORY: His mother died of a CVA at 53 years of age. He had two sisters who died of cancer, one from ovarian and one from colorectal, one sister who died from complications of diabetes. SOCIAL HISTORY: The patient lives with wife, three children. He is a retired industrial engineer. He retired in [**2165**]. He gave up smoking 40 years ago. He rarely uses alcohol.

Coronary atherosclerosis of native coronary artery,Hematoma complicating a procedure,Peripheral vascular complications, not elsewhere classified,Angiodysplasia of stomach and duodenum with hemorrhage,Acute kidney failure, unspecified,Congestive heart failure, unspecified,Hepatic encephalopathy,Iron deficiency anemia secondary to blood loss (chronic),Subendocardial infarction, subsequent episode of care

Crnry athrscl natve vssl,Hematoma complic proc,Surg comp-peri vasc syst,Angio stm/dudn w hmrhg,Acute kidney failure NOS,CHF NOS,Hepatic encephalopathy,Chr blood loss anemia,Subendo infarct, subseq

Admission Date: [**2193-2-21**] Discharge Date: [**2193-3-4**] Date of Birth: [**2116-9-11**] Sex: M Service: ROM MEDICINE HISTORY OF THE PRESENT ILLNESS: The patient is a 73-year-old man with a history of CAD, status post CABG times two vessels, LIMA to LAD, SVG to RCA in [**2178**], hypertension, type 2 diabetes, cholangiocarcinoma status post Roux-en-Y, hepaticojejunostomy, status post cholecystectomy and common bile duct incisions in [**1-25**] complicated by GI bleeds secondary to gastric telangiectasias, status post multiple Argon laser ablations who presents for elective catheterization. The patient described shortness of breath for several weeks and chest pain with exertion. The patient had a recent admission at [**Hospital 2725**] Hospital where he presented with a small MI. He was transfused 2 units there. The patient was admitted there for seven days. He says that he has had no chest pain since discharge from [**Location (un) 2725**]. PAST MEDICAL HISTORY: 1. CAD, status post CABG in [**2178**] with LIMA to LAD, SVG to RCA, status post a non-Q wave MI in [**10-27**] with an ETT MIBI that showed a questionable ischemia. 2. Hypertension. 3. Type 2 diabetes. 4. BPH. 5. Cholangiocarcinoma. 6. Klatskin's tumor, status post cholecystectomy and bile duct excision and Roux-en-Y hepaticojejunostomy and PTC drain placement. 7. CHF with an EF of 25%. 8. Chronic renal insufficiency with baseline elevated creatinine. 9. GI bleed secondary to gastric AVMs treated with Argon laser ablation. 10. Anemia of chronic disease with transfusion requirements. 11. History of encephalopathy. SOCIAL HISTORY: The patient lives with wife, three children. He is a retired industrial engineer. He retired in [**2165**]. He gave up smoking 40 years ago. He rarely uses alcohol. FAMILY HISTORY: His mother died of a CVA at 53 years of age. He had two sisters who died of cancer, one from ovarian and one from colorectal, one sister who died from complications of diabetes. ADMISSION MEDICATIONS: 1. Lactulose 2 ounces q.i.d. 2. Neomycin 500 mg t.i.d. 3. Ursodiol 300 b.i.d. 4. Lasix 40 q.d. 5. Imdur 30 q.d. 6. Lisinopril 5 q.d. 7. Iron sulfate 325 t.i.d. 8. Protonix 40 q.d. 9. Toprol XL 150 q.d. 10. Diabetic diet. 11. Ambien 10 mg q.h.s. ALLERGIES: Indocin causes anaphylaxis. PHYSICAL EXAMINATION: General: The patient was an elderly man lying in bed, comfortable, in no acute distress. Lungs: Decreased breath sounds at the bases, right greater than left with bibasilar crackles to a quarter of the way up, otherwise clear to auscultation. Cardiac: Regular rate and rhythm. Distant heart sounds. No murmurs appreciated. Abdomen: Hepatobiliary scar with PTC drain in place. The abdomen was tympanic. Positive hepatomegaly to 5 cm below the costal margin. No splenomegaly appreciated. Extremities: There was 3+ pitting edema bilaterally, Guaiac positive. LABORATORY/RADIOLOGIC DATA: White count 8.2, hematocrit 36.3, platelets 222,000. Sodium 139, potassium 5.1, chloride 106, bicarbonate 24, BUN 36, creatinine 1.9, glucose 98. Baseline creatinine 1.2. Coagulations were normal. AST 67, ALT 63, alkaline phosphatase 348, total bilirubin 0.7, albumin 2.6 on [**2193-1-28**]. HOSPITAL COURSE: The patient underwent cardiac catheterization on [**2193-2-22**] which found graft occlusion of the SVG RCA. He had successful PTCA and stenting of the ramus intermedius and was started on aspirin, Plavix, Integrelin post catheterization. On [**2193-2-23**], he developed melena, dizziness. He was found to be hypotensive to 70/50 with decreased 02 saturations. He was transferred to the MICU and urgent endoscopy showed clots, small bleeding, with friable and granular antrum of the stomach. The patient was aggressively resuscitated with 6 units of packed red blood cells, vitamin K, and fluid boluses for decreased urine output. He was started on IV Protonix b.i.d. The patient developed acute renal failure, likely secondary to ATN from hypotension and contrast. In light of the patient's poor EF and increasing volume overload the patient was started on urgent hemodialysis. A dialysis catheter was placed in the right groin site. The patient transiently needed dopamine for hypotension. He was continued on antiplatelet agents. The patient improved with hemodialysis and was felt stable for transfer to the floor. The patient was transferred to the floor and urine output improved. The patient had post ATN diuresis. His pulmonary status improved. With his increased urine output, his creatinine trended down. His hemodialysis catheter was pulled. The patient started complaining of increasing pain at the site of his hemodialysis catheter; cross-cover noted the patient to have a bruit at the site. The patient had a femoral ultrasound which showed a 3 cm pseudoaneurysm. The patient was taken to ultrasound and had thrombin injection. The pseudoaneurysm was thrombosed. The patient was noted to still have persistent AV fistula at the site and will need a follow-up ultrasound in one months time. After the hemodialysis catheter was pulled, the patient was allowed to ambulate and sit in a chair. In this setting, he had increasing pedal edema formation from 1+ to 3+. The patient's urine output began to drop off so the patient was re-initiated on his Lasix, initially 40 mg q.d. which was then increased to 40 mg b.i.d., aiming to keep his urine output at net minus liter per day. The patient's creatinine drifted down to 1.7 despite diuresis. At the time of discharge, the patient still had 3+ pitting edema, however, the patient was felt stable for discharge to home as he was able to ambulate without dyspnea and maintained high 02 saturations. The patient was willing to follow-up with his cardiologist. His cardiologist was contact[**Name (NI) **] and the patient will see his cardiologist tomorrow for repeat laboratory checks and the determination of what dose of Lasix to continue on. During the hospital course, the patient had slightly elevated liver enzymes to the 100s. These were attributed to hepatic congestion from his CHF. His transaminases trended down. His alkaline phosphatase remained slightly elevated in the 300s. The patient was continued on Lactulose q.i.d. to q. four hours, aiming for three to four bowel movements per day. The patient showed no signs of encephalopathy during the hospital course. The patient's diabetes was controlled with a diabetic diet and a regular insulin sliding scale. CONDITION ON DISCHARGE: Stable. DISCHARGE DIAGNOSIS: 1. Coronary artery disease, status post percutaneous transluminal coronary angioplasty and stenting of ramus intermedius. 2. Upper gastrointestinal bleed. 3. Acute renal failure requiring temporary hemodialysis. 4. Pseudoaneurysm. 5. Residual AV fistula in the right inguinal region. 6. Hypertension. 7. Hepatic insufficiency. 8. Diabetes mellitus. DISCHARGE MEDICATIONS: 1. Lactulose 15 mils t.i.d. 2. Neomycin 500 mg two tablets p.o. q. eight hours. 3. Ursodiol 300 mg p.o. t.i.d. 4. Ferrous sulfate 325 p.o. t.i.d. 5. Protonix 40 mg b.i.d. 6. Lasix 40 mg p.o. q.d. The patient was instructed to take an additional dose tonight and then the dose will be determined by the cardiologist. 7. Aspirin 325 mg q.d. 8. Ambien 10 mg p.o. q.h.s. 9. Plavix 75 mg p.o. q.d. times 30 days. 10. Metoprolol 25 mg p.o. b.i.d. DISCHARGE FOLLOW-UP: The patient is to follow-up with his cardiologist tomorrow for a recheck of his BP and laboratories and determine what dose of Lasix and BP medications the patient should be on. The patient should follow-up with his primary care physician. [**Name10 (NameIs) **] needs a femoral ultrasound in one month to evaluate for resolution of his AV fistula in the right inguinal region. [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1775**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1776**] Dictated By:[**Name8 (MD) 20317**] MEDQUIST36 D: [**2193-3-4**] 05:24 T: [**2193-3-4**] 17:34 JOB#: [**Job Number 37209**]

414,998,997,537,584,428,572,280,410

{'Coronary atherosclerosis of native coronary artery,Hematoma complicating a procedure,Peripheral vascular complications, not elsewhere classified,Angiodysplasia of stomach and duodenum with hemorrhage,Acute kidney failure, unspecified,Congestive heart failure, unspecified,Hepatic encephalopathy,Iron deficiency anemia secondary to blood loss (chronic),Subendocardial infarction, subsequent episode of care'}

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 73-year-old man with a history of CAD, status post CABG times two vessels, LIMA to LAD, SVG to RCA in [**2178**], hypertension, type 2 diabetes, cholangiocarcinoma status post Roux-en-Y, hepaticojejunostomy, status post cholecystectomy and common bile duct incisions in [**1-25**] complicated by GI bleeds secondary to gastric telangiectasias, status post multiple Argon laser ablations who presents for elective catheterization. The patient described shortness of breath for several weeks and chest pain with exertion. The patient had a recent admission at [**Hospital 2725**] Hospital where he presented with a small MI. He was transfused 2 units there. The patient was admitted there for seven days. He says that he has had no chest pain since discharge from [**Location (un) 2725**]. MEDICAL HISTORY: 1. CAD, status post CABG in [**2178**] with LIMA to LAD, SVG to RCA, status post a non-Q wave MI in [**10-27**] with an ETT MIBI that showed a questionable ischemia. 2. Hypertension. 3. Type 2 diabetes. 4. BPH. 5. Cholangiocarcinoma. 6. Klatskin's tumor, status post cholecystectomy and bile duct excision and Roux-en-Y hepaticojejunostomy and PTC drain placement. 7. CHF with an EF of 25%. 8. Chronic renal insufficiency with baseline elevated creatinine. 9. GI bleed secondary to gastric AVMs treated with Argon laser ablation. 10. Anemia of chronic disease with transfusion requirements. 11. History of encephalopathy. MEDICATION ON ADMISSION: ALLERGIES: Indocin causes anaphylaxis. PHYSICAL EXAM: FAMILY HISTORY: His mother died of a CVA at 53 years of age. He had two sisters who died of cancer, one from ovarian and one from colorectal, one sister who died from complications of diabetes. SOCIAL HISTORY: The patient lives with wife, three children. He is a retired industrial engineer. He retired in [**2165**]. He gave up smoking 40 years ago. He rarely uses alcohol. ### Response: {'Coronary atherosclerosis of native coronary artery,Hematoma complicating a procedure,Peripheral vascular complications, not elsewhere classified,Angiodysplasia of stomach and duodenum with hemorrhage,Acute kidney failure, unspecified,Congestive heart failure, unspecified,Hepatic encephalopathy,Iron deficiency anemia secondary to blood loss (chronic),Subendocardial infarction, subsequent episode of care'}

CHIEF COMPLAINT: Shortness of breath PRESENT ILLNESS: 55 y/o male history of stage III non-small cell lung cancer, consistent with squamous cell s/p chemotherapy and radiation treatments as well as mutliple prior bronchoscopies with Dr. [**Last Name (STitle) 3373**] for tumor debulking and stent placement to the left mainstem bronchus who now presents with shortness of breath. The patient lives in [**State 5111**], but receives his pulmonary care here in [**Location (un) 86**]. He is in [**Location (un) 86**] for a stent placement however, before a scheduled appointment with Dr. [**Last Name (STitle) 3373**] he presented this morning with acute onset of shortness of breath and chest tightness. EMS was called and found patient saturating 50% on RA with intense tachypnia. Patient was placed on his home O2 of 3 L which increased his saturations to about 70%. He was transitioned to NRB with 90% saturations and transferred to [**Hospital1 18**] ED. In ED initial VS were HR 95, BP 123/73, RR 24, satting 99% on NRB. US showed PTX on left side per ED report without evidence of tension pneumothorax. A portable CXR showed collapse of the left lung with tracheal deviation toward side of collapse. While in the ER,had acute SOB/Tachypnea with drop in sats with NRB on to 70's% which spontaneously returned to 100%. Labs were within normal limits, except for a bicarbonate of 20. Patient's IP physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] was conatacted in the ED and made aware of the patient's admission. Plan was for ICU admission with bronchoscopy/stenting of the left mainstem later on this afternoon. On arrival to the MICU, Pt. was sedated with propofol, intubated, his VS were HR: 94, BP: 113/69, O2sat: 100% on 100FiO2 and vetilated, RR: 18 on the vent. Vent settings were TV: 600cc, RR: 18, PEEP: 5, FiO2: 96%. MEDICAL HISTORY: NSCLC HTN DM Hypothyroidism s/p appendectomy age 17 s/p hemorrhoidectomy s/p back surgery [**08**] years ago MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete. Information was obtained from PatientFamily/Caregiver. 1. Pioglitazone 30 mg PO DAILY 2. Levothyroxine Sodium 200 mcg PO DAILY 3. fenofibrate *NF* 135 mg Oral QD 4. Atorvastatin 40 mg PO DAILY 5. MetFORMIN (Glucophage) 850 mg PO BID 6. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation Inhalation [**Hospital1 **] 7. Albuterol Inhaler [**12-13**] PUFF IH Q6H:PRN SOB 8. Benicar HCT *NF* (olmesartan-hydrochlorothiazide) 20-12.5 mg Oral QD ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: ADMISSION EXAM: Vitals - HR: 95, BP: 123/73, RR: 24, satting 99% on NRB General: Intubated, sedated HEENT: Sclera anicteric, MMM, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: Foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Defer given sedation FAMILY HISTORY: Brother with history of melanoma SOCIAL HISTORY: Lives with his wife [**Name (NI) 7346**] in [**State 5111**]. Has two children occupation working as an oil refinery operator with reported chemical exposures. Smoking history quit [**2090**] smoking [**12-13**] pack per day since he was a teenager Alcohol since diagnosis decreased from 12 pack per week

Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified acquired hypothyroidism,Personal history of tobacco use,Other and unspecified hyperlipidemia,Late effect of radiation,Acute respiratory failure,Methicillin susceptible pneumonia due to Staphylococcus aureus,Malignant neoplasm of main bronchus,Other pneumothorax,Other emphysema,Anemia, unspecified,Chronic and other pulmonary manifestations due to radiation

Hypertension NOS,DMII wo cmp nt st uncntr,Hypothyroidism NOS,History of tobacco use,Hyperlipidemia NEC/NOS,Late effect of radiation,Acute respiratry failure,Meth sus pneum d/t Staph,Malig neo main bronchus,Other pneumothorax,Emphysema NEC,Anemia NOS,Chr pul manif d/t radiat

Admission Date: [**2101-7-11**] Discharge Date: [**2101-7-15**] Date of Birth: [**2045-10-5**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Doctor First Name 2080**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Left mainstem stent placement [**2101-7-11**] by Dr.[**First Name4 (NamePattern1) 1151**] [**Last Name (NamePattern1) 3373**] History of Present Illness: 55 y/o male history of stage III non-small cell lung cancer, consistent with squamous cell s/p chemotherapy and radiation treatments as well as mutliple prior bronchoscopies with Dr. [**Last Name (STitle) 3373**] for tumor debulking and stent placement to the left mainstem bronchus who now presents with shortness of breath. The patient lives in [**State 5111**], but receives his pulmonary care here in [**Location (un) 86**]. He is in [**Location (un) 86**] for a stent placement however, before a scheduled appointment with Dr. [**Last Name (STitle) 3373**] he presented this morning with acute onset of shortness of breath and chest tightness. EMS was called and found patient saturating 50% on RA with intense tachypnia. Patient was placed on his home O2 of 3 L which increased his saturations to about 70%. He was transitioned to NRB with 90% saturations and transferred to [**Hospital1 18**] ED. In ED initial VS were HR 95, BP 123/73, RR 24, satting 99% on NRB. US showed PTX on left side per ED report without evidence of tension pneumothorax. A portable CXR showed collapse of the left lung with tracheal deviation toward side of collapse. While in the ER,had acute SOB/Tachypnea with drop in sats with NRB on to 70's% which spontaneously returned to 100%. Labs were within normal limits, except for a bicarbonate of 20. Patient's IP physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] was conatacted in the ED and made aware of the patient's admission. Plan was for ICU admission with bronchoscopy/stenting of the left mainstem later on this afternoon. On arrival to the MICU, Pt. was sedated with propofol, intubated, his VS were HR: 94, BP: 113/69, O2sat: 100% on 100FiO2 and vetilated, RR: 18 on the vent. Vent settings were TV: 600cc, RR: 18, PEEP: 5, FiO2: 96%. Review of systems: Unable to assess given sedation and intubation. Past Medical History: NSCLC HTN DM Hypothyroidism s/p appendectomy age 17 s/p hemorrhoidectomy s/p back surgery [**08**] years ago Social History: Lives with his wife [**Name (NI) 7346**] in [**State 5111**]. Has two children occupation working as an oil refinery operator with reported chemical exposures. Smoking history quit [**2090**] smoking [**12-13**] pack per day since he was a teenager Alcohol since diagnosis decreased from 12 pack per week Family History: Brother with history of melanoma Physical Exam: ADMISSION EXAM: Vitals - HR: 95, BP: 123/73, RR: 24, satting 99% on NRB General: Intubated, sedated HEENT: Sclera anicteric, MMM, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: Foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Defer given sedation DISCHARGE EXAM: Vitals: T 98.1 BP 140/82 P 77 RR 18 O2 sat 96% RA Gen: comfortable laying in bed in NAD Neck: supple no JVD appreciated Chest: distant heart sound. nl S1 S2 no mummurs, rubs, or gallops Lungs: rhonci b/l moving good air. No accessory muscle use Abdomen: soft NTND, BS normoactive Neuro: AOx3 Pertinent Results: IMAGING: CXR [**2101-7-11**] - Pre-operative IMPRESSION: Near complete collapse of the left lung with leftward mediastinal shift. CT may be obtained to assess further for cause of lung collapse. CXR [**2101-7-11**] - Post-operative 1. ET tube 7.5 cm from the carina. 2. Marked improvement of the aeration of the left lung with possible small left pleural effusion. No pneumothorax. CXR [**2101-7-12**]- ET tube is 8.2 cm above the carina. A left mainstem bronchus stent is in place. Since the prior radiograph, there is no significant change. Small left pleural effusion is unchanged The right lung is clear. There is no focal consolidation, or pneumothorax. The bony structures are intact. CXR [**2101-7-13**]-FINDINGS: Portable AP chest radiograph is obtained. Endotracheal tube is no longer visualized. Cardiomediastinal contours are stable. Right lung remains clear. Small left pleural effusion is again noted. Left lung is better aerated. No pneumothorax. CT chest [**2101-7-14**]-IMPRESSION: 1. Unremarkable position of the new stent in the left main bronchus. 2. Post-radiation changes, stable. Mediastinal lymphoid tissue, unchanged. Thickening of the trachea, unchanged 3. Interval decrease in the size of the right lower lobe nodule, currently cavitated. ADMISSION LABS: [**2101-7-11**] 10:07AM BLOOD WBC-8.8 RBC-4.60 Hgb-13.8* Hct-41.9 MCV-91 MCH-30.1 MCHC-33.0 RDW-13.7 Plt Ct-233 [**2101-7-11**] 10:07AM BLOOD Neuts-83.4* Lymphs-9.4* Monos-4.3 Eos-2.0 Baso-0.9 [**2101-7-11**] 10:07AM BLOOD Plt Ct-233 [**2101-7-11**] 10:07AM BLOOD PT-9.2* PTT-25.7 INR(PT)-0.8* [**2101-7-11**] 10:07AM BLOOD Glucose-180* UreaN-16 Creat-1.2 Na-134 K-4.7 Cl-103 HCO3-20* AnGap-16 [**2101-7-11**] 04:04PM BLOOD Type-ART pO2-236* pCO2-77* pH-7.14* calTCO2-28 Base XS--4 [**2101-7-11**] 07:53PM BLOOD Type-ART Temp-36.4 Rates-/18 Tidal V-540 PEEP-5 FiO2-100 pO2-283* pCO2-35 pH-7.40 calTCO2-22 Base XS--1 AADO2-391 REQ O2-69 -ASSIST/CON Intubat-INTUBATED [**2101-7-11**] 04:04PM BLOOD Glucose-173* Lactate-0.3* Na-136 K-4.3 Cl-102 [**2101-7-11**] 04:04PM BLOOD Hgb-12.5* calcHCT-38 O2 Sat-99 RELEVENT LABS: [**2101-7-12**] 03:52AM BLOOD WBC-10.3 RBC-3.71* Hgb-11.1* Hct-33.3* MCV-90 MCH-30.0 MCHC-33.4 RDW-13.5 Plt Ct-194 [**2101-7-12**] 05:30AM BLOOD Hct-32.1* [**2101-7-12**] 03:52AM BLOOD Plt Ct-194 [**2101-7-12**] 03:52AM BLOOD Glucose-160* UreaN-15 Creat-1.0 Na-136 K-4.0 Cl-106 HCO3-21* AnGap-13 [**2101-7-12**] 04:05AM BLOOD Type-ART Temp-36.4 Rates-/18 Tidal V-540 PEEP-5 FiO2-50 pO2-137* pCO2-35 pH-7.42 calTCO2-23 Base XS-0 -ASSIST/CON Intubat-INTUBATED [**2101-7-12**] 04:05AM BLOOD Lactate-1.0 DISCHARGE LABS: [**2101-7-15**] 06:35AM BLOOD WBC-6.0 RBC-3.59* Hgb-10.9* Hct-32.6* MCV-91 MCH-30.3 MCHC-33.4 RDW-13.9 Plt Ct-186 Brief Hospital Course: 55 yo male with non-small cell lung cancer with known left main stem bronchus tumor burden presenting with acute worsening SOB. #Left main bronchial obstruction/hypoxia/h/o NSCLC: The patient presented to [**Hospital1 18**] with shortness of breath and hypoxia. He was subsequently found to have near total collapse of his left lung with mediastinal shift towards the collapsed lung on chest X-ray. The patient has a known tumor in left mainstem region. He has had 3 previous bronchial stents for left main bronchial obstruction and hypoxia . He was intubated on admission and admitted to the MICU. He underwent bronchoscopy by interventional pulmonary who placed a metal stent in his left mainstem bronchus. A repeat chest xray immediately following the procedure showed reinflation of the upper lobe but persistant collapse in the lower lobe. He was extubated on post operative day one without respiratory distress, satting well on 50% face tent mask. He was transferred to the general medical floors on hospital day 2. His supplemental O2 was weaned and he was ultimately satting well on room air at discharge. The patient was noted to have desaturations into the 80s on ambulatory pulse ox, but remained asymptomatic with no shortness of breath during these episodes. Final CXR prior to discharge showed better aeration of the left lung. Per interventional pulmonary he will need to have an official 6 min walk test and be evaluated for pulmonary rehab when he returns home to [**State 5111**]. He will have outpatient pulmonary follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 90949**] of [**Last Name (LF) 11084**], [**First Name3 (LF) **] on [**2101-7-26**]. # Presumed Post Obstructive Pneumonia- During the bronchoscopy the patient was noted to have several thick mucous plugs, and per Interventional pulmonary was started on Levofloxacin for presumptive post-obstructive pneumonia. His BAL cultures grew oxacillin sensitive staph aureus which was also sensitive to levofloxacin. He received one dose of IV vancomycin while the sensitivities from the culture were pending. He also received one dose of IV nafcilin. He was ultimately sent home on PO levofloxacin and will have a 7 day course of antibiotics, ending 3 days after discharge. #Anemia, NOS: During his stay in the MICU the patient was noted to have a drop in hematocrit from 41.9 pre-operatively to 32.1 post-op day 1. He received 3.5 liters of normal saline during his MICU stay and the drop was thought to possibly be dilution versus peri-procedural bleeding. The patient maintained good urine output with no signs of end organ damage such chest pain or decreased urine output and no obvious sign of bleeding were noted. His baseline Hct appears to be around 35. His hemoglobin and hematocrit remained stable throughout the hospital course and were 10.9/32.6 on discharge. #Diabetes, type 2, controlled no complications: This is a chronic stable issue. He is on metformin and Actos at home. While in the hospital he was placed on a insulin sliding scale. #HLD: This is a chronic stable issue. At home he is on atorvastatin 40mg and Trilipix 135mg. He was continued on the atorvastatin in the hospital. His Trilipix was held, as it is not on formulary, but the patient who told to continue both medications at discharge. #HTN: This is a chronic stable issue. He is onolmesartan-HCTZ. These medications were held as the patient's blood pressures were stable but on the low side at SBP between 100-120. On discharge his BP was 140/70 and it was recommended to the patient to resume his home BP medications. #Hypothyroid: This is a chronic stable issue. He was continued on synthroid 200mcg each day Transitional Issues: - Will need to follow up with PCP to get an offical 6 minute walk test and evaluation for pulmonary rehab - Will establish outpatient pulmonary follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 90949**] of [**Last Name (LF) 11084**], [**First Name3 (LF) **] on [**2101-7-26**]. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientFamily/Caregiver. 1. Pioglitazone 30 mg PO DAILY 2. Levothyroxine Sodium 200 mcg PO DAILY 3. fenofibrate *NF* 135 mg Oral QD 4. Atorvastatin 40 mg PO DAILY 5. MetFORMIN (Glucophage) 850 mg PO BID 6. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation Inhalation [**Hospital1 **] 7. Albuterol Inhaler [**12-13**] PUFF IH Q6H:PRN SOB 8. Benicar HCT *NF* (olmesartan-hydrochlorothiazide) 20-12.5 mg Oral QD Discharge Medications: 1. Albuterol Inhaler [**12-13**] PUFF IH Q6H:PRN SOB 2. Atorvastatin 40 mg PO DAILY 3. Levothyroxine Sodium 200 mcg PO DAILY 4. Levofloxacin 750 mg PO DAILY Day 1 [**2101-7-11**] RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*3 Tablet Refills:*0 5. Benicar HCT *NF* (olmesartan-hydrochlorothiazide) 20-12.5 mg Oral QD 6. fenofibrate *NF* 135 mg Oral QD 7. MetFORMIN (Glucophage) 850 mg PO BID 8. Pioglitazone 30 mg PO DAILY 9. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation INHALATION [**Hospital1 **] Discharge Disposition: Home Discharge Diagnosis: Left main bronchus obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 62311**], It was a pleasure participating in your care at [**Hospital1 18**]. You were admitted to the hospital because you were having difficutly breathing. You were found to have near total collapse of your left lung due to an obstruction of one of the main airways. You had a bronschopy to relieve the obstruction. You were also found to have a pneumonia and were started on antibiotics to treat the infection. Followup Instructions: PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 699**] Appt: [**2101-7-18**] @11:00 am Phone number: [**Telephone/Fax (1) 90950**] [**Street Address(2) 90951**]. [**Location (un) 90952**], [**Numeric Identifier 90953**] -please make sure to get 6 min walk test and evaluate for pulmonary rehab DIVISION: PULMONARY WITH: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 90949**] WHEN: [**7-26**] 7:30am PHONE: [**Telephone/Fax (1) 90954**] WHERE: [**2088**] 6th Ave South, [**Location (un) **] [**Location (un) 11084**] [**Doctor Last Name **] FAX: [**Telephone/Fax (1) 90955**] .

401,250,244,V158,272,909,518,482,162,512,492,285,508

{'Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified acquired hypothyroidism,Personal history of tobacco use,Other and unspecified hyperlipidemia,Late effect of radiation,Acute respiratory failure,Methicillin susceptible pneumonia due to Staphylococcus aureus,Malignant neoplasm of main bronchus,Other pneumothorax,Other emphysema,Anemia, unspecified,Chronic and other pulmonary manifestations due to radiation'}

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: Shortness of breath PRESENT ILLNESS: 55 y/o male history of stage III non-small cell lung cancer, consistent with squamous cell s/p chemotherapy and radiation treatments as well as mutliple prior bronchoscopies with Dr. [**Last Name (STitle) 3373**] for tumor debulking and stent placement to the left mainstem bronchus who now presents with shortness of breath. The patient lives in [**State 5111**], but receives his pulmonary care here in [**Location (un) 86**]. He is in [**Location (un) 86**] for a stent placement however, before a scheduled appointment with Dr. [**Last Name (STitle) 3373**] he presented this morning with acute onset of shortness of breath and chest tightness. EMS was called and found patient saturating 50% on RA with intense tachypnia. Patient was placed on his home O2 of 3 L which increased his saturations to about 70%. He was transitioned to NRB with 90% saturations and transferred to [**Hospital1 18**] ED. In ED initial VS were HR 95, BP 123/73, RR 24, satting 99% on NRB. US showed PTX on left side per ED report without evidence of tension pneumothorax. A portable CXR showed collapse of the left lung with tracheal deviation toward side of collapse. While in the ER,had acute SOB/Tachypnea with drop in sats with NRB on to 70's% which spontaneously returned to 100%. Labs were within normal limits, except for a bicarbonate of 20. Patient's IP physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] was conatacted in the ED and made aware of the patient's admission. Plan was for ICU admission with bronchoscopy/stenting of the left mainstem later on this afternoon. On arrival to the MICU, Pt. was sedated with propofol, intubated, his VS were HR: 94, BP: 113/69, O2sat: 100% on 100FiO2 and vetilated, RR: 18 on the vent. Vent settings were TV: 600cc, RR: 18, PEEP: 5, FiO2: 96%. MEDICAL HISTORY: NSCLC HTN DM Hypothyroidism s/p appendectomy age 17 s/p hemorrhoidectomy s/p back surgery [**08**] years ago MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete. Information was obtained from PatientFamily/Caregiver. 1. Pioglitazone 30 mg PO DAILY 2. Levothyroxine Sodium 200 mcg PO DAILY 3. fenofibrate *NF* 135 mg Oral QD 4. Atorvastatin 40 mg PO DAILY 5. MetFORMIN (Glucophage) 850 mg PO BID 6. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation Inhalation [**Hospital1 **] 7. Albuterol Inhaler [**12-13**] PUFF IH Q6H:PRN SOB 8. Benicar HCT *NF* (olmesartan-hydrochlorothiazide) 20-12.5 mg Oral QD ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: ADMISSION EXAM: Vitals - HR: 95, BP: 123/73, RR: 24, satting 99% on NRB General: Intubated, sedated HEENT: Sclera anicteric, MMM, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: Foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Defer given sedation FAMILY HISTORY: Brother with history of melanoma SOCIAL HISTORY: Lives with his wife [**Name (NI) 7346**] in [**State 5111**]. Has two children occupation working as an oil refinery operator with reported chemical exposures. Smoking history quit [**2090**] smoking [**12-13**] pack per day since he was a teenager Alcohol since diagnosis decreased from 12 pack per week ### Response: {'Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified acquired hypothyroidism,Personal history of tobacco use,Other and unspecified hyperlipidemia,Late effect of radiation,Acute respiratory failure,Methicillin susceptible pneumonia due to Staphylococcus aureus,Malignant neoplasm of main bronchus,Other pneumothorax,Other emphysema,Anemia, unspecified,Chronic and other pulmonary manifestations due to radiation'}

CHIEF COMPLAINT: Confusion noted during outpatient appointment PRESENT ILLNESS: 78 year old female with PMHx HTN, dCHF, Diabetes, CKD, Atrial fibrillation on coumadin, ischemic stroke, admitted after presenting to cardiology clinic today with confusion and Somnolence. Of note, she was recently discharged at the beginning of [**2139-5-5**] after presyncope/falls. At that time, lasix was stopped and atenolol was switched to metoprolol as there was concern that blunting of tachycardia could be contributing to falls. She was discharged to rehab (previously living at home). MEDICAL HISTORY: -- Hypertension -- CHF with diastolic dysfunction -- Diabetes diet controlled -- Prior large pulmonary embolism in the setting of gynecological surgery with RV dysfunction, which has since resolved. -- Atrial fibrillation acute ischemic stroke with homonymous hemianopia [**3-/2138**] -- osteoarthritis -- chronic back pain h/o spinal stenosis on chronic opiates -- obstructive sleep apnea on CPAP -- hypercholesterolemia -- stress incontinence -- bilateral pulmonary embolism in [**5-/2136**] -- asthma -- obesity -- diverticulosis -- Cholelithiasis -- s/p hernia surgery [**2133**] -- endometrial ca s/p surgery and radiation [**2133**] now in remission MEDICATION ON ADMISSION: Confirmed with rehab. albuterol sulfate 90 mcg/actuation 1-2 Puffs Q4H PRN Tylenol PRN Milk of magnesis PRN dulcolax PRN Fleet Enema PRN fluticasone-salmeterol 100-50 mcg/dose [**Hospital1 **] isosorbide mononitrate 60 mg Tablet Extended Release daily sucralfate 1 gram [**Hospital1 **] omeprazole 20 mg daily oxybutynin chloride 5 mg TID docusate sodium 100 mg [**Hospital1 **] oxycodone 5 mg Q6 PRN losartan 100mg daily felodipine 5mg daily warfarin 7.5mg Tues and Fri. warfarin 5 mg [**Doctor First Name **],MO,WE,TH,SA metoprolol succinate 50 mg daily INR [**5-25**]: 1.5 INR [**5-18**]: 1.9 INR [**5-15**]: 1.8 ALLERGIES: Zestril / Norvasc / spironolactone PHYSICAL EXAM: Physical Exam on Admission: Vitals - 98.4 144/72 64 97%RA GENERAL: Pleasant, well appearing female in NAD , awake and alert HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRL/EOMI. MM Dry. OP clear. CARDIAC: irregularly irregular. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. LUNGS: CTAB, good air movement biaterally. ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: No edema, 2+ dorsalis pedis/ posterior tibial pulses. NEURO: A&Ox2- to self and [**Hospital1 18**]. Knows her son's name but not phone number. She thinks her last fall was 6 months ago and doesnt remember a recent hospitalization. Unable to say days of the week backwards. Knows where she lives. CN 2-12 intact. Preserved [**Hospital1 **] to fine touch throughout. With regard to strength, has 4+ strength in distal UE on left, otherwise [**5-9**] in proximal left UE and RUE. Quadriceps are 4+/5 b/l, gastrocnemius is [**5-9**] b/l. She refuses to stand, even with assistance. Finger to nose not preserved, however may be secondary to poor understanding of the test. heel to shin difficult to assess given patient compliance PSYCH: Listens and responds to questions appropriately, pleasant . ***************** . Physical Exam on Transfer to ICU: GENERAL: Intubated, NAD HEENT: Normocephalic, atraumatic. No scleral icterus. MMM, OP clear. CARDIAC: irregularly irregular. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. LUNGS: CTAB ABDOMEN: Soft, NT, ND. +BS EXTREMITIES: 1+ edema FAMILY HISTORY: Mother: DM Father: DM Sister: HTN SOCIAL HISTORY: She is a widow, lives alone in an apartment, 3 living children. After recent hospitalization, she was discharged to rehab. Distant smoking history, denies ETOH. From [**Location (un) 4708**]. Previoulsy worked in childcare.

Malignant neoplasm of brain, unspecified,Cerebral edema,Intracerebral hemorrhage,Acute respiratory failure following trauma and surgery,Grand mal status,Chronic diastolic heart failure,Acidosis,Urinary tract infection, site not specified,Iatrogenic cerebrovascular infarction or hemorrhage,Other iatrogenic hypotension,Nonspecific abnormal electroencephalogram [EEG],Pure hypercholesterolemia,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Atrial fibrillation,Long-term (current) use of anticoagulants,Esophageal reflux,Personal history of venous thrombosis and embolism,Other late effects of cerebrovascular disease,Homonymous bilateral field defects,Asthma, unspecified type, unspecified,Obstructive sleep apnea (adult)(pediatric),Obesity, unspecified,Body Mass Index 33.0-33.9, adult,Osteoarthrosis, unspecified whether generalized or localized, lower leg,Diverticulosis of colon (without mention of hemorrhage),Personal history of malignant neoplasm of other parts of uterus,Personal history of tobacco use,Family history of other cardiovascular diseases,Family history of diabetes mellitus,Do not resuscitate status,Encounter for palliative care

Malig neo brain NOS,Cerebral edema,Intracerebral hemorrhage,Ac resp flr fol trma/srg,Grand mal status,Chr diastolic hrt fail,Acidosis,Urin tract infection NOS,Iatrogen CV infarc/hmrhg,Iatrogenc hypotnsion NEC,Abn electroencephalogram,Pure hypercholesterolem,DMII renl nt st uncntrld,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Atrial fibrillation,Long-term use anticoagul,Esophageal reflux,Hx-ven thrombosis/embols,Late effect CV dis NEC,Homonymous hemianopsia,Asthma NOS,Obstructive sleep apnea,Obesity NOS,BMI 33.0-33.9,adult,Osteoarthros NOS-l/leg,Dvrtclo colon w/o hmrhg,Hx-uterus malignancy NEC,History of tobacco use,Fam hx-cardiovas dis NEC,Fam hx-diabetes mellitus,Do not resusctate status,Encountr palliative care

Admission Date: [**2139-6-2**] Discharge Date: [**2139-6-21**] Date of Birth: [**2060-7-7**] Sex: F Service: NEUROLOGY Allergies: Zestril / Norvasc / spironolactone Attending:[**First Name3 (LF) 20506**] Chief Complaint: Confusion noted during outpatient appointment Major Surgical or Invasive Procedure: Lumbar puncture Brain biopsy Intubation History of Present Illness: 78 year old female with PMHx HTN, dCHF, Diabetes, CKD, Atrial fibrillation on coumadin, ischemic stroke, admitted after presenting to cardiology clinic today with confusion and Somnolence. Of note, she was recently discharged at the beginning of [**2139-5-5**] after presyncope/falls. At that time, lasix was stopped and atenolol was switched to metoprolol as there was concern that blunting of tachycardia could be contributing to falls. She was discharged to rehab (previously living at home). Per report from the ER, patient has had confusion at home x 3 weeks, though no family accompanies her to corroborate this story, and patient denies this. The patient is not sure why she is in the hospital. Per OMR, she saw her cardiologist today, who referred her to the ER after she appeared to be dehydrated, somnolent, and confused. This morning, the patient denies headache, blurry Vision, numbness, tingling or weakness. No CP. +SOB, worsening DOE. No increae LE edema. No nausea, vomiting. Past Medical History: -- Hypertension -- CHF with diastolic dysfunction -- Diabetes diet controlled -- Prior large pulmonary embolism in the setting of gynecological surgery with RV dysfunction, which has since resolved. -- Atrial fibrillation acute ischemic stroke with homonymous hemianopia [**3-/2138**] -- osteoarthritis -- chronic back pain h/o spinal stenosis on chronic opiates -- obstructive sleep apnea on CPAP -- hypercholesterolemia -- stress incontinence -- bilateral pulmonary embolism in [**5-/2136**] -- asthma -- obesity -- diverticulosis -- Cholelithiasis -- s/p hernia surgery [**2133**] -- endometrial ca s/p surgery and radiation [**2133**] now in remission Social History: She is a widow, lives alone in an apartment, 3 living children. After recent hospitalization, she was discharged to rehab. Distant smoking history, denies ETOH. From [**Location (un) 4708**]. Previoulsy worked in childcare. Family History: Mother: DM Father: DM Sister: HTN Physical Exam: Physical Exam on Admission: Vitals - 98.4 144/72 64 97%RA GENERAL: Pleasant, well appearing female in NAD , awake and alert HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRL/EOMI. MM Dry. OP clear. CARDIAC: irregularly irregular. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. LUNGS: CTAB, good air movement biaterally. ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: No edema, 2+ dorsalis pedis/ posterior tibial pulses. NEURO: A&Ox2- to self and [**Hospital1 18**]. Knows her son's name but not phone number. She thinks her last fall was 6 months ago and doesnt remember a recent hospitalization. Unable to say days of the week backwards. Knows where she lives. CN 2-12 intact. Preserved [**Hospital1 **] to fine touch throughout. With regard to strength, has 4+ strength in distal UE on left, otherwise [**5-9**] in proximal left UE and RUE. Quadriceps are 4+/5 b/l, gastrocnemius is [**5-9**] b/l. She refuses to stand, even with assistance. Finger to nose not preserved, however may be secondary to poor understanding of the test. heel to shin difficult to assess given patient compliance PSYCH: Listens and responds to questions appropriately, pleasant . ***************** . Physical Exam on Transfer to ICU: GENERAL: Intubated, NAD HEENT: Normocephalic, atraumatic. No scleral icterus. MMM, OP clear. CARDIAC: irregularly irregular. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. LUNGS: CTAB ABDOMEN: Soft, NT, ND. +BS EXTREMITIES: 1+ edema NEUROLOGIC: Mental status: Intubated, off sedation, minimal arousal to voice/stimulation. Not following commands. Cranial nerves: Pupils sluggishly reactive, both post-surgical, R 4->3, L 3.5->3. Gaze midline and conjugate, face appears symmetric. Motor: Withdraws LUE and LLE weakly, no response RUE, triple flexion RLE. Sensory: withdraws to noxious stimulation weakly as above, L>R Coordination: unable to assess Gait: unable to assess . **************** Physical Exam on Discharge: ????? Pertinent Results: [**2139-6-2**] 03:10PM BLOOD WBC-5.7 RBC-4.88 Hgb-13.6 Hct-42.2 MCV-87 MCH-27.9 MCHC-32.3 RDW-15.3 Plt Ct-327# [**2139-6-2**] 03:10PM BLOOD Neuts-58.1 Lymphs-32.9 Monos-5.6 Eos-2.7 Baso-0.6 [**2139-6-2**] 03:10PM BLOOD PT-33.4* PTT-45.9* INR(PT)-3.2* [**2139-6-2**] 03:10PM BLOOD Glucose-117* UreaN-15 Creat-1.1 Na-140 K-3.1* Cl-101 HCO3-26 AnGap-16 [**2139-6-2**] 03:10PM BLOOD ALT-12 AST-27 LD(LDH)-240 AlkPhos-70 TotBili-0.3 [**2139-6-2**] 03:10PM BLOOD cTropnT-<0.01 [**2139-6-2**] 03:10PM BLOOD proBNP-936* [**2139-6-2**] 03:10PM BLOOD Calcium-10.1 Phos-3.9 Mg-1.6 [**2139-6-2**] 03:16PM BLOOD Lactate-1.6 MICROBIOLOGY: [**2139-6-2**] URINE URINE CULTURE-PENDING EMERGENCY [**Hospital1 **] [**2139-6-2**] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [**Hospital1 **] CSF: [**2139-6-9**] 12:20PM CEREBROSPINAL FLUID (CSF) WBC-20 RBC-670* Polys-0 Lymphs-84 Monos-12 Macroph-4 [**2139-6-9**] 12:20PM CEREBROSPINAL FLUID (CSF) WBC-10 RBC-2415* Polys-23 Lymphs-65 Monos-4 Eos-4 Mesothe-4 [**2139-6-9**] 12:20PM CEREBROSPINAL FLUID (CSF) TotProt-216* Glucose-66 LD(LDH)-52 CSF cytology results: ATYPICAL. Many lymphocytes, including scattered larger atypical lymphoid cells. No carcinoma is seen. CSF flow cytometry: Non-diagnostic study. Clonality could not be assessed in this case due to insufficient numbers of B cells. Cell marker analysis was attempted, but was non-diagnostic in this case due to insufficient numbers of cells. If clinically indicated, we recommend a repeat specimen be submitted to the flow cytometry laboratory. Brain biopsy pathology results: 1. Brain, core biopsy #1 (A-B): Glioblastoma, WHO Grade IV. See note. 2. Brain, core biopsy #2 (C): Glioblastoma, WHO Grade IV. See note. 3. Brain, core biopsy #3 (D): Glioblastoma, WHO Grade IV. See note. Note: Sections show fibrillary tumor with necrosis. Tumor cells are pleomorphic with irregular nuclei. STUDIES: [**6-2**] CT head: Loss of [**Doctor Last Name 352**]-white differentiation within the right thalamus and posterior limb of the internal capsule, with mild mass effect, which is new compared with [**2138-3-4**], and may represent a recent infarction. If clinically indicated, this could be better evaluated with MRI [**6-2**] CT C spine: 1. No acute fracture or new subluxation of the cervical spine. 2. Multilevel degenerative changes as described above. 3. Thyroid goiter, which if clinically indicated could be further evaluated with ultrasound if not already performed. [**6-2**] CXR: FINDINGS: Frontal and lateral chest radiographs demonstrate low lung volumes, though clear lungs. There is no pleural effusion or pneumothorax. The cardiac silhouette is top normal. The mediastinal contours are notable only for tortuosity of the thoracic aorta. The pulmonary vasculature is normal. [**6-4**] MRI: Multiple foci of abnormal signal in the corpus callosum, the largest is centered in the left splenium. These lesions demonstrate bright T2 FLAIR signal as well as mild slow diffusion and are hypodense on CT. MRI with contrast is suggested for further characterization. Differential diagnosis includes a metastatic disease with high cellularity, or lymphoma. A demyelinating process is much less likely. 2. Very limited MRA examination demonstrating possible severe narrowing of the distal right M1 segment [**6-4**] MRI with add'l sequences: Multiple enhancing lesions along the corpus callosum as described above as well as in the suprasellar region, pineal gland, and right thalamus. Differential diagnosis involves metastatic disease or lymphoma CT chest/abd/pelvis [**6-5**]: IMPRESSION: 1. Heterogenous thyroid gland, which may be further evaluated with ultrasound if clinically warranted. 2. Cholelithiasis without evidence of cholecystitis. 3. Hypodensity within the pancreatic body (series 2, image 51) may represent interdigitation of fat. 4. Diverticulosis without evidence of diverticulitis. 5. Stable L1 wedge compression deformity. 6. Air within the bladder may represent recent instrumentation. 7. Main pulmonary artery measures 3.6 cm, unchanged since [**2137-9-17**], raising the question of pulmonary artery hypertension. CT head [**2139-6-10**]: IMPRESSION: 1. Status post left occipital approach biopsy with hypoattenuation in this region, which could represent postprocedural edema versus infarct, which could be further delineated by MRI. 2. Similar distribution of metastatic lesions in the corpus callosum, suprasellar cistern, right thalamus, and left splenium, better depicted on preceding MRI dated [**2139-6-4**]. EEG [**2139-6-11**]: IMPRESSION: This is an abnormal continuous ICU monitoring study because of 29 brief electrographic seizures in the left parietotemporal region as is described earlier under continuous EEG. A few of these seizures had clinical correlation with rhythmic movements of lips. In addition, in the interictal phase there are nearly continuous left parietotemporal periodic epileptiform discharges (PLEDs) indicative of an active epileptogenic focus in this region due to an underlying acute necrotic pathology. Furthermore, background is diffusely slow indicative of moderate to severe diffuse cerebral dysfunction on non-specific etiology. Brief Hospital Course: SUMMARY: 78 year old female with PMHx HTN, dCHF, diabetes, atrial fibrillation on coumadin with past ischemic stroke, presents with altered mental status, found to have new brain lesions. . Hospital Course: The patient was initially admitted to the general medicine service. A CT was done and revealed a likely subacute ischemic stroke in the right thalamus/[**Last Name (LF) **], [**First Name3 (LF) **] neuro was contact[**Name (NI) **]. [**Name2 (NI) **] disinhibtition, just bradyphrenia. Slow for responses, low tone in voice, less active, ? difficulty with spatial orientation, no dysarthia. Following the neurology consult she received an MRI/MRA as there appeared to be persistent edema associated with the lesions on CT that would be atypical of a stroke. The MRI revealed multiple enhancing lesions along the CC and elsewhere concerning for metastatic process versus lymphoma. . The patient was transferred to the neurology service for further work-up and evaluation. Nsurg consulted for brain biopsy. An LP was attempted by the general service and the neurology service unsuccessfully. It was subsequently done under IR and was remarkable for a high protein and atypical cells. The cytology showed many lymphocytes, including scattered larger atypical lymphoid cells. The patient was taken for brain biopsy on [**6-10**] which was uncomplicated. Post-op head CT showed a small amount of intraventricular hemorrhage in the left temporal [**Doctor Last Name 534**]. . Overnight from [**Date range (1) 95249**] she became less responsive and then developed rhythmic eye movements to left side and generalized shaking. She was given ativan 1mg x 2 after which she developed tonic gaze deviation to the left and continued to be unresponsive. She was loaded with Keppra 1000mg IV x 1 and started on 500mg [**Hospital1 **]. CT head appeared stable from her post-op scan. She subsequently became hypotensive and desaturated. She also developed a fib with RVR. She was transferred to the ICU and intubated. She was given decadron 10mg IV x 1 and started on 4mg Q6hrs. . ICU course: . # NEURO: She remained intubated on a propofol drip overnight with resolution of clinical seizure activity. She was connected to LTM the next morning ([**6-11**]) which initially showed left sided PLED's. She subsequently began to have more epileptiform activity on EEG with runs of left-sided rhythmic theta activity. She was given an additional 1000mg Keppra IV and her maintenance dose was increased to 1000mg [**Hospital1 **]. EEG subsequently became more quiet but continued to show intermittent left-sided PLED's. She was taken off sedation and began to awake slowly. On the am of [**6-12**] she was noted to have some rhythmic eye blinking with left eye deviation and was given 2mg ativan IV. EEG showed frequent left-sided PLED's which occasionally evolved into runs of rhythmic theta. She was loaded with Phenytoin and started on 100mg IV Q8hrs. She continued to have some intermittent rhythmic eye blinking which was treated with ativan when persistent. She had no additional further evidence of seizure activity. EEG monitoring was discontinued on [**6-14**]. . She was continued on decadron 4mg Q6hrs for her brain lesions. Final pathology results revealed grade IV glioblastoma. This was discussed with her family, and given her poor prognosis with few viable treatment options she was made DNR/DNI. # CV: She was maintained on telemetry monitoring throughout her admission. She was started on an amiodarone drip upon transfer to the ICU for her a fib with RVR. She was continued on metoprolol 5mg IV Q6hrs and losartan 100mg daily. HR subsequently remained well-controlled. Her home lasix was held due to her volume depletion upon admission. Coumadin was held for her brain biopsy on [**6-10**] and was not restarted given the change in her goals of care. . # Respiratory: She remained intubated pending pathology results and discussion regarding goals of care with her family. Respiratory status remained stable and she was weaned to CPAP. Per her family's wishes she was made CMO and extubated on [**2139-6-18**]. . # ID: She remained afebrile. She completed a course of ceftriaxone for a UTI. . # Renal/GU: Mild renal insufficiency improved with gentle IVF suggesting hypovolemia, likely from decreased PO intake in setting of mental status changes. She developed transient hypernatremia to 152 which resolved with free water flushes and IVF. . # FEN/GI: She remained NPO due to her mental status. An OG tube was placd and she was started on tube feeds. She was continued on her home omeprazole and sucralfate for GERD. . # Endocrine: She was maintained on fingersticks and ISS for blood glucose control. # Code status and End of Life Care: Patient was initially full code upon admission. Once the pathology results from her brain biopsy returned and her poor prognosis was recognized, a family meeting was held involving her health care proxy (son [**Name (NI) **] [**Name (NI) 95250**]), daughter, and close family friend [**Name (NI) **] [**Name (NI) **]. They initially decided to make her DNR/DNI but to continue current level of care pending the arrival of her other son from [**Name (NI) 4708**]. When it became clear that her son would not be able to obtain the necessary paperwork for several weeks the family decided to proceed with terminal extubation. She was made CMO and extubated on [**6-18**]. All medications were stopped except for those to provide comfort. Palliative care was consulted. The patient passed away comfortably on [**2139-6-21**] at 7:55 AM. Confirmed by ausculatation of heart and lungs. Pupils fixed and dilated. Pronounced by: [**First Name9 (NamePattern2) 95251**] [**Last Name (LF) 95252**], [**First Name3 (LF) **]. The Attending, Dr. [**Last Name (STitle) 1206**] was notified at 08:00 AM. Family, admitting was notified. Family declined autopsy. A Death was certificate completed Medications on Admission: Confirmed with rehab. albuterol sulfate 90 mcg/actuation 1-2 Puffs Q4H PRN Tylenol PRN Milk of magnesis PRN dulcolax PRN Fleet Enema PRN fluticasone-salmeterol 100-50 mcg/dose [**Hospital1 **] isosorbide mononitrate 60 mg Tablet Extended Release daily sucralfate 1 gram [**Hospital1 **] omeprazole 20 mg daily oxybutynin chloride 5 mg TID docusate sodium 100 mg [**Hospital1 **] oxycodone 5 mg Q6 PRN losartan 100mg daily felodipine 5mg daily warfarin 7.5mg Tues and Fri. warfarin 5 mg [**Doctor First Name **],MO,WE,TH,SA metoprolol succinate 50 mg daily INR [**5-25**]: 1.5 INR [**5-18**]: 1.9 INR [**5-15**]: 1.8 Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Grade IV glioblastoma Seizures Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/a

191,348,431,518,345,428,276,599,997,458,794,272,250,403,585,427,V586,530,V125,438,368,493,327,278,V853,715,562,V104,V158,V174,V180,V498,V667

{'Malignant neoplasm of brain, unspecified,Cerebral edema,Intracerebral hemorrhage,Acute respiratory failure following trauma and surgery,Grand mal status,Chronic diastolic heart failure,Acidosis,Urinary tract infection, site not specified,Iatrogenic cerebrovascular infarction or hemorrhage,Other iatrogenic hypotension,Nonspecific abnormal electroencephalogram [EEG],Pure hypercholesterolemia,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Atrial fibrillation,Long-term (current) use of anticoagulants,Esophageal reflux,Personal history of venous thrombosis and embolism,Other late effects of cerebrovascular disease,Homonymous bilateral field defects,Asthma, unspecified type, unspecified,Obstructive sleep apnea (adult)(pediatric),Obesity, unspecified,Body Mass Index 33.0-33.9, adult,Osteoarthrosis, unspecified whether generalized or localized, lower leg,Diverticulosis of colon (without mention of hemorrhage),Personal history of malignant neoplasm of other parts of uterus,Personal history of tobacco use,Family history of other cardiovascular diseases,Family history of diabetes mellitus,Do not resuscitate status,Encounter for palliative care'}

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: Confusion noted during outpatient appointment PRESENT ILLNESS: 78 year old female with PMHx HTN, dCHF, Diabetes, CKD, Atrial fibrillation on coumadin, ischemic stroke, admitted after presenting to cardiology clinic today with confusion and Somnolence. Of note, she was recently discharged at the beginning of [**2139-5-5**] after presyncope/falls. At that time, lasix was stopped and atenolol was switched to metoprolol as there was concern that blunting of tachycardia could be contributing to falls. She was discharged to rehab (previously living at home). MEDICAL HISTORY: -- Hypertension -- CHF with diastolic dysfunction -- Diabetes diet controlled -- Prior large pulmonary embolism in the setting of gynecological surgery with RV dysfunction, which has since resolved. -- Atrial fibrillation acute ischemic stroke with homonymous hemianopia [**3-/2138**] -- osteoarthritis -- chronic back pain h/o spinal stenosis on chronic opiates -- obstructive sleep apnea on CPAP -- hypercholesterolemia -- stress incontinence -- bilateral pulmonary embolism in [**5-/2136**] -- asthma -- obesity -- diverticulosis -- Cholelithiasis -- s/p hernia surgery [**2133**] -- endometrial ca s/p surgery and radiation [**2133**] now in remission MEDICATION ON ADMISSION: Confirmed with rehab. albuterol sulfate 90 mcg/actuation 1-2 Puffs Q4H PRN Tylenol PRN Milk of magnesis PRN dulcolax PRN Fleet Enema PRN fluticasone-salmeterol 100-50 mcg/dose [**Hospital1 **] isosorbide mononitrate 60 mg Tablet Extended Release daily sucralfate 1 gram [**Hospital1 **] omeprazole 20 mg daily oxybutynin chloride 5 mg TID docusate sodium 100 mg [**Hospital1 **] oxycodone 5 mg Q6 PRN losartan 100mg daily felodipine 5mg daily warfarin 7.5mg Tues and Fri. warfarin 5 mg [**Doctor First Name **],MO,WE,TH,SA metoprolol succinate 50 mg daily INR [**5-25**]: 1.5 INR [**5-18**]: 1.9 INR [**5-15**]: 1.8 ALLERGIES: Zestril / Norvasc / spironolactone PHYSICAL EXAM: Physical Exam on Admission: Vitals - 98.4 144/72 64 97%RA GENERAL: Pleasant, well appearing female in NAD , awake and alert HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRL/EOMI. MM Dry. OP clear. CARDIAC: irregularly irregular. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. LUNGS: CTAB, good air movement biaterally. ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: No edema, 2+ dorsalis pedis/ posterior tibial pulses. NEURO: A&Ox2- to self and [**Hospital1 18**]. Knows her son's name but not phone number. She thinks her last fall was 6 months ago and doesnt remember a recent hospitalization. Unable to say days of the week backwards. Knows where she lives. CN 2-12 intact. Preserved [**Hospital1 **] to fine touch throughout. With regard to strength, has 4+ strength in distal UE on left, otherwise [**5-9**] in proximal left UE and RUE. Quadriceps are 4+/5 b/l, gastrocnemius is [**5-9**] b/l. She refuses to stand, even with assistance. Finger to nose not preserved, however may be secondary to poor understanding of the test. heel to shin difficult to assess given patient compliance PSYCH: Listens and responds to questions appropriately, pleasant . ***************** . Physical Exam on Transfer to ICU: GENERAL: Intubated, NAD HEENT: Normocephalic, atraumatic. No scleral icterus. MMM, OP clear. CARDIAC: irregularly irregular. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. LUNGS: CTAB ABDOMEN: Soft, NT, ND. +BS EXTREMITIES: 1+ edema FAMILY HISTORY: Mother: DM Father: DM Sister: HTN SOCIAL HISTORY: She is a widow, lives alone in an apartment, 3 living children. After recent hospitalization, she was discharged to rehab. Distant smoking history, denies ETOH. From [**Location (un) 4708**]. Previoulsy worked in childcare. ### Response: {'Malignant neoplasm of brain, unspecified,Cerebral edema,Intracerebral hemorrhage,Acute respiratory failure following trauma and surgery,Grand mal status,Chronic diastolic heart failure,Acidosis,Urinary tract infection, site not specified,Iatrogenic cerebrovascular infarction or hemorrhage,Other iatrogenic hypotension,Nonspecific abnormal electroencephalogram [EEG],Pure hypercholesterolemia,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Atrial fibrillation,Long-term (current) use of anticoagulants,Esophageal reflux,Personal history of venous thrombosis and embolism,Other late effects of cerebrovascular disease,Homonymous bilateral field defects,Asthma, unspecified type, unspecified,Obstructive sleep apnea (adult)(pediatric),Obesity, unspecified,Body Mass Index 33.0-33.9, adult,Osteoarthrosis, unspecified whether generalized or localized, lower leg,Diverticulosis of colon (without mention of hemorrhage),Personal history of malignant neoplasm of other parts of uterus,Personal history of tobacco use,Family history of other cardiovascular diseases,Family history of diabetes mellitus,Do not resuscitate status,Encounter for palliative care'}

CHIEF COMPLAINT: Neutropenic fever Tachycardia PRESENT ILLNESS: Patient is a 51 Y M with a recent diagnosis of HLH receiving Dexamethasone and VP-16; HTN, DM2, RA, obesity who is transferred from Rehab on [**11-25**] for neutropenic fever. He was admitted to [**Hospital1 18**] from [**10-29**] - [**11-20**] initially for pancytopenia, hyperferritinemia, [**Month/Year (2) **] and was determined to have HLH. His hospital course was complicated by agitation requiring intubation, hypotension, delerium, hypernatremia, sinus tachycardia, neutropenic fever, hyperglycemia, and weakness. He was initially started on high-dose steroids (dex 20mg IV daily), IVIg 40g IV daily x4d, and on [**2165-11-4**] etoposide 150mg/m2 days 1,4,8,11. Received last dose of etoposide on [**11-26**]. . Pt was recently admitted to BMT from [**Date range (1) 13695**] for neutropenic fever during which time he received cefepime and bactrim. After 3 days of being afebrile and negative culture data, patient was discharged home with instructions to return to ED if febrile. . Today, had VNA visit where temp elevated to 102, he felt fine at the time however was tired. Had no localizing symptoms. He was advised to present to nearest hospital given concern for febrile neutropenia and need to initiate IV antibiotics as soon as possible in this setting. He went to [**Location (un) 11248**] [**Hospital **]. At ED there pt had temp to 102.9 with rigors. UA was reportedly positive with 10-20 WBCs and cxr was clear. Initially HRs were 140s in sinus tachycardia, which improved to 120s with 1L IVF. BP remained stable. Labs were notable for WBC 1.5 with 75% PMN (ANC 1.16), hct 31, plt 110. Na 129, K 4.0 Cl 8 BUN 21 and Cr 1.1 (0.6 on d/c yesterday). He received IV vancomycin and zosyn for febrile neutropenia and was transferred to [**Hospital1 18**] ED for admission to BMT for mgmt of febrile neutropenia. . In [**Hospital1 18**] ED, initial VS 105.1 146 140/88 34 100% on RA. Pt triggered for HR. He received 2L of fluid which improvement of HRs to 120s. Blood cultures were taken. Per ED had no UOP however did not have a foley in place. He received: - Acetaminophen 1000mg - Ketorolac 30mg/mL - Cefepime 2g x 1 Given heart rate, patient was admitted to ICU for further montioring. VS prior to transfer were 120s 120s-130s/60 19 95% RA . On floor, did not have any complaints. Endorsed sweats. Also endorsed polyuria and urgency but no dysuria or flank pain. Also endorsed polydipsia that was chronic in nature. . MEDICAL HISTORY: 1. Syncope 2. Neutropenic fever 3. Pancytopenia 4. Coagulopathy secondary to hypofibrinogenemia s/p cryoprecipitate infusions 5. Hemophagocytic lymphohistiocytosis (HLH), initially started on high-dose steroids (dex 20mg IV daily), IVIg 40g IV daily x4d, and on [**2165-11-4**] etoposide 150mg/m2 days 1,4,8,11. 6. [**Date Range 5779**] 7. Seizure disorder secondary to HLH with normal brain MRI 8. Generalized weakness. 9. Delerium secondary to HLH and ICU stay 10. Rheumatoid arthritis. 11. Diabetes Type II 12. Hypertension 13. Obesity 14. Insomnia 15. OA 16. s/p intubation for 3 days for agitation [**11/2165**] MEDICATION ON ADMISSION: Pantoprazole 40 mg PO Q24H Micafungin 100 mg IV Q24H Heparin 5000 UNIT SC TID [**12-1**] @ 1822 View Acetaminophen 650 mg PO/NG Q6H:PRN FEVER Potassium Phosphate Replacement (Oncology) IV Sliding Scale Calcium Gluconate IV Sliding Scale Magnesium Sulfate IV Sliding Scale Potassium Chloride IV Sliding Scale Senna 1 TAB PO/NG [**Hospital1 **]:PRN constipation Docusate Sodium 100 mg PO BID Ondansetron 4 mg IV Q8H:PRN nausea Insulin SC Sulfameth/Trimethoprim SS 1 TAB PO/NG DAILY Dexamethasone 10 mg PO/NG DAILY Vitamin D 400 UNIT PO/NG DAILY Calcium Carbonate 1000 mg PO/NG [**Hospital1 **] LeVETiracetam 500 mg PO/NG [**Hospital1 **] ALLERGIES: metformin PHYSICAL EXAM: Physical Exam on Arrival to MICU Tmax: 38.2 ??????C (100.7 ??????F) Tcurrent: 38.2 ??????C (100.7 ??????F) HR: 112 (112 - 119) bpm BP: 137/73(90) {137/73(90) - 137/73(90)} mmHg RR: 21 (21 - 24) insp/min SpO2: 96% Heart rhythm: ST (Sinus Tachycardia) General Appearance: Well nourished, No acute distress, Overweight / Obese, Diaphoretic Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic, hard palate lesions Lymphatic: Cervical WNL, Supraclavicular WNL Cardiovascular: (S1: Normal), (S2: Normal), tachycardic Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ) Abdominal: Soft, Non-tender, Bowel sounds present, Obese Extremities: Right lower extremity edema: Absent, Left lower extremity edema: Absent, large ecchymotic areas Skin: Warm, Rash: ecchymoses on LE Neurologic: Attentive, Follows simple commands, Responds to: Verbal stimuli, Oriented (to): person, place, name, Movement: Purposeful, Tone: Normal FAMILY HISTORY: Diabetes and hypertension on maternal side of his family. Colon cancer- father SOCIAL HISTORY: Married. Does not smoke or use any drugs. Denies regular alcohol use. Currently in rehab in NH

Disseminated candidiasis,Hemophagocytic syndromes,Acute kidney failure, unspecified,Alkalosis,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Rheumatoid arthritis,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Esophageal reflux,Insomnia, unspecified

Disseminated candidiasis,Hemophagocytic syndromes,Acute kidney failure NOS,Alkalosis,Hypertension NOS,DMII wo cmp nt st uncntr,Rheumatoid arthritis,Elev transaminase/ldh,Esophageal reflux,Insomnia NOS

Admission Date: [**2165-11-29**] Discharge Date: [**2165-12-13**] Date of Birth: [**2114-10-29**] Sex: M Service: MEDICINE Allergies: metformin Attending:[**First Name3 (LF) 3963**] Chief Complaint: Neutropenic fever Tachycardia Major Surgical or Invasive Procedure: PICC LINE PLACEMENT History of Present Illness: Patient is a 51 Y M with a recent diagnosis of HLH receiving Dexamethasone and VP-16; HTN, DM2, RA, obesity who is transferred from Rehab on [**11-25**] for neutropenic fever. He was admitted to [**Hospital1 18**] from [**10-29**] - [**11-20**] initially for pancytopenia, hyperferritinemia, [**Month/Year (2) **] and was determined to have HLH. His hospital course was complicated by agitation requiring intubation, hypotension, delerium, hypernatremia, sinus tachycardia, neutropenic fever, hyperglycemia, and weakness. He was initially started on high-dose steroids (dex 20mg IV daily), IVIg 40g IV daily x4d, and on [**2165-11-4**] etoposide 150mg/m2 days 1,4,8,11. Received last dose of etoposide on [**11-26**]. . Pt was recently admitted to BMT from [**Date range (1) 13695**] for neutropenic fever during which time he received cefepime and bactrim. After 3 days of being afebrile and negative culture data, patient was discharged home with instructions to return to ED if febrile. . Today, had VNA visit where temp elevated to 102, he felt fine at the time however was tired. Had no localizing symptoms. He was advised to present to nearest hospital given concern for febrile neutropenia and need to initiate IV antibiotics as soon as possible in this setting. He went to [**Location (un) 11248**] [**Hospital **]. At ED there pt had temp to 102.9 with rigors. UA was reportedly positive with 10-20 WBCs and cxr was clear. Initially HRs were 140s in sinus tachycardia, which improved to 120s with 1L IVF. BP remained stable. Labs were notable for WBC 1.5 with 75% PMN (ANC 1.16), hct 31, plt 110. Na 129, K 4.0 Cl 8 BUN 21 and Cr 1.1 (0.6 on d/c yesterday). He received IV vancomycin and zosyn for febrile neutropenia and was transferred to [**Hospital1 18**] ED for admission to BMT for mgmt of febrile neutropenia. . In [**Hospital1 18**] ED, initial VS 105.1 146 140/88 34 100% on RA. Pt triggered for HR. He received 2L of fluid which improvement of HRs to 120s. Blood cultures were taken. Per ED had no UOP however did not have a foley in place. He received: - Acetaminophen 1000mg - Ketorolac 30mg/mL - Cefepime 2g x 1 Given heart rate, patient was admitted to ICU for further montioring. VS prior to transfer were 120s 120s-130s/60 19 95% RA . On floor, did not have any complaints. Endorsed sweats. Also endorsed polyuria and urgency but no dysuria or flank pain. Also endorsed polydipsia that was chronic in nature. . Past Medical History: 1. Syncope 2. Neutropenic fever 3. Pancytopenia 4. Coagulopathy secondary to hypofibrinogenemia s/p cryoprecipitate infusions 5. Hemophagocytic lymphohistiocytosis (HLH), initially started on high-dose steroids (dex 20mg IV daily), IVIg 40g IV daily x4d, and on [**2165-11-4**] etoposide 150mg/m2 days 1,4,8,11. 6. [**Date Range 5779**] 7. Seizure disorder secondary to HLH with normal brain MRI 8. Generalized weakness. 9. Delerium secondary to HLH and ICU stay 10. Rheumatoid arthritis. 11. Diabetes Type II 12. Hypertension 13. Obesity 14. Insomnia 15. OA 16. s/p intubation for 3 days for agitation [**11/2165**] Social History: Married. Does not smoke or use any drugs. Denies regular alcohol use. Currently in rehab in NH Family History: Diabetes and hypertension on maternal side of his family. Colon cancer- father Physical Exam: Physical Exam on Arrival to MICU Tmax: 38.2 ??????C (100.7 ??????F) Tcurrent: 38.2 ??????C (100.7 ??????F) HR: 112 (112 - 119) bpm BP: 137/73(90) {137/73(90) - 137/73(90)} mmHg RR: 21 (21 - 24) insp/min SpO2: 96% Heart rhythm: ST (Sinus Tachycardia) General Appearance: Well nourished, No acute distress, Overweight / Obese, Diaphoretic Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic, hard palate lesions Lymphatic: Cervical WNL, Supraclavicular WNL Cardiovascular: (S1: Normal), (S2: Normal), tachycardic Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ) Abdominal: Soft, Non-tender, Bowel sounds present, Obese Extremities: Right lower extremity edema: Absent, Left lower extremity edema: Absent, large ecchymotic areas Skin: Warm, Rash: ecchymoses on LE Neurologic: Attentive, Follows simple commands, Responds to: Verbal stimuli, Oriented (to): person, place, name, Movement: Purposeful, Tone: Normal Pertinent Results: Admission Labs [**2165-11-28**] 12:00AM BLOOD WBC-1.9* RBC-2.46* Hgb-7.2* Hct-20.7* MCV-84 MCH-29.4 MCHC-34.9 RDW-14.7 Plt Ct-181 [**2165-11-28**] 12:00AM BLOOD Neuts-39* Bands-3 Lymphs-40 Monos-9 Eos-2 Baso-0 Atyps-2* Metas-1* Myelos-2* Blasts-2* [**2165-11-28**] 12:00AM BLOOD PT-12.4 PTT-23.5 INR(PT)-1.0 [**2165-11-28**] 12:00AM BLOOD Glucose-146* UreaN-22* Creat-0.6 Na-133 K-4.0 Cl-99 HCO3-27 AnGap-11 [**2165-11-28**] 12:00AM BLOOD ALT-40 AST-24 AlkPhos-96 TotBili-0.9 [**2165-11-28**] 12:00AM BLOOD Calcium-7.9* Phos-3.4 Mg-1.9 [**2165-11-29**] 11:10PM BLOOD Lipase-55 [**2165-11-29**] 11:10PM BLOOD Albumin-2.0* Calcium-5.4* Phos-1.6*# Mg-1.2* [**2165-11-29**] 11:10PM BLOOD Ferritn-3981* [**2165-11-30**] 02:33PM BLOOD Fibrino-690* [**2165-11-30**] 03:30AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015 [**2165-11-30**] 03:30AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [**2165-11-30**] 03:30AM URINE RBC-<1 WBC-4 Bacteri-NONE Yeast-NONE Epi-0 [**2165-11-30**] 03:30AM URINE Mucous-RARE [**2165-11-28**] 10:13AM HCT-29.4*# . PERTINENT LABS [**2165-11-30**] 02:33PM BLOOD Fibrino-690* [**2165-12-13**] 12:00AM BLOOD ALT-56* AST-39 LD(LDH)-415* AlkPhos-144* TotBili-0.8 [**2165-11-29**] 11:10PM BLOOD Ferritn-3981* [**2165-12-2**] 09:30AM BLOOD Ferritn-[**Numeric Identifier 14641**]* [**2165-12-12**] 12:23AM BLOOD Ferritn-4655* [**2165-12-5**] 05:45AM BLOOD Triglyc-283* . Blood Culture, Routine (Final [**2165-12-5**]): [**Female First Name (un) **] ALBICANS. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 333-6868D [**2165-11-29**]. Aerobic Bottle Gram Stain (Final [**2165-12-1**]): BUDDING YEAST. [**Date range (1) 90629**] BLOOD CULTURE : NO GROWTH. . DISCHARGE [**2165-12-13**] 12:00AM BLOOD WBC-1.6* RBC-2.80* Hgb-8.6* Hct-25.3* MCV-90 MCH-30.6 MCHC-33.9 RDW-16.4* Plt Ct-115* [**2165-12-13**] 12:00AM BLOOD Neuts-62 Bands-0 Lymphs-27 Monos-6 Eos-0 Baso-1 Atyps-1* Metas-3* Myelos-0 Blasts-0 [**2165-12-13**] 12:00AM BLOOD PT-13.0 PTT-24.8 INR(PT)-1.1 [**2165-12-13**] 12:00AM BLOOD Glucose-163* UreaN-18 Creat-0.5 Na-137 K-3.9 Cl-101 HCO3-27 AnGap-13 [**2165-12-13**] 12:00AM BLOOD ALT-56* AST-39 LD(LDH)-415* AlkPhos-144* TotBili-0.8 [**2165-12-12**] 12:23AM BLOOD Ferritn-4655* [**2165-12-8**] 12:14AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-T0.1 [**2165-12-8**] 12:14AM BLOOD B-GLUCAN- >500 pg/mL . CT CHEST [**2165-12-1**] Both lungs show suggestion of early interstitial disease diffusely with interlobular septal thickening peripherally, both at the superior and inferior aspects of the lungs. Opacity at the left lung base likely represents atelectasis; however, early atypical infection cannot be excluded. Consolidated typical pneumonia is not noted on this study. Pulmonary nodules are again noted. A 3 mm pulmonary nodule is noted within the right lower lobe (2, 33), previously 3 mm. Additional nodule is noted within the left lower lobe (2, 20) measuring 3 mm, unchanged in size and appearance compared to the prior examination. A 4 mm nodule in the left lower lobe (2, 26) is slightly decreased in size on today's study and likely represents measurement difference. Left hilar lymph node measures 13 mm (2, 19) previously 14 mm. A subcarinal lymph node measures 8 mm in short axis diameter (2, 24). Axillary lymph nodes do not meet CT size criteria for pathologic enlargement. Heart and great vessels are unremarkable. Trace pericardial effusion is noted. Airways are patent to the subsegmental level. This study is not optimized for subdiaphragmatic evaluation. Within this limitation, structures within the abdomen are unremarkable. Visualized osseous structures show no focal lytic or sclerotic lesions suspicious for malignancy. IMPRESSION: 1. Trace pericardial effusion. 2. Stable small pulmonary nodules. 3. Stable mediastinal and hilar lymphadenopathy. 4. Atelectasis left lung base; however, early atypical infection cannot be excluded as this is more prominant than on the prior CT. A typical consolidative pneumonia is not present. 5. Suggestion of early interstitial lung disease noted diffusely at the peripheral aspects of the lungs. . TT ECHO [**2165-12-2**] The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thicknesses and cavity size are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size is normal with borderline normal free wall function. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are structurally normal. No vegetation or abscess is seen. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes with low normal global biventricular systolic function. Mild mitral regurgitation with normal valve morphology. Compared with the prior study (images reviewed) of [**2165-11-4**], mild mitral regurgitation is now seen and left ventricular systolic function is less vigorous (may be related to faster heart rate). If the clinical suspicion for endocarditis is moderate or high, a TEE may be useful to better define the mitral valve morphology, however fungal endocarditis typically has large vegetations which are not seen. . [**2165-12-4**] U/S No evidence of DVT in the left upper extremity. . CXR [**2165-12-5**] Lungs are clear. There is crowding of the pulmonary vasculature in the left lower lobe as a result of lower lung volumes. There is stable cardiomegaly. The hilar and remainder of the mediastinal contours are normal. There is no pneumothorax or pleural effusion. IMPRESSION: No evidence of pneumonia. . [**2165-12-6**] Placement of a 5 French, 44 cm double-lumen PICC via a right brachial vein with its tip in the lower SVC. The PICC is ready for use. . [**2165-12-8**] CT ABDOMEN The visualized lung bases are clear with no focal consolidation or pleural effusion. The visualized heart is unremarkable. Trace pleural effusion is noted. The liver demonstrates an unchanged subcentimeter hypodensity in the left lobe of the liver (2, 19), which is too small to characterize but likely represents a hepatic cyst and is similar in appearance compared to [**2165-10-30**]. The gallbladder, spleen, pancreas, and bilateral adrenal glands appear unremarkable. Both kidneys enhance and excrete contrast symmetrically without evidence of hydronephrosis or renal calculi. Subcentimeter hypodensities within the left kidney are too small to characterize but likely represent renal cysts. A 12 x 10 mm hypodensity in the lower pole of the left kidney (300B, 37) is unchanged since the prior exam but too small to characterize. Intra-abdominal loops of large and small bowel are within normal limits. There is no free air or free fluid within the abdomen. Retroperitoneal and mesenteric lymph nodes do not meet CT size criteria for pathologic enlargement. There is thickening and fat stranding along the course of the upper ureter. There is minimal asymmeteric thickening of the bladder at the site of insertion of the right ureter. Overall findings may represent pyeloureteritis. The rectum and sigmoid colon are unremarkable. Pelvic lymph nodes do not meet CT size criteria for pathologic enlargement. There is no pelvic free fluid. Visualized osseous structures show no focal lytic or sclerotic lesions suspicious for malignancy. IMPRESSION: There is thickening and fat stranding along the course of the upper ureter and mild dilation at the mid to distal ureter. There is minimal asymmeteric thickening of the bladder at the site of insertion of the right ureter. Overall findings may represent pyeloureteritis. Brief Hospital Course: The patient is a 51yoM with history of HLH s/p etoposide infusion on [**11-26**], DM, HTN, RA with recent hospitalization for neutropenic fever who presented with tachycardia and fever with moderate neutropenia. Given concern for sepsis, the patient was initially admitted to the ICU. Once stabilized, he was transferred to the floor on [**2165-12-1**]. . # SIRS/Sepsis. Most likely [**3-6**] fungemia. Met SIRS criteria with leukopenia/moderate neutropenia ANC 1035 and left shift as well as tachycardia. Pan-cultured. Given his immunosuppressed state on steroid and chemotherapy, he was initially started on vancomycin and cefepime and Antihypertensives were held. He was found to have fungemia with blood cultures on [**2165-11-29**] had [**5-6**] positive bottles for yeast. Ambisome was started when yeast was found on his blood culture. He was changed to Micafungin on [**2165-12-1**] and his PICC line was removed. Urine culture and cryptococcal antigen were negative. Given positive source, vanc/cefepime were discontinued. Additional infectious work-up was essentially negative, including: Herpes Virus 6 DNA, HITOPLASMA DNA PCR, coccidioides antibody, blastomycoes antibody, BK virus, Adenovirus, EBV and CMV PCRs. . # Fungemia: [**Female First Name (un) **] albicans. Found in blood culture and likely secondary to PICC line in setting of neutropenia. ID was consulted. Initially on ambisome, then changed to micafungin when cryptococcal antigen was negative and culture showed branching yeast. Patient was treated with Micafungin from [**12-1**] to [**12-3**]. Echocardiography revealed no evidence of fungal endocarditis. Abdominal imaging revealed no abdominal source of fungemia. Ophthalmology was consulted and initially noted retinal lesions of unclear etiology (ischemic vs fungal.) Serial exam on [**12-9**] showed no changes in lesion, but recommended one week follow up. Fluconazole IV was started on [**12-4**] with plan to treat until [**12-29**]. Fluconazole IV was chosen as optimal treatment b/c of possible candidal endophtalmitis. . #Pyelonephritis Patient developed low grade fevers after defervescing on treatment of fungemia. Abdominal CT ultimately showed thickening and fat stranding along the course of the upper ureter, mild dilation at the mid to distal ureter, asymmeteric thickening of the bladder at the site of insertion of the right ureter suggestive of pyeloureteritis. The patient was started on Cefepime on [**12-6**] and remained afebrile thereafter. Given complicated UTI, he was placed on a 10 day course to be completed on [**2165-12-15**]. . # Hemophagocytic lymphohistiocytosis: Diagnosed [**2165-10-3**]. Peak ferritin around the time of diagnosis was [**Numeric Identifier 90630**]; prior to discharge was 4655. Triglycerides prior to d/c were 283. Patient is on HLH-94 protocol. He was on dexamethasone 10mg daily and prior to admission he last received etoposide on [**2165-11-26**]. While inpatient, he received etoposide on [**12-3**] (week 5) and [**12-10**] (week 6). Dexamethasone was decreased from 10mg to 5mg qd on [**12-3**] per protocol for week 5. [week 7 due for decrease dose to 1.25mg dex/mm2 (pt is 204mm2)]. He was maintained on bactrim for PCP [**Name Initial (PRE) 1102**]. . # Sinus tachycardia. Most likely [**3-6**] SIRS/sepsis, hypovolemia with fever. Not hypoxic, chest pain, or RH strain on ECG. Patient was given IVF given suspicious for SIRS/sepsis. Beta blocker was initially held. Resolved with treatment of underlying cause. Beta blocker resumed prior to discharge. . # Pancytopenia: ANC 1035 on admission. Likely related to chemotherapy. However further suppression could be from on going infection. His counts improved with treatment of his fungemia. Given continued courses of chemo and discharged on neupogen. . # Hypertension. Metoprolol was held while in the MICU given sepsis. Resumed metoprolol prior to discharge. . # GERD: Continued protonix. . # DM2: Patient was maintained on NPH and Humalog sliding scale [**First Name8 (NamePattern2) **] [**Last Name (un) **] recommendations. . # Seizure disorder: Continued keppra. . # Osteoporosis: Continued calcium/vit D. . #LE edema Furosemide initially held and patient developed some LE edema with IVF administration for chemo. Improved with prn IV lasix and ultimately discharged on. furosemide 20 mg daily. PPX: Bactrim, SC heparin (while inpatient), pantoprazole IV access for long term iv antifungal-picc [**12-6**] Medications on Admission: Pantoprazole 40 mg PO Q24H Micafungin 100 mg IV Q24H Heparin 5000 UNIT SC TID [**12-1**] @ 1822 View Acetaminophen 650 mg PO/NG Q6H:PRN FEVER Potassium Phosphate Replacement (Oncology) IV Sliding Scale Calcium Gluconate IV Sliding Scale Magnesium Sulfate IV Sliding Scale Potassium Chloride IV Sliding Scale Senna 1 TAB PO/NG [**Hospital1 **]:PRN constipation Docusate Sodium 100 mg PO BID Ondansetron 4 mg IV Q8H:PRN nausea Insulin SC Sulfameth/Trimethoprim SS 1 TAB PO/NG DAILY Dexamethasone 10 mg PO/NG DAILY Vitamin D 400 UNIT PO/NG DAILY Calcium Carbonate 1000 mg PO/NG [**Hospital1 **] LeVETiracetam 500 mg PO/NG [**Hospital1 **] Discharge Medications: 1. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 2. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). Disp:*60 Tablet, Chewable(s)* Refills:*2* 3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 6. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). Disp:*120 Tablet(s)* Refills:*2* 7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 8. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical once a day as needed for pain. Disp:*20 Adhesive Patch, Medicated(s)* Refills:*0* 9. cefepime 2 gram Recon Soln Sig: 2G Recon Solns Injection Q8H (every 8 hours) for 4 days. Disp:*12 Recon Soln(s)* Refills:*0* 10. fluconazole in NaCl (iso-osm) 200 mg/100 mL Piggyback Sig: Six Hundred (600) mg Intravenous Q24H (every 24 hours) for 17 days. Disp:*[**Numeric Identifier 14641**] mg* Refills:*0* 11. Neupogen 480 mcg/0.8 mL Syringe Sig: One (1) syringe Injection once a day for 10 days. Disp:*10 syringes* Refills:*2* 12. metoprolol tartrate 25 mg Tablet Sig: half Tablet PO twice a day. Disp:*30 Tablet(s)* Refills:*2* 13. ondansetron 4 mg Tablet, Rapid Dissolve Sig: [**2-3**] Tablet, Rapid Dissolves PO every eight (8) hours as needed for nausea. Disp:*60 Tablet, Rapid Dissolve(s)* Refills:*0* 14. NPH insulin human recomb 100 unit/mL Suspension Sig: Twenty (20) Units Subcutaneous once a day: with breakfast. Disp:*qs Units* Refills:*2* 15. insulin lispro 100 unit/mL Solution Sig: per sliding scale Subcutaneous four times a day: Please give the number of units according to the sliding scale . Disp:*qs * Refills:*2* 16. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 17. dexamethasone 1 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily). Disp:*150 Tablet(s)* Refills:*2* 18. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: Hemophagocytic lymphohistiocytosis 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: Dear Mr [**Known lastname 11559**], You were admitted to the hospital because you were having fevers. You were found to have a blood infection with a fungus called [**Female First Name (un) 564**]. We started you on an antifungal medication, and you improved. You will need to continue IV medication for a total of four weeks to completely clear the infection. This type of infection can also affect your eyes, so we had you evaluated by ophthalmology. You developed fevers again with some urinary symptoms, and we found that you had a kidney infection. We started you on an antibiotic, and you improved. You will need to continue taking this medication IV for ten days to clear this infection. While you were here, you also received treatment for your HLH (Hemophagocytic lymphohistiocytosis) with Etoposide and Dexamethasone. You will need to follow up with Dr [**Last Name (STitle) 3759**] for continued treatment. It was a pleasure taking care of you. Followup Instructions: Department: BMT/ONCOLOGY UNIT When: TUESDAY [**2165-12-17**] at 8:30 AM [**Telephone/Fax (1) 447**] Building: Fd [**Hospital Ward Name 1826**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3971**] Campus: EAST Best Parking: Main Garage Department: HEMATOLOGY/BMT When: WEDNESDAY [**2166-1-1**] at 2:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD [**Telephone/Fax (1) 3241**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Please make an appointment with an endocrinologist to continue treatment of your diabetes

112,288,584,276,401,250,714,790,530,780

{'Disseminated candidiasis,Hemophagocytic syndromes,Acute kidney failure, unspecified,Alkalosis,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Rheumatoid arthritis,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Esophageal reflux,Insomnia, 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: Neutropenic fever Tachycardia PRESENT ILLNESS: Patient is a 51 Y M with a recent diagnosis of HLH receiving Dexamethasone and VP-16; HTN, DM2, RA, obesity who is transferred from Rehab on [**11-25**] for neutropenic fever. He was admitted to [**Hospital1 18**] from [**10-29**] - [**11-20**] initially for pancytopenia, hyperferritinemia, [**Month/Year (2) **] and was determined to have HLH. His hospital course was complicated by agitation requiring intubation, hypotension, delerium, hypernatremia, sinus tachycardia, neutropenic fever, hyperglycemia, and weakness. He was initially started on high-dose steroids (dex 20mg IV daily), IVIg 40g IV daily x4d, and on [**2165-11-4**] etoposide 150mg/m2 days 1,4,8,11. Received last dose of etoposide on [**11-26**]. . Pt was recently admitted to BMT from [**Date range (1) 13695**] for neutropenic fever during which time he received cefepime and bactrim. After 3 days of being afebrile and negative culture data, patient was discharged home with instructions to return to ED if febrile. . Today, had VNA visit where temp elevated to 102, he felt fine at the time however was tired. Had no localizing symptoms. He was advised to present to nearest hospital given concern for febrile neutropenia and need to initiate IV antibiotics as soon as possible in this setting. He went to [**Location (un) 11248**] [**Hospital **]. At ED there pt had temp to 102.9 with rigors. UA was reportedly positive with 10-20 WBCs and cxr was clear. Initially HRs were 140s in sinus tachycardia, which improved to 120s with 1L IVF. BP remained stable. Labs were notable for WBC 1.5 with 75% PMN (ANC 1.16), hct 31, plt 110. Na 129, K 4.0 Cl 8 BUN 21 and Cr 1.1 (0.6 on d/c yesterday). He received IV vancomycin and zosyn for febrile neutropenia and was transferred to [**Hospital1 18**] ED for admission to BMT for mgmt of febrile neutropenia. . In [**Hospital1 18**] ED, initial VS 105.1 146 140/88 34 100% on RA. Pt triggered for HR. He received 2L of fluid which improvement of HRs to 120s. Blood cultures were taken. Per ED had no UOP however did not have a foley in place. He received: - Acetaminophen 1000mg - Ketorolac 30mg/mL - Cefepime 2g x 1 Given heart rate, patient was admitted to ICU for further montioring. VS prior to transfer were 120s 120s-130s/60 19 95% RA . On floor, did not have any complaints. Endorsed sweats. Also endorsed polyuria and urgency but no dysuria or flank pain. Also endorsed polydipsia that was chronic in nature. . MEDICAL HISTORY: 1. Syncope 2. Neutropenic fever 3. Pancytopenia 4. Coagulopathy secondary to hypofibrinogenemia s/p cryoprecipitate infusions 5. Hemophagocytic lymphohistiocytosis (HLH), initially started on high-dose steroids (dex 20mg IV daily), IVIg 40g IV daily x4d, and on [**2165-11-4**] etoposide 150mg/m2 days 1,4,8,11. 6. [**Date Range 5779**] 7. Seizure disorder secondary to HLH with normal brain MRI 8. Generalized weakness. 9. Delerium secondary to HLH and ICU stay 10. Rheumatoid arthritis. 11. Diabetes Type II 12. Hypertension 13. Obesity 14. Insomnia 15. OA 16. s/p intubation for 3 days for agitation [**11/2165**] MEDICATION ON ADMISSION: Pantoprazole 40 mg PO Q24H Micafungin 100 mg IV Q24H Heparin 5000 UNIT SC TID [**12-1**] @ 1822 View Acetaminophen 650 mg PO/NG Q6H:PRN FEVER Potassium Phosphate Replacement (Oncology) IV Sliding Scale Calcium Gluconate IV Sliding Scale Magnesium Sulfate IV Sliding Scale Potassium Chloride IV Sliding Scale Senna 1 TAB PO/NG [**Hospital1 **]:PRN constipation Docusate Sodium 100 mg PO BID Ondansetron 4 mg IV Q8H:PRN nausea Insulin SC Sulfameth/Trimethoprim SS 1 TAB PO/NG DAILY Dexamethasone 10 mg PO/NG DAILY Vitamin D 400 UNIT PO/NG DAILY Calcium Carbonate 1000 mg PO/NG [**Hospital1 **] LeVETiracetam 500 mg PO/NG [**Hospital1 **] ALLERGIES: metformin PHYSICAL EXAM: Physical Exam on Arrival to MICU Tmax: 38.2 ??????C (100.7 ??????F) Tcurrent: 38.2 ??????C (100.7 ??????F) HR: 112 (112 - 119) bpm BP: 137/73(90) {137/73(90) - 137/73(90)} mmHg RR: 21 (21 - 24) insp/min SpO2: 96% Heart rhythm: ST (Sinus Tachycardia) General Appearance: Well nourished, No acute distress, Overweight / Obese, Diaphoretic Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic, hard palate lesions Lymphatic: Cervical WNL, Supraclavicular WNL Cardiovascular: (S1: Normal), (S2: Normal), tachycardic Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ) Abdominal: Soft, Non-tender, Bowel sounds present, Obese Extremities: Right lower extremity edema: Absent, Left lower extremity edema: Absent, large ecchymotic areas Skin: Warm, Rash: ecchymoses on LE Neurologic: Attentive, Follows simple commands, Responds to: Verbal stimuli, Oriented (to): person, place, name, Movement: Purposeful, Tone: Normal FAMILY HISTORY: Diabetes and hypertension on maternal side of his family. Colon cancer- father SOCIAL HISTORY: Married. Does not smoke or use any drugs. Denies regular alcohol use. Currently in rehab in NH ### Response: {'Disseminated candidiasis,Hemophagocytic syndromes,Acute kidney failure, unspecified,Alkalosis,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Rheumatoid arthritis,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Esophageal reflux,Insomnia, unspecified'}

CHIEF COMPLAINT: Lethargy PRESENT ILLNESS: This is a 78 year-old female with a history of ILD who presents with altered mental status. Per the daughters report she was suffering from respiratory symptoms for the last 2 weeks with fever, mild cough and laryngitis. She is on 3 liters O2 at the NH. She was tx with 1 week of Levo starting [**2137-1-31**] for possible PNA. Although her respiratory symptoms were improving on monday she noted her to be significantly fatigued in her nursing home and less conversational. She required more assistance yesterday and was dropping objects. Today she was found slumped in her wheelchair, lethargic but opening her eyes to voice. VS, FS 117, BP 84/54 R, 87/52 L, P 62, R 12, 100% 3L NC. On review of her med list it appears lasix 60mg PO was started [**2-15**] and lopressor 25mg PO BID was started on [**2137-2-14**]. It was thought she was having a CHF exacerbation. Her Chem7 yesterday was Na 140, K4.2, bicarb 36, BUN 53, Cr 1.6, Ca 8.4. . In the ED, Inital VS 97.3, HR 70, BP 98/70, R 18, 100%. FOund to be hypoglyemic and given D50 with improvement of BG to 189. CT head negative. Became more arousable and able to answer questions. EKG showed Aflutter with Ventricular rate in the 60s. CXR showed BL lower lob markings felt consistent with CHF or PNA. BNP 2586. In the ED she developed hypotension with SBP to the 70s but responded to 2L IVF bolus. She was given Levo 750mg and Vanco 1gm IV. Blood culture was drawn. She was admitted to the ICU for AMS and recent hypotension. VS prior to transfer were 96.2 71 97/55, 20, 100% on oxygen. The daughter (HCP) was called and confirmed full code status while in the ED. . ROS: The patient denies any fevers, chills, weight change, nausea, vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia, chest pain, shortness of breath, orthopnea, PND, lower extremity edema, cough, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. MEDICAL HISTORY: - Hypertension. - Diabetes. - Arthritis-pain in all joints. - Carpal tunnel syndrome. - Depression and anxiety-apparently since [**2086**] with h/o auditory hallucinations. - Interestitial lung disease diagnosed 7/[**2135**]. - SVT in the setting of hypoxia with admission [**5-28**] - [**5-28**] PNA treated with Vanc, Cefepime MEDICATION ON ADMISSION: Seroquel 25mg PO qam, 50mg PO qpm vitamin D3 800 U daily prilosec 20mg PO BID caclium carbonate 1000mg PO BID tramadol 25mg PO BID acetylcysteine 200mg/1ml, 3ml via neb q3h gabapentin 100mg PO TID glipizide 5mg PO daily cardizem 360mg SR PO daily celebrew 200mg PO daily fluvoxamine 200mg PO daily robitussion 20mls PO daily bisacodyl 10mg Supp daily prn cheratussin AC 10ml PO q4h prn erythromycin opth ointment [**1-20**] inch to left eyelip [**Hospital1 **] as needed MOM 30ml PO daily prn senna 2 tabs daily prn fleet enema supp daily simethicone 80mg PO QID mirtazapine 30mg PO qhs lasix 60mg PO daily (start [**2-15**]) lopressor 25mg PO BID (start [**2-14**]) albuterol neb q6h ipratropium neb q6h ALLERGIES: Penicillins PHYSICAL EXAM: GEN: elderly AA female, ill appearing, somulent, responsive to noxious stimulis, intermittantly following commands. HEENT: PERRL 2 to 1mm BL, sclera anicteric, MMM. NECK: JVD to angle of jaw (has TR), no bruits, trachea midline FAMILY HISTORY: Mother died age 24 from apparent poisoning, father died at 90s of old age SOCIAL HISTORY: Transfered from [**Hospital3 **]. Per OMR has 10 children including 2 daughters in [**Name (NI) 86**] (others in [**Name (NI) 6482**], elsewhere). Also has a granddaughter in [**Name (NI) 86**] ([**Doctor First Name **]). Denies [**Male First Name (un) 1554**].

Unspecified septicemia,Acute respiratory failure,Septic shock,Bacterial pneumonia, unspecified,Atrial flutter,Acute kidney failure, unspecified,Other and unspecified coagulation defects,Hyperosmolality and/or hypernatremia,Congestive heart failure, unspecified,Severe sepsis,Other chronic pulmonary heart diseases,Thrombocytopenia, unspecified,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Dysthymic disorder,Carpal tunnel syndrome,Arthropathy, unspecified, multiple sites,Unspecified essential hypertension,Postinflammatory pulmonary fibrosis

Septicemia NOS,Acute respiratry failure,Septic shock,Bacterial pneumonia NOS,Atrial flutter,Acute kidney failure NOS,Coagulat defect NEC/NOS,Hyperosmolality,CHF NOS,Severe sepsis,Chr pulmon heart dis NEC,Thrombocytopenia NOS,DMII oth nt st uncntrld,Dysthymic disorder,Carpal tunnel syndrome,Arthropathy NOS-mult,Hypertension NOS,Postinflam pulm fibrosis

Admission Date: [**2137-2-19**] Discharge Date: [**2137-2-23**] Date of Birth: [**2058-6-25**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 5893**] Chief Complaint: Lethargy Major Surgical or Invasive Procedure: Intubation Central venous line placement Arterial line placement History of Present Illness: This is a 78 year-old female with a history of ILD who presents with altered mental status. Per the daughters report she was suffering from respiratory symptoms for the last 2 weeks with fever, mild cough and laryngitis. She is on 3 liters O2 at the NH. She was tx with 1 week of Levo starting [**2137-1-31**] for possible PNA. Although her respiratory symptoms were improving on monday she noted her to be significantly fatigued in her nursing home and less conversational. She required more assistance yesterday and was dropping objects. Today she was found slumped in her wheelchair, lethargic but opening her eyes to voice. VS, FS 117, BP 84/54 R, 87/52 L, P 62, R 12, 100% 3L NC. On review of her med list it appears lasix 60mg PO was started [**2-15**] and lopressor 25mg PO BID was started on [**2137-2-14**]. It was thought she was having a CHF exacerbation. Her Chem7 yesterday was Na 140, K4.2, bicarb 36, BUN 53, Cr 1.6, Ca 8.4. . In the ED, Inital VS 97.3, HR 70, BP 98/70, R 18, 100%. FOund to be hypoglyemic and given D50 with improvement of BG to 189. CT head negative. Became more arousable and able to answer questions. EKG showed Aflutter with Ventricular rate in the 60s. CXR showed BL lower lob markings felt consistent with CHF or PNA. BNP 2586. In the ED she developed hypotension with SBP to the 70s but responded to 2L IVF bolus. She was given Levo 750mg and Vanco 1gm IV. Blood culture was drawn. She was admitted to the ICU for AMS and recent hypotension. VS prior to transfer were 96.2 71 97/55, 20, 100% on oxygen. The daughter (HCP) was called and confirmed full code status while in the ED. . ROS: The patient denies any fevers, chills, weight change, nausea, vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia, chest pain, shortness of breath, orthopnea, PND, lower extremity edema, cough, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. Past Medical History: - Hypertension. - Diabetes. - Arthritis-pain in all joints. - Carpal tunnel syndrome. - Depression and anxiety-apparently since [**2086**] with h/o auditory hallucinations. - Interestitial lung disease diagnosed 7/[**2135**]. - SVT in the setting of hypoxia with admission [**5-28**] - [**5-28**] PNA treated with Vanc, Cefepime Social History: Transfered from [**Hospital3 **]. Per OMR has 10 children including 2 daughters in [**Name (NI) 86**] (others in [**Name (NI) 6482**], elsewhere). Also has a granddaughter in [**Name (NI) 86**] ([**Doctor First Name **]). Denies [**Male First Name (un) 1554**]. Family History: Mother died age 24 from apparent poisoning, father died at 90s of old age Physical Exam: GEN: elderly AA female, ill appearing, somulent, responsive to noxious stimulis, intermittantly following commands. HEENT: PERRL 2 to 1mm BL, sclera anicteric, MMM. NECK: JVD to angle of jaw (has TR), no bruits, trachea midline COR: regularly irregular no M/G/R, normal S1 S2, radial pulses +1 PULM: BL prominent crackles, no rhonchi. ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: 3+ BL LE edema to thigh, no palpable cords NEURO: somulent, responsive to noxious stimulus and intermittantly to voice., CN II ?????? XII grossly intact. Moves all 4 extremities. Patellar DTR difficult to illicit. Plantar reflex downgoing. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: Labs on admission: [**2137-2-19**] 01:45AM BLOOD WBC-5.6 RBC-5.20 Hgb-11.6* Hct-40.7 MCV-78* MCH-22.4* MCHC-28.5* RDW-17.0* Plt Ct-73* [**2137-2-19**] 01:45AM BLOOD PT-19.2* PTT-30.3 INR(PT)-1.8* [**2137-2-19**] 10:00AM BLOOD FDP-10-40* [**2137-2-19**] 01:45AM BLOOD Glucose-70 UreaN-56* Creat-2.0*# Na-138 K-5.3* Cl-97 HCO3-33* AnGap-13 [**2137-2-19**] 01:45AM BLOOD LD(LDH)-605* TotBili-0.6 [**2137-2-19**] 01:14PM BLOOD ALT-261* AST-343* LD(LDH)-250 AlkPhos-97 TotBili-0.6 [**2137-2-19**] 01:45AM BLOOD proBNP-2586* [**2137-2-19**] 10:00AM BLOOD Calcium-7.8* Phos-3.0 Mg-2.1 [**2137-2-19**] 10:00AM BLOOD Hapto-60 [**2137-2-19**] 01:14PM BLOOD TSH-2.0 [**2137-2-19**] 07:23AM BLOOD Type-ART pO2-89 pCO2-61* pH-7.38 calTCO2-37* Base XS-7 [**2137-2-19**] 10:28AM BLOOD Type-CENTRAL VE Temp-34.2 FiO2-. pO2-59* pCO2-58* pH-7.38 calTCO2-36* Base XS-6 Intubat-NOT INTUBA Comment-NASAL [**Last Name (un) 154**] [**2137-2-19**] 04:05AM BLOOD Lactate-2.9* WBC [**2137-2-22**] 04:30 16.2* [**2137-2-21**] 19:03 11.6* [**2137-2-21**] 14:01 11.1* [**2137-2-19**] 01:45 5.6 INR [**2137-2-22**] 04:30 4.3* [**2137-2-21**] 19:03 2.9* [**2137-2-21**] 03:23 1.8* [**2137-2-20**] 05:25 1.8* Creatinine [**2137-2-22**] 04:30 1.9* [**2137-2-21**] 21:00 1.6* [**2137-2-21**] 14:01 1.3* [**2137-2-21**] 03:23 0.7 [**2137-2-20**] 05:25 0.9 [**2137-2-19**] 10:00 1.4* [**2137-2-19**] 01:45 2.0* LFTS ALT AST LD(LDH) AlkPhos DirBili [**2137-2-22**] 04:30 179* 313* 736* 93 2.5* [**2137-2-19**] 13:14 261* 343* 250 97 0.6 MICRO: Blood cultures - NGTD x 2 MRSA screen - (+) Urine cx - NGTD Legionella ag - (-) C. diff toxin - (-) IMAGING: CT head: IMPRESSION: 1. No evidence of an acute intracranial process. MRI would be more sensitive for an acute infarction, if indicated. 2. Likely retrocerebellar arachnoid cyst in the right posterior fossa. . TTE: The left atrium is normal in size. The right atrium is dilated. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The right ventricular cavity is markedly dilated with severe global free wall hypokinesis. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic valve leaflets are moderately thickened. Severe aortic valve stenosis is not suggested. The mitral valve appears structurally normal with trivial mitral regurgitation. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [**2136-5-21**], right atrial and right ventricular cavity enlargement with now identified, with marked right ventricular free wall hypokinesis and new tricuspid regurgitation. This constellation of findings is suggestive of an acute pulonary process (e.g, pulmonary embolism). LE U/S: IMPRESSION: No evidence of deep venous thrombosis in the right or left lower limb. CXR (admission): IMPRESSION: 1. Diffuse chronic bilateral interstitial lung disease (IPF). 2. Prominent hila from prominent pulmonary vessels suggesting pulmonary hypertension. 3. Progressive cardiomegaly. CXR (intubated): FINDINGS: AP single view of the chest has been obtained with patient in supine position. The patient has been now intubated and ETT is seen to reach the central portion of the right main bronchus. It should be withdrawn by at least 3 cm so to avoid obstruction of the left main bronchus. Previously described left internal jugular approach central venous line remains in unchanged position. An apparently new NG tube reaches only to mid portion of esophagus. No pneumothorax has been generated. Previously described extensive bilateral interstitial congestion and probably edema pattern remains. Brief Hospital Course: 78 year old female with history of progressive interstitial lung disease, presents in respiratory distress, hypotension, and increased lethargy. . #Shock: Patient arrived hypotensive despite extensive IVF resuscitation and required dopamine via PIV. Multiple etiologies were in the differential diagnosis. Septic shock was the most likely etiology, given her respiratory symptoms prior to admission, but her skin was cool on exam and all cultures were negative. With marked peripheral edema and cool extremities, we also considered cardiogenic shock, which was supported by an echocardiogram showing increased right-sided failure, confirmed on repeat echo. She was covered broadly for infection with Cefepime and Vanco, with the addition of Azithromycin and Flagyl later in the hospitalization. Central venous access was obtained and an arterial line was placed for close blood pressure and ABG monitoring. She was persistently tachycardic and started on metoprolol and diltiazem for control of her atrial fibrilliation/atrial flutter, without success. The patient's blood pressure began to drop once again and she was placed on phenylephrine and eventually needed to be started on norepinephrine + vasopression with minimal effect. The family was informed about her poor prognosis and wished for care to be withdrawn. She passed away soon after. . # Hypoxemic respiratory failure, in setting of ILD: At baseline, she is on 3L. On admission, her respiratory status was close to baseline, but her progressive lung disease combined with the fluids she was given to support her blood pressures would intermittently put her into pulmonary edema. Her oxygen requirement slowly climbed and her chest x-rays appeared to worsen, requiring intubation due to increased work of breathing, outstripping non-invasive ventilation. Her arterial blood gases were consistently acidotic with relatively normal [**Name (NI) 96100**], indicating a metabolic acidosis that was not correcting. As above, a family meeting was held to discuss her poor prognosis. The decision was made to extubate her and she passed away soon after. . # Altered mental status - She arrived quite lethargic, likely [**2-20**] to hypotension vs delirium. Her CT head was negative and her shock was treated as above. Her sensorium improved briefly for 1 day, but quickly deteriorated during her respiratory failure. . # Thrombocytopenia / coagulopathy: She has a known history of thrombocytopenia, but was apparently not worked up before. She had not had any exposure to heparin since her previous hospitalization. Her last recorded platelet count in [**Month (only) **] [**2136**] was 188. DIC labs were normal and she was continued on heparin SQ. RUQ U/S showed an incidental finding of ?acalculous cholecystitis and IR was consulted. They believed that the gallbladder wall was edematous, but not neccessarily indicative of acalculous cholecystitis and was likely secondary to her hypoalbuminemia and heart failure. No intervention was performed. . # Atrial fibrillation/atrial flutter: As described above in "Shock". She was tried on increasing amounts of AV nodal blockers to control her tachycardia, without effect. Tachycardia likely secondary to septic state. Medications on Admission: Seroquel 25mg PO qam, 50mg PO qpm vitamin D3 800 U daily prilosec 20mg PO BID caclium carbonate 1000mg PO BID tramadol 25mg PO BID acetylcysteine 200mg/1ml, 3ml via neb q3h gabapentin 100mg PO TID glipizide 5mg PO daily cardizem 360mg SR PO daily celebrew 200mg PO daily fluvoxamine 200mg PO daily robitussion 20mls PO daily bisacodyl 10mg Supp daily prn cheratussin AC 10ml PO q4h prn erythromycin opth ointment [**1-20**] inch to left eyelip [**Hospital1 **] as needed MOM 30ml PO daily prn senna 2 tabs daily prn fleet enema supp daily simethicone 80mg PO QID mirtazapine 30mg PO qhs lasix 60mg PO daily (start [**2-15**]) lopressor 25mg PO BID (start [**2-14**]) albuterol neb q6h ipratropium neb q6h Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Septic and cardiogenic shock Discharge Condition: Deceased Discharge Instructions: N/A Followup Instructions: N/A

038,518,785,482,427,584,286,276,428,995,416,287,250,300,354,716,401,515

{'Unspecified septicemia,Acute respiratory failure,Septic shock,Bacterial pneumonia, unspecified,Atrial flutter,Acute kidney failure, unspecified,Other and unspecified coagulation defects,Hyperosmolality and/or hypernatremia,Congestive heart failure, unspecified,Severe sepsis,Other chronic pulmonary heart diseases,Thrombocytopenia, unspecified,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Dysthymic disorder,Carpal tunnel syndrome,Arthropathy, unspecified, multiple sites,Unspecified essential hypertension,Postinflammatory pulmonary fibrosis'}

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: Lethargy PRESENT ILLNESS: This is a 78 year-old female with a history of ILD who presents with altered mental status. Per the daughters report she was suffering from respiratory symptoms for the last 2 weeks with fever, mild cough and laryngitis. She is on 3 liters O2 at the NH. She was tx with 1 week of Levo starting [**2137-1-31**] for possible PNA. Although her respiratory symptoms were improving on monday she noted her to be significantly fatigued in her nursing home and less conversational. She required more assistance yesterday and was dropping objects. Today she was found slumped in her wheelchair, lethargic but opening her eyes to voice. VS, FS 117, BP 84/54 R, 87/52 L, P 62, R 12, 100% 3L NC. On review of her med list it appears lasix 60mg PO was started [**2-15**] and lopressor 25mg PO BID was started on [**2137-2-14**]. It was thought she was having a CHF exacerbation. Her Chem7 yesterday was Na 140, K4.2, bicarb 36, BUN 53, Cr 1.6, Ca 8.4. . In the ED, Inital VS 97.3, HR 70, BP 98/70, R 18, 100%. FOund to be hypoglyemic and given D50 with improvement of BG to 189. CT head negative. Became more arousable and able to answer questions. EKG showed Aflutter with Ventricular rate in the 60s. CXR showed BL lower lob markings felt consistent with CHF or PNA. BNP 2586. In the ED she developed hypotension with SBP to the 70s but responded to 2L IVF bolus. She was given Levo 750mg and Vanco 1gm IV. Blood culture was drawn. She was admitted to the ICU for AMS and recent hypotension. VS prior to transfer were 96.2 71 97/55, 20, 100% on oxygen. The daughter (HCP) was called and confirmed full code status while in the ED. . ROS: The patient denies any fevers, chills, weight change, nausea, vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia, chest pain, shortness of breath, orthopnea, PND, lower extremity edema, cough, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. MEDICAL HISTORY: - Hypertension. - Diabetes. - Arthritis-pain in all joints. - Carpal tunnel syndrome. - Depression and anxiety-apparently since [**2086**] with h/o auditory hallucinations. - Interestitial lung disease diagnosed 7/[**2135**]. - SVT in the setting of hypoxia with admission [**5-28**] - [**5-28**] PNA treated with Vanc, Cefepime MEDICATION ON ADMISSION: Seroquel 25mg PO qam, 50mg PO qpm vitamin D3 800 U daily prilosec 20mg PO BID caclium carbonate 1000mg PO BID tramadol 25mg PO BID acetylcysteine 200mg/1ml, 3ml via neb q3h gabapentin 100mg PO TID glipizide 5mg PO daily cardizem 360mg SR PO daily celebrew 200mg PO daily fluvoxamine 200mg PO daily robitussion 20mls PO daily bisacodyl 10mg Supp daily prn cheratussin AC 10ml PO q4h prn erythromycin opth ointment [**1-20**] inch to left eyelip [**Hospital1 **] as needed MOM 30ml PO daily prn senna 2 tabs daily prn fleet enema supp daily simethicone 80mg PO QID mirtazapine 30mg PO qhs lasix 60mg PO daily (start [**2-15**]) lopressor 25mg PO BID (start [**2-14**]) albuterol neb q6h ipratropium neb q6h ALLERGIES: Penicillins PHYSICAL EXAM: GEN: elderly AA female, ill appearing, somulent, responsive to noxious stimulis, intermittantly following commands. HEENT: PERRL 2 to 1mm BL, sclera anicteric, MMM. NECK: JVD to angle of jaw (has TR), no bruits, trachea midline FAMILY HISTORY: Mother died age 24 from apparent poisoning, father died at 90s of old age SOCIAL HISTORY: Transfered from [**Hospital3 **]. Per OMR has 10 children including 2 daughters in [**Name (NI) 86**] (others in [**Name (NI) 6482**], elsewhere). Also has a granddaughter in [**Name (NI) 86**] ([**Doctor First Name **]). Denies [**Male First Name (un) 1554**]. ### Response: {'Unspecified septicemia,Acute respiratory failure,Septic shock,Bacterial pneumonia, unspecified,Atrial flutter,Acute kidney failure, unspecified,Other and unspecified coagulation defects,Hyperosmolality and/or hypernatremia,Congestive heart failure, unspecified,Severe sepsis,Other chronic pulmonary heart diseases,Thrombocytopenia, unspecified,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Dysthymic disorder,Carpal tunnel syndrome,Arthropathy, unspecified, multiple sites,Unspecified essential hypertension,Postinflammatory pulmonary fibrosis'}

CHIEF COMPLAINT: CHIEF COMPLAINT: chest pain REASON FOR CCU ADMISSION: heart failure PRESENT ILLNESS: Mr. [**Known lastname 7173**] is a 67y/o gentleman with HTN, HLD, DM2, prostate cancer s/p XRT, bicuspid aorta with severe AS, and CAD s/p CABG [**2135**] with known graft disease based on cardiac cath in [**2142**] (patient declined redo sternotomy, AVR, and CABG at the time) who presented with chest pain,underwent emergent cardiac cath due to concern for STEMI, and was found to have unchanged disease but is in heart failure. Pt initially presented to [**Hospital1 **]-N by ambulance with c/o lightheadedness, and syncope while climbing stairs. He felt normal prior to this and says his sx only began with the syncopal episode that occurred on the stairs. He had not had CP or SOB prior to the syncope. (Of note, wife reports different story and states that he has had increased SOB for past 2 days, increased LE edema, and unability to sleep lying down due to SOB.) Ambulance called and EMT reported pt to be diaphoretic on their arrival and slightly "out of it." He also c/o nausea and vomiting at that time. An IV was placed and fluids started and he improved. He was brought to [**Hospital1 **]-N where he was c/o left arm pain which was dull and of moderate intensity. An EKG showed SR and diffuse ST depressions in nearly all leads (not including aVR and V1). Given heparin, zofran, and aspirin and transferred to [**Hospital1 18**]. . At his baseline, he can walk about [**12-16**] mile before feeling short of breath. He states that he has only had problems with DOE for about 6 months now and it has been progressive. He does take lasix at home and has had problems with [**Name2 (NI) **] and pulm edema in past but they have been mild. He was in this usual state of health until 1 week ago when he presented to [**Hospital1 **] [**Location (un) 620**] due to dizziness/lightheadedness. He was found to be relatively hypotensive; it was determined that he was taking his medications incorrectly (Lasix, Imdur, HCTZ). He was told to hold them, and then restart his Lasix a few days ago, which he did. He subsequently developed the sx his wife described. . In the ED, initial VS were: Pulse: 106, RR: 24, BP: 120/70, O2Sat: 100, O2Flow: cpap. Labs were notable for troponin 0.32, BNP 2490, Cr 1.3 (baseline 0.7-0.8). He underwent cardiac cath due to concern for STEMI, and was found to have unchanged disease compared to his prior cath in 11/[**2142**]. He was mildly hypoxic so was started on BiPAP and was admitted to the CCU team. . On arrival to the ICU, VS BP 107/64, P 98, RR 25, 99% CPAP. He denies CP, N/V, but admits to continued SOB. No pain. Admits to feeling diaphoretic. . ROS positive per HPI, otherwise negative. MEDICAL HISTORY: bicuspid aortic valve with moderate-severe AS hypertension hyperlipidemia Diabetes --c/b neuropathy of feet, bilateral Charcot deformity --c/b retinopathy (almost no vision right eye, poor vision left eye) CAD --[**2129**] Cx stent --[**12/2135**] CABG: LIMA to LAD, radial to PDA, SVG to ramus/OM2 CVA ([**2129**] during MI); Left occipital, w/ mild residual visual changes Prostate cancer s/p external beam radiation [**2142**] s/p hernia repair s/p penile implant s/p remote surgery after being involved in a chemical explosion as a child possible mild allergic asthma per patient report MEDICATION ON ADMISSION: GABAPENTIN - (Prescribed by Other Provider) - 800 mg Tablet - 1 Tablet(s) by mouth three times a day INSULIN GLARGINE [LANTUS] - (Prescribed by Other Provider) - 100 unit/mL Solution - 60 units daily at dinner INSULIN LISPRO [HUMALOG] - (Prescribed by Other Provider) - 100 unit/mL Solution - four times a day per sliding scale LEVOTHYROXINE - (Prescribed by Other Provider) - 50 mcg Tablet - 1 Tablet(s) by mouth every morning METOPROLOL TARTRATE - (Prescribed by Other Provider) - 50 mg Tablet - 2 Tablet(s) by mouth every morning, 2 tablets at 2pm, 1 tablet at hs RAMIPRIL - (Prescribed by Other Provider) - 10 mg Capsule - 1 Capsule(s) by mouth twice a day RANITIDINE HCL [ZANTAC] - (Prescribed by Other Provider) - 150 mg Tablet - 1 Tablet(s) by mouth as needed ROSUVASTATIN [CRESTOR] - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth every day, additional [**12-14**] a tablet on Monday/Wed/Saturday ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet, Chewable - 1 Tablet(s) by mouth every evening ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (Prescribed by Other Provider) - 2,000 unit Capsule - 1 Capsule(s) by mouth daily ALLERGIES: Peanut PHYSICAL EXAM: ADMISSION EXAM: VS: BP 107/64, HR 98, RR 25, O2 sat 99% CPAP GENERAL: NAD. Oriented x3. Mood, affect appropriate. lying flat in bed s/p cath HEENT: NCAT. Sclera anicteric. PERRL, EOMI. CPAP in place NECK: unable to assess JVD [**1-14**] large neck and patient positioning CARDIAC: RRR, normal S1, S2. 3/6 systolic murmur heard best at USB. No rubs, gallops. LUNGS: Exam limited by patient positioning. Decreased BS at bases bilaterally. CTAB anteriorly in upper lobes ABDOMEN: Soft, obese, NT. EXTREMITIES: No c/c/e. SKIN: no rashes. PULSES: 2+ radial and DP bilat FAMILY HISTORY: Brother died at age 47 from an MI and diabetes. Mother died at age 64 from complications of cardiovascular disease and diabetes. Sister also died at age 64 from cardiovascular disease. SOCIAL HISTORY: Patient is married. He has two children from a former marriage. Tobacco: Patient smoked 4ppd x 30 years, quitting [**2115-2-18**] ETOH: Prior heavy ETOH, quit in [**2110**] Contact upon discharge: Home Care Services: Denies

Coronary atherosclerosis of autologous vein bypass graft,Congenital insufficiency of aortic valve,Other acute and subacute forms of ischemic heart disease, other,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Personal history of malignant neoplasm of prostate,Aortic valve disorders,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Arthropathy associated with neurological disorders,Background diabetic retinopathy,Personal history of tobacco use,Congestive heart failure, unspecified,Encounter for palliative care

Crn ath atlg vn bps grft,Cong aorta valv insuffic,Ac ischemic hrt dis NEC,Hypertension NOS,Hyperlipidemia NEC/NOS,Hx-prostatic malignancy,Aortic valve disorder,DMII neuro nt st uncntrl,Neuropathy in diabetes,Arthropathy w nerve dis,Diabetic retinopathy NOS,History of tobacco use,CHF NOS,Encountr palliative care

Admission Date: [**2145-4-21**] Discharge Date: [**2145-4-21**] Date of Birth: [**2077-4-30**] Sex: M Service: MEDICINE Allergies: Peanut Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: CHIEF COMPLAINT: chest pain REASON FOR CCU ADMISSION: heart failure Major Surgical or Invasive Procedure: cardiac catheterization [**2145-4-21**] History of Present Illness: Mr. [**Known lastname 7173**] is a 67y/o gentleman with HTN, HLD, DM2, prostate cancer s/p XRT, bicuspid aorta with severe AS, and CAD s/p CABG [**2135**] with known graft disease based on cardiac cath in [**2142**] (patient declined redo sternotomy, AVR, and CABG at the time) who presented with chest pain,underwent emergent cardiac cath due to concern for STEMI, and was found to have unchanged disease but is in heart failure. Pt initially presented to [**Hospital1 **]-N by ambulance with c/o lightheadedness, and syncope while climbing stairs. He felt normal prior to this and says his sx only began with the syncopal episode that occurred on the stairs. He had not had CP or SOB prior to the syncope. (Of note, wife reports different story and states that he has had increased SOB for past 2 days, increased LE edema, and unability to sleep lying down due to SOB.) Ambulance called and EMT reported pt to be diaphoretic on their arrival and slightly "out of it." He also c/o nausea and vomiting at that time. An IV was placed and fluids started and he improved. He was brought to [**Hospital1 **]-N where he was c/o left arm pain which was dull and of moderate intensity. An EKG showed SR and diffuse ST depressions in nearly all leads (not including aVR and V1). Given heparin, zofran, and aspirin and transferred to [**Hospital1 18**]. . At his baseline, he can walk about [**12-16**] mile before feeling short of breath. He states that he has only had problems with DOE for about 6 months now and it has been progressive. He does take lasix at home and has had problems with [**Name2 (NI) **] and pulm edema in past but they have been mild. He was in this usual state of health until 1 week ago when he presented to [**Hospital1 **] [**Location (un) 620**] due to dizziness/lightheadedness. He was found to be relatively hypotensive; it was determined that he was taking his medications incorrectly (Lasix, Imdur, HCTZ). He was told to hold them, and then restart his Lasix a few days ago, which he did. He subsequently developed the sx his wife described. . In the ED, initial VS were: Pulse: 106, RR: 24, BP: 120/70, O2Sat: 100, O2Flow: cpap. Labs were notable for troponin 0.32, BNP 2490, Cr 1.3 (baseline 0.7-0.8). He underwent cardiac cath due to concern for STEMI, and was found to have unchanged disease compared to his prior cath in 11/[**2142**]. He was mildly hypoxic so was started on BiPAP and was admitted to the CCU team. . On arrival to the ICU, VS BP 107/64, P 98, RR 25, 99% CPAP. He denies CP, N/V, but admits to continued SOB. No pain. Admits to feeling diaphoretic. . ROS positive per HPI, otherwise negative. Past Medical History: bicuspid aortic valve with moderate-severe AS hypertension hyperlipidemia Diabetes --c/b neuropathy of feet, bilateral Charcot deformity --c/b retinopathy (almost no vision right eye, poor vision left eye) CAD --[**2129**] Cx stent --[**12/2135**] CABG: LIMA to LAD, radial to PDA, SVG to ramus/OM2 CVA ([**2129**] during MI); Left occipital, w/ mild residual visual changes Prostate cancer s/p external beam radiation [**2142**] s/p hernia repair s/p penile implant s/p remote surgery after being involved in a chemical explosion as a child possible mild allergic asthma per patient report Social History: Patient is married. He has two children from a former marriage. Tobacco: Patient smoked 4ppd x 30 years, quitting [**2115-2-18**] ETOH: Prior heavy ETOH, quit in [**2110**] Contact upon discharge: Home Care Services: Denies Family History: Brother died at age 47 from an MI and diabetes. Mother died at age 64 from complications of cardiovascular disease and diabetes. Sister also died at age 64 from cardiovascular disease. Physical Exam: ADMISSION EXAM: VS: BP 107/64, HR 98, RR 25, O2 sat 99% CPAP GENERAL: NAD. Oriented x3. Mood, affect appropriate. lying flat in bed s/p cath HEENT: NCAT. Sclera anicteric. PERRL, EOMI. CPAP in place NECK: unable to assess JVD [**1-14**] large neck and patient positioning CARDIAC: RRR, normal S1, S2. 3/6 systolic murmur heard best at USB. No rubs, gallops. LUNGS: Exam limited by patient positioning. Decreased BS at bases bilaterally. CTAB anteriorly in upper lobes ABDOMEN: Soft, obese, NT. EXTREMITIES: No c/c/e. SKIN: no rashes. PULSES: 2+ radial and DP bilat DISCHARGE EXAM: [patient expired] Pertinent Results: ADMISSION LABS: [**2145-4-20**] 11:54PM BLOOD WBC-16.9* RBC-4.40*# Hgb-13.9*# Hct-42.1# MCV-96 MCH-31.6 MCHC-33.0 RDW-13.6 Plt Ct-239 [**2145-4-20**] 11:54PM BLOOD Neuts-86.9* Lymphs-6.8* Monos-4.5 Eos-1.6 Baso-0.3 [**2145-4-20**] 11:54PM BLOOD PT-12.6* PTT-150* INR(PT)-1.2* [**2145-4-20**] 11:54PM BLOOD Glucose-249* UreaN-29* Creat-1.3* Na-133 K-4.2 Cl-97 HCO3-20* AnGap-20 [**2145-4-20**] 11:54PM BLOOD proBNP-2490* [**2145-4-20**] 11:54PM BLOOD cTropnT-0.32* [**2145-4-21**] 02:50AM BLOOD CK-MB-112* MB Indx-5.9 cTropnT-1.71* [**2145-4-21**] 02:50AM BLOOD Calcium-9.0 Phos-4.9* Mg-2.0 CARDIAC CATHETERIZATION [**2145-4-21**]: [final report pending] Brief Hospital Course: Mr. [**Known lastname 7173**] is a 67y/o gentleman with HTN, HLD, DM2, prostate cancer s/p XRT, bicuspid aorta with severe AS, and CAD s/p CABG [**2135**] with known graft disease based on cardiac cath in [**2142**] (patient declined redo sternotomy, AVR, and CABG at the time) who presented with chest pain, underwent emergent cardiac cath due to concern for STEMI, and was found to have unchanged disease but was in clinical heart failure. Over the course of the night, CCU team attempted diuresis with Lasix 20g IV x1 (poor response) then started Lasix gtt at 5/hr with urine output ~30-40/hr. Blood pressures were systolic ~85 so he did not tolerate the Nitro gtt that was ordered. We placed him on CPAP. At 6AM, team was paged that patient had requested to remove CPAP. He was oxygenating fine, but had HR 100-130 with SBP ~75-85. He was mentating fine but endorsed diaphoresis and nausea (vomited a few times). No chest pain. Began to feel ??????as if I am drowning.?????? Team confirmed his code status: under no circumstance would he want chest compressions, or endotracheal intubation. Even if his immediate illness might be reversible. CCU resident called his wife [**Name (NI) **] and confirmed this with her; she knew he felt this way and had written her a letter the day before mentioning that he knew he was dying ?????? would not want resuscitation. Cardiology Fellow was at the bedside at this time. Team attempted diuresis again with a Lasix drip but he became persistently hypotensive and tachycardic. Started Dopamine. Continued to complain of dyspnea. Team considered ACS (though unlikely given his cath findings from hours earlier); though possibly an element of ongoing ischemia as 2AM cardiac enzymes were elevated. Also considered PE. TTE at the bedside did not show any obvious signs of acute RV pressure/volume overload but his LV appeared very hypokinetic. Attending came to the bedside and looked at TTE. It was determined that he probably had acute on chronic worsening LV failure. After discussing the findings with patient and family, and explaining that there were no measures available to reverse his underlying disease, both patient and family understood and requested that patient be transitioned to comfort-focused care. He had been back on CPAP at the time but requested for it to be removed. His dyspnea was treated with supplemental O2, fan by the bedside, and morphine boluses. Mr. [**Known lastname 7173**] had a bradycardic/PEA arrest and expired at 8:30AM, with family (including [**Name (NI) **], wife/HCP) arriving soon thereafter. [**Doctor First Name **] declined post-mortem exam. Family was appreciative of communication between team and family, as well as the treatment of her husband??????s symptoms at the end of his life. Medications on Admission: GABAPENTIN - (Prescribed by Other Provider) - 800 mg Tablet - 1 Tablet(s) by mouth three times a day INSULIN GLARGINE [LANTUS] - (Prescribed by Other Provider) - 100 unit/mL Solution - 60 units daily at dinner INSULIN LISPRO [HUMALOG] - (Prescribed by Other Provider) - 100 unit/mL Solution - four times a day per sliding scale LEVOTHYROXINE - (Prescribed by Other Provider) - 50 mcg Tablet - 1 Tablet(s) by mouth every morning METOPROLOL TARTRATE - (Prescribed by Other Provider) - 50 mg Tablet - 2 Tablet(s) by mouth every morning, 2 tablets at 2pm, 1 tablet at hs RAMIPRIL - (Prescribed by Other Provider) - 10 mg Capsule - 1 Capsule(s) by mouth twice a day RANITIDINE HCL [ZANTAC] - (Prescribed by Other Provider) - 150 mg Tablet - 1 Tablet(s) by mouth as needed ROSUVASTATIN [CRESTOR] - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth every day, additional [**12-14**] a tablet on Monday/Wed/Saturday ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet, Chewable - 1 Tablet(s) by mouth every evening ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (Prescribed by Other Provider) - 2,000 unit Capsule - 1 Capsule(s) by mouth daily Discharge Medications: [patient expired] Discharge Disposition: Expired Discharge Diagnosis: [patient expired] Discharge Condition: [patient expired] Discharge Instructions: [patient expired] Followup Instructions: [patient expired]

414,746,411,401,272,V104,424,250,357,713,362,V158,428,V667

{'Coronary atherosclerosis of autologous vein bypass graft,Congenital insufficiency of aortic valve,Other acute and subacute forms of ischemic heart disease, other,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Personal history of malignant neoplasm of prostate,Aortic valve disorders,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Arthropathy associated with neurological disorders,Background diabetic retinopathy,Personal history of tobacco use,Congestive heart failure, unspecified,Encounter for palliative care'}

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: CHIEF COMPLAINT: chest pain REASON FOR CCU ADMISSION: heart failure PRESENT ILLNESS: Mr. [**Known lastname 7173**] is a 67y/o gentleman with HTN, HLD, DM2, prostate cancer s/p XRT, bicuspid aorta with severe AS, and CAD s/p CABG [**2135**] with known graft disease based on cardiac cath in [**2142**] (patient declined redo sternotomy, AVR, and CABG at the time) who presented with chest pain,underwent emergent cardiac cath due to concern for STEMI, and was found to have unchanged disease but is in heart failure. Pt initially presented to [**Hospital1 **]-N by ambulance with c/o lightheadedness, and syncope while climbing stairs. He felt normal prior to this and says his sx only began with the syncopal episode that occurred on the stairs. He had not had CP or SOB prior to the syncope. (Of note, wife reports different story and states that he has had increased SOB for past 2 days, increased LE edema, and unability to sleep lying down due to SOB.) Ambulance called and EMT reported pt to be diaphoretic on their arrival and slightly "out of it." He also c/o nausea and vomiting at that time. An IV was placed and fluids started and he improved. He was brought to [**Hospital1 **]-N where he was c/o left arm pain which was dull and of moderate intensity. An EKG showed SR and diffuse ST depressions in nearly all leads (not including aVR and V1). Given heparin, zofran, and aspirin and transferred to [**Hospital1 18**]. . At his baseline, he can walk about [**12-16**] mile before feeling short of breath. He states that he has only had problems with DOE for about 6 months now and it has been progressive. He does take lasix at home and has had problems with [**Name2 (NI) **] and pulm edema in past but they have been mild. He was in this usual state of health until 1 week ago when he presented to [**Hospital1 **] [**Location (un) 620**] due to dizziness/lightheadedness. He was found to be relatively hypotensive; it was determined that he was taking his medications incorrectly (Lasix, Imdur, HCTZ). He was told to hold them, and then restart his Lasix a few days ago, which he did. He subsequently developed the sx his wife described. . In the ED, initial VS were: Pulse: 106, RR: 24, BP: 120/70, O2Sat: 100, O2Flow: cpap. Labs were notable for troponin 0.32, BNP 2490, Cr 1.3 (baseline 0.7-0.8). He underwent cardiac cath due to concern for STEMI, and was found to have unchanged disease compared to his prior cath in 11/[**2142**]. He was mildly hypoxic so was started on BiPAP and was admitted to the CCU team. . On arrival to the ICU, VS BP 107/64, P 98, RR 25, 99% CPAP. He denies CP, N/V, but admits to continued SOB. No pain. Admits to feeling diaphoretic. . ROS positive per HPI, otherwise negative. MEDICAL HISTORY: bicuspid aortic valve with moderate-severe AS hypertension hyperlipidemia Diabetes --c/b neuropathy of feet, bilateral Charcot deformity --c/b retinopathy (almost no vision right eye, poor vision left eye) CAD --[**2129**] Cx stent --[**12/2135**] CABG: LIMA to LAD, radial to PDA, SVG to ramus/OM2 CVA ([**2129**] during MI); Left occipital, w/ mild residual visual changes Prostate cancer s/p external beam radiation [**2142**] s/p hernia repair s/p penile implant s/p remote surgery after being involved in a chemical explosion as a child possible mild allergic asthma per patient report MEDICATION ON ADMISSION: GABAPENTIN - (Prescribed by Other Provider) - 800 mg Tablet - 1 Tablet(s) by mouth three times a day INSULIN GLARGINE [LANTUS] - (Prescribed by Other Provider) - 100 unit/mL Solution - 60 units daily at dinner INSULIN LISPRO [HUMALOG] - (Prescribed by Other Provider) - 100 unit/mL Solution - four times a day per sliding scale LEVOTHYROXINE - (Prescribed by Other Provider) - 50 mcg Tablet - 1 Tablet(s) by mouth every morning METOPROLOL TARTRATE - (Prescribed by Other Provider) - 50 mg Tablet - 2 Tablet(s) by mouth every morning, 2 tablets at 2pm, 1 tablet at hs RAMIPRIL - (Prescribed by Other Provider) - 10 mg Capsule - 1 Capsule(s) by mouth twice a day RANITIDINE HCL [ZANTAC] - (Prescribed by Other Provider) - 150 mg Tablet - 1 Tablet(s) by mouth as needed ROSUVASTATIN [CRESTOR] - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth every day, additional [**12-14**] a tablet on Monday/Wed/Saturday ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet, Chewable - 1 Tablet(s) by mouth every evening ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (Prescribed by Other Provider) - 2,000 unit Capsule - 1 Capsule(s) by mouth daily ALLERGIES: Peanut PHYSICAL EXAM: ADMISSION EXAM: VS: BP 107/64, HR 98, RR 25, O2 sat 99% CPAP GENERAL: NAD. Oriented x3. Mood, affect appropriate. lying flat in bed s/p cath HEENT: NCAT. Sclera anicteric. PERRL, EOMI. CPAP in place NECK: unable to assess JVD [**1-14**] large neck and patient positioning CARDIAC: RRR, normal S1, S2. 3/6 systolic murmur heard best at USB. No rubs, gallops. LUNGS: Exam limited by patient positioning. Decreased BS at bases bilaterally. CTAB anteriorly in upper lobes ABDOMEN: Soft, obese, NT. EXTREMITIES: No c/c/e. SKIN: no rashes. PULSES: 2+ radial and DP bilat FAMILY HISTORY: Brother died at age 47 from an MI and diabetes. Mother died at age 64 from complications of cardiovascular disease and diabetes. Sister also died at age 64 from cardiovascular disease. SOCIAL HISTORY: Patient is married. He has two children from a former marriage. Tobacco: Patient smoked 4ppd x 30 years, quitting [**2115-2-18**] ETOH: Prior heavy ETOH, quit in [**2110**] Contact upon discharge: Home Care Services: Denies ### Response: {'Coronary atherosclerosis of autologous vein bypass graft,Congenital insufficiency of aortic valve,Other acute and subacute forms of ischemic heart disease, other,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Personal history of malignant neoplasm of prostate,Aortic valve disorders,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Arthropathy associated with neurological disorders,Background diabetic retinopathy,Personal history of tobacco use,Congestive heart failure, unspecified,Encounter for palliative care'}

CHIEF COMPLAINT: melena PRESENT ILLNESS: 56 y/o M with PMH congenital heart disease s/p VSD repair, PVR and MVR, CHF, DM, afib on coumadin and mult. GIB who presents from [**Hospital1 1501**] with 2 days of black stools. Of note the patient was recently discharged from [**Hospital1 18**] on [**2-14**] after an admisison for GIB. He underwent EGD with small bowel enteroscopy as well as colonoscopy. EGD showed mild gastritis and no active bleeding. Capsule endoscopy was also performed on [**2-13**] that showed a few mild erosions in the duodenum and proximal small bowel as well as a few nonbleeding redspots in the mid and distal small bowel. Since discharge from [**Hospital1 18**] the patient reports that he has had dark stools but has not had any BRBPR. On sunday night the patient developed a tightness in his abdomen which he describes as a knot. He also had some nausea, however denied abdominal pain, SOB, CP, or LH. Labs at his [**Hospital1 1501**] this morning showed Hct 20.1 (down from 27 on [**2-27**]) and he was sent to [**Hospital1 18**] for further workup. . In ED VS were T 97 HR 85 BP 96/53 86% TM. Rectal exam showed guaiac pos. black stool, no blood. He was given a total of 4L NS as well as 2 units RBCs. He also received protonix 40mg IV. On arrival to the ICU the patient reported feeling much better. he cont. to deny abdominal pain, SOB, CP. He had an additional black, guaiac pos. stool on arrival to the ICU. MEDICAL HISTORY: #congenital heart disease -s/p pulmonic valvulotomy in [**2160**] -s/p VSD repair [**2185**] -[**2199-12-24**]: redo sternotomy, PVR (porcine), MVR (porcine), VSD closure, PFO closure #CHF #s/p trach, open J-tube in [**1-10**] #DM #anxiety #depression #A fib #RBBB #RLE varicosities #s/p R hernia repair #s/p appy MEDICATION ON ADMISSION: 1. Atorvastatin 20 mg Daily 2. Ascorbic Acid 500 mg [**Hospital1 **] 3. Fluoxetine 20 mg DAILY 4. Docusate Sodium 50 mg/5 mL [**Hospital1 **] 5. Miconazole Nitrate 2 % Powder QID 6. Albuterol Sulfate 2.5 mg/3 mL Inhalation Q6H PRN 7. Ipratropium Bromide 0.02 % Solution Q6 PRN 8. Clonazepam 0.5 mg Tablet PO BID PRN 9. Lansoprazole 30 mg Tablet Daily 10. Aspirin 81 mg TabletDaily 11. Ferrous Sulfate 300 mg/5 mL Daily 12. Metoprolol Tartrate 25 mg Tablet PO twice a day. 13. Insulin Glargine Twenty (20) UNITS Subcutaneous at bedtime. ALLERGIES: Aldactone PHYSICAL EXAM: VS: Temp 98.0 98.0 113/51 97% trach. Gen - Alert, no acute distress HEENT - PERRL, extraocular motions intact, anicteric, mucous membranes moist, trach in place Neck - no JVD, no cervical lymphadenopathy Chest - [**Month (only) **]. BS at bases, otherwise clear to auscultation bilaterally CV - Irregular, III/VI SEM loudest at RUSB Abd - Soft, nontender, nondistended, with normoactive bowel sounds Extr - No clubbing, cyanosis, 2+ pitting edema b/l LE with chronic venous stasis changes Neuro - Alert and oriented x 3, cranial nerves [**1-14**] intact, upper and lower extremity strength 5/5 bilaterally, sensation grossly intact Skin - No rashes Rectal: guaiac positive stool FAMILY HISTORY: father had MI at age 55 SOCIAL HISTORY: disabled never used tobacco occasional ETOH

Hemorrhage of gastrointestinal tract, unspecified,Acute respiratory failure,Chronic systolic heart failure,Pneumonia due to other specified organism,Bacteremia,Acute kidney failure, unspecified,Delirium due to conditions classified elsewhere,Hyperosmolality and/or hypernatremia,Iron deficiency anemia secondary to blood loss (chronic),Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Foreign body in larynx,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other specified bacteria,Depressive disorder, not elsewhere classified,Anxiety state, unspecified,Heart valve replaced by transplant,Tracheostomy status,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction

Gastrointest hemorr NOS,Acute respiratry failure,Chr systolic hrt failure,Pneumon oth spec orgnsm,Bacteremia,Acute kidney failure NOS,Delirium d/t other cond,Hyperosmolality,Chr blood loss anemia,Atrial fibrillation,DMII wo cmp uncntrld,Foreign body in larynx,Oth specf bacteria,Depressive disorder NEC,Anxiety state NOS,Heart valve transplant,Tracheostomy status,Cholelithiasis NOS

Admission Date: [**2200-3-4**] Discharge Date: [**2200-4-1**] Date of Birth: [**2143-8-4**] Sex: M Service: MEDICINE Allergies: Aldactone Attending:[**First Name3 (LF) 3984**] Chief Complaint: melena Major Surgical or Invasive Procedure: EGD Attempt at capsule endoscopy x 2 PICC placement [**2200-3-14**] History of Present Illness: 56 y/o M with PMH congenital heart disease s/p VSD repair, PVR and MVR, CHF, DM, afib on coumadin and mult. GIB who presents from [**Hospital1 1501**] with 2 days of black stools. Of note the patient was recently discharged from [**Hospital1 18**] on [**2-14**] after an admisison for GIB. He underwent EGD with small bowel enteroscopy as well as colonoscopy. EGD showed mild gastritis and no active bleeding. Capsule endoscopy was also performed on [**2-13**] that showed a few mild erosions in the duodenum and proximal small bowel as well as a few nonbleeding redspots in the mid and distal small bowel. Since discharge from [**Hospital1 18**] the patient reports that he has had dark stools but has not had any BRBPR. On sunday night the patient developed a tightness in his abdomen which he describes as a knot. He also had some nausea, however denied abdominal pain, SOB, CP, or LH. Labs at his [**Hospital1 1501**] this morning showed Hct 20.1 (down from 27 on [**2-27**]) and he was sent to [**Hospital1 18**] for further workup. . In ED VS were T 97 HR 85 BP 96/53 86% TM. Rectal exam showed guaiac pos. black stool, no blood. He was given a total of 4L NS as well as 2 units RBCs. He also received protonix 40mg IV. On arrival to the ICU the patient reported feeling much better. he cont. to deny abdominal pain, SOB, CP. He had an additional black, guaiac pos. stool on arrival to the ICU. Past Medical History: #congenital heart disease -s/p pulmonic valvulotomy in [**2160**] -s/p VSD repair [**2185**] -[**2199-12-24**]: redo sternotomy, PVR (porcine), MVR (porcine), VSD closure, PFO closure #CHF #s/p trach, open J-tube in [**1-10**] #DM #anxiety #depression #A fib #RBBB #RLE varicosities #s/p R hernia repair #s/p appy Social History: disabled never used tobacco occasional ETOH Family History: father had MI at age 55 Physical Exam: VS: Temp 98.0 98.0 113/51 97% trach. Gen - Alert, no acute distress HEENT - PERRL, extraocular motions intact, anicteric, mucous membranes moist, trach in place Neck - no JVD, no cervical lymphadenopathy Chest - [**Month (only) **]. BS at bases, otherwise clear to auscultation bilaterally CV - Irregular, III/VI SEM loudest at RUSB Abd - Soft, nontender, nondistended, with normoactive bowel sounds Extr - No clubbing, cyanosis, 2+ pitting edema b/l LE with chronic venous stasis changes Neuro - Alert and oriented x 3, cranial nerves [**1-14**] intact, upper and lower extremity strength 5/5 bilaterally, sensation grossly intact Skin - No rashes Rectal: guaiac positive stool Pertinent Results: [**2200-3-4**] 11:15AM BLOOD WBC-9.0# RBC-2.39* Hgb-6.9* Hct-21.9* MCV-91 MCH-28.9 MCHC-31.6 RDW-14.1 Plt Ct-323# [**2200-3-9**] 06:30AM BLOOD WBC-6.4 RBC-3.33* Hgb-10.0* Hct-30.6* MCV-92 MCH-30.0 MCHC-32.7 RDW-15.2 Plt Ct-284 [**2200-3-4**] 11:15AM BLOOD PT-11.9 PTT-29.9 INR(PT)-1.0 [**2200-3-4**] 11:15AM BLOOD Glucose-118* UreaN-73* Creat-2.0*# Na-139 K-4.1 Cl-93* HCO3-37* AnGap-13 [**2200-3-9**] 06:30AM BLOOD Glucose-141* UreaN-9 Creat-0.7 Na-151* K-4.2 Cl-111* HCO3-33* AnGap-11 [**2200-3-4**] 11:15AM BLOOD ALT-17 AST-34 CK(CPK)-135 AlkPhos-140* TotBili-0.1 [**2200-3-4**] 11:15AM BLOOD cTropnT-0.04* [**2200-3-4**] 11:15AM BLOOD Calcium-8.9 Phos-4.4 Mg-3.2* [**2200-3-7**] 05:30AM BLOOD Calcium-9.3 Phos-3.7 Mg-1.8 [**2200-3-6**] 06:35AM BLOOD VitB12-851 Folate-GREATER TH Hapto-197 [**2200-3-4**] 12:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.008 [**2200-3-4**] 12:00PM URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [**2200-3-4**] 12:00PM URINE RBC-0-2 WBC-0-2 Bacteri-OCC Yeast-NONE Epi-0 [**2200-3-9**] 06:54AM URINE Hours-RANDOM UreaN-855 Creat-119 Na-45 [**2200-3-9**] 06:54AM URINE Osmolal-572 . CT ABD W&W/O C [**2200-3-6**] 2:23 PM CT ABD W&W/O C; CT PELVIS W/CONTRAST Reason: source of GI bleeding.Please administer PO and IV contrast.C Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 56 year old man with congenital heart dz, s/p VSD repair, GI bleeding. REASON FOR THIS EXAMINATION: source of GI bleeding.Please administer PO and IV contrast.Concer for small bowel source, CT enterography please. CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: GI bleeding, query source, concern for small bowel source, CT enterography please. COMPARISON: [**2200-1-23**]. TECHNIQUE: Multiple MDCT images were obtained through the abdomen and pelvis after the administration of 150 cc of Optiray intravenously. There are technical limitations to this study since it appears that the patient was not administered the VoLumen and this limits the accuracy of this study. Multiplanar reformations were derived. FINDINGS: CT ABDOMEN WITH IV CONTRAST AND WITH LIMITED ORAL CONTRAST: Again there is evidence of median sternotomy and four-chamber cardiac dilatation consistent with a history of conigential cardiac disease. There are essentially unchanged bilateral pleural effusions and associated compressive atelectasis. The IVC and hepatic veins appear dilated but otherwise the liver, gallbladder, pancreas, spleen, adrenal glands and kidneys appear unremarkable. Within the limitations of the study there is no evidence of a gross mass within the bowel or for extravasation of intravenous contrast into the bowel lumen. A ventral defect previously seen has resolved with residual soft tissue being demonstrated. There is no free fluid or free air within the abdomen or pelvic lymphadenopathy. There is left gynecomastia. A J-tube is again seen. CT OF THE PELVIS WITH IV CONTRAST AND WITH LIMITED ORAL CONTRAST: No intravenous contrast is seen within the lumen of the pelvic loops of bowel though enteric contrast is seen in the rectosigmoid area. There is no significant free fluid or free air or pelvic lymphadenopathy and the bladder and distal ureters appear normal. There is an unchanged small fluid collection measuring 3.9 x 2.6 cm overlying the left common femoral (2, 111). MUSCULOSKELETAL: Persistent severe thoracolumbar scoliosis but no suspicious lytic or blastic lesion. IMPRESSION: 1. Technically limited study without sufficient oral contrast; within these limitations no GI bleed is unambiguously defined and no gross mass is identified. Enteric contrast is seen in the sigmoid rectum of unknown origin. For further clarification consider a tagged red blood cell nuclear medicine study with delayed views if bleed is intermittent. 2. Essentially unchanged bilateral pleural effusions with associated compressive atelectasis. 3. Unchanged massive cardiomegaly with associated mege-pulmonary artery and a seroma overlying the left common femoral artery. . G/GJ/GI TUBE CHECK PORT [**2200-3-8**] 1:07 PM G/GJ/GI TUBE CHECK PORT Reason: eval for correct placement of J-tube [**Hospital 93**] MEDICAL CONDITION: 56 year old man with J-tube that fell out today, was replaced at the bedside. please eval for proper replacement, and that the tube is in correct position to resume tube feeds. thanks REASON FOR THIS EXAMINATION: eval for correct placement of J-tube EXAMINATION: Injection of J-tube. Injection of a J-tube was performed without a radiologist present and shows contrast in several loops of non-distended small bowel. Brief Hospital Course: 56 y/o M with PMH congenital heart disease s/p VSD repair, PVR and MVR, CHF, DM, afib on coumadin and mult. GIB who presents from skilled nursing facility with 2 days of black stools. . # Anemia/black stools: Has had extensive workup this month without discovering active bleeding source, including EGD, small bowel enteroscopy, capsule endoscopy and colonoscopy. He did have some erosions in duodenum and small bowel which may be source of chronic slow bleed. He received 3 units of PRBCs upon admission and an additional 7 spread out through his course. He never had a notable large bleed but hematocrit continuously drifted down slowly. His bleeding is complicated by the need to keep him anticoagulated due to Afib and large atrial size. GI followed him while here. At one point there was consideration of transfer to [**Hospital6 **] for double balloon enteroscopy, as repeat EGD was thought to be low yield as most of the erosions were not within reach. However, he had some respiratory distress requiring placement on the ventilator and the GI team at [**Hospital1 2177**] recommended deferring the procedure at this time. Repeat capsule endoscopy was attempted this admission but he could not swallow enough in order to tolerate capsule placement (with or without endoscopy). He is considered transfusion dependent at this time. We recommend checking hematocrits weekly and transfusing for Hct < 25. . # Acute on chronic resp. failure: Trached during admission in [**Month (only) 404**] for heart surgery due to difficulty weaning. No longer on vent at rehab per patient. His trach mask was continued. Inhalers and nebulizers were continued. He was transferred to the MICU twice for respiratory distress requiring mechanical ventilation. His first transfer was in the the setting of volume overload and mucous plugging which improved with treatment of the MRSA/stenotrophomonas in his sputum. The second incident of respiratory failure was in the setting of getting high doses of IV ativan leading to likely respiratory depression. He completed a 5 day course of Bactrim for Stenotrophomonas and completed a 7 day course of vanco. . # Acute renal failure: He was diuresed given volume overload affecting respiratory status. After being diuresed for 3 days, he developed oliguria with urine microscopy consistent with ATN. Diuresis has been held and can be restarted when needed for volume overload and creatinine allows. His creatinine has currently plateaued at 2.1. Good urine output currently, and as his creatinine remained at approximately 2, his lasix was restarted at 20mg po bid. His creatinine should be checked one week after discharge and adjusted accordingly. . # Paroxysmal Atrial Fibrillation:Patient was previously on coumadin. Given his large atrial size (>8 cm), anticoagulation with coumadin was restarted (INR will need to be monitored at rehab and coumadin adjusted prn). Cardiology was consulted. Rate control was acheived with a beta blocker. In light of his chronic lower GI bleed, it was decided by the ICU team that his anticoagulation would be discontinued. His PCP was notified via voice mail. . # Congenital heart disease: s/p recent surgery. No CAD on cath in [**12-10**]. Cardiology was consulted for periop risk assessment given his history - feel no increased risk since no CAD on cath. LVEF 45-50% on TTE [**1-10**]. Continued on outpatient regimen of lipitor, metoprolol, ASA. . # Anxiety/depression: increased fluoxetine to 30. Held benzos given resp depression as above. . # DM: Cont. outpatient glargine and RISS Medications on Admission: 1. Atorvastatin 20 mg Daily 2. Ascorbic Acid 500 mg [**Hospital1 **] 3. Fluoxetine 20 mg DAILY 4. Docusate Sodium 50 mg/5 mL [**Hospital1 **] 5. Miconazole Nitrate 2 % Powder QID 6. Albuterol Sulfate 2.5 mg/3 mL Inhalation Q6H PRN 7. Ipratropium Bromide 0.02 % Solution Q6 PRN 8. Clonazepam 0.5 mg Tablet PO BID PRN 9. Lansoprazole 30 mg Tablet Daily 10. Aspirin 81 mg TabletDaily 11. Ferrous Sulfate 300 mg/5 mL Daily 12. Metoprolol Tartrate 25 mg Tablet PO twice a day. 13. Insulin Glargine Twenty (20) UNITS Subcutaneous at bedtime. 14. Insulin Lispro 100 unit/mL Solution [**Hospital1 **]: Sliding Scale Coverage Subcutaneous four times a day. 15. Nutrition Tube Feeds Glucerna Tube Feeds 90cc/hour 16. lasix 20mg PGT [**Hospital1 **] 17. ? coumadin at rehab, INR here normal Discharge Medications: 1. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 2. Heparin Flush PICC (100 units/ml) 2 mL IV DAILY:PRN 10 ml NS followed by 2 mL of 100 Units/mL heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 3. Fluoxetine 10 mg Capsule [**Hospital1 **]: Two (2) Capsule PO DAILY (Daily). 4. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: 0.5 Tablet PO BID (2 times a day): please hold for SBP < 95 or HR < 55. 5. Atorvastatin 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 6. Ascorbic Acid 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 8. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One Hundred (100) mg PO BID (2 times a day). 9. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 10. insulin see attached sliding scale 11. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q6H (every 6 hours) as needed. 12. Haloperidol 0.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day) as needed for anxiety. 13. Clotrimazole 10 mg Troche [**Last Name (STitle) **]: One (1) Troche Mucous membrane QID (4 times a day) as needed for thrush. 14. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Last Name (STitle) **]: Two (2) Puff Inhalation QID (4 times a day) as needed for shortness of breath or wheezing. 15. Ferrous Sulfate 300 mg/5 mL Liquid [**Last Name (STitle) **]: Five (5) mL PO once a day. 16. Albuterol 90 mcg/Actuation Aerosol [**Last Name (STitle) **]: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 17. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Topical four times a day. 18. Aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. 19. Insulin Glargine 100 unit/mL Cartridge [**Last Name (STitle) **]: Twenty (20) units Subcutaneous at bedtime. 20. Insulin Lispro 100 unit/mL Cartridge [**Last Name (STitle) **]: as per sliding scale units Subcutaneous qachs. 21. Lasix 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day. 22. Outpatient Lab Work please draw chem 7 to monitor creatinine on lasix 23. Ciprofloxacin in D5W 400 mg/200 mL Piggyback [**Last Name (STitle) **]: Four Hundred (400) mg Intravenous Q12H (every 12 hours) for 7 days. 24. Haloperidol 0.5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO HS (at bedtime). 25. Haloperidol 0.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily) as needed for anxiety. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 1294**] Discharge Diagnosis: Primary GI Bleed Respiratory failure-hypercarbia enterococcus bacteremia . Secondary Mitral and Pulmonic tissue valve replacement Congenital heart Disease Acute renal failure [**1-4**] ATN MRSA/Stenotrophomonas HAP Discharge Condition: Stable, afebrile, ambulatory with assistance Discharge Instructions: . You were admitted to the hospital after you were found to have dark black stool. You have had extensive workup for GI bleeding in the past and again this admission. You were administered several units of blood for low hematocrit, and we feel that you may need to continue transfusions chronically. In addition you developed problems with your breathing that were related to a class of medications called benzodiazepines, as well as a likely pneumonia. You required mechanical ventilation at night. You also had an infection of your bloodstream that was treated with ciprofloxacin that you will have to take for a total of 14 days. You will not be taking coumadin for your atrial fibrillation for now as you have had bleeding. . Please keep all of your appointments with your doctors and take [**Name5 (PTitle) **] of your medications as prescribed. . Please return to the hospital if you have bloody vomit, large amounts of blood in your stool, large drop in hematocrit at rehab, dizziness, low blood pressure, poor urine output, or any new symptoms that you are concerned about. Followup Instructions: Please followup with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 24305**], at [**Telephone/Fax (1) 24306**] within 1 week of leaving rehab. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**] Completed by:[**2200-4-22**]

578,518,428,483,790,584,293,276,280,427,250,933,041,311,300,V422,V440,574

{'Hemorrhage of gastrointestinal tract, unspecified,Acute respiratory failure,Chronic systolic heart failure,Pneumonia due to other specified organism,Bacteremia,Acute kidney failure, unspecified,Delirium due to conditions classified elsewhere,Hyperosmolality and/or hypernatremia,Iron deficiency anemia secondary to blood loss (chronic),Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Foreign body in larynx,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other specified bacteria,Depressive disorder, not elsewhere classified,Anxiety state, unspecified,Heart valve replaced by transplant,Tracheostomy status,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction'}

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: melena PRESENT ILLNESS: 56 y/o M with PMH congenital heart disease s/p VSD repair, PVR and MVR, CHF, DM, afib on coumadin and mult. GIB who presents from [**Hospital1 1501**] with 2 days of black stools. Of note the patient was recently discharged from [**Hospital1 18**] on [**2-14**] after an admisison for GIB. He underwent EGD with small bowel enteroscopy as well as colonoscopy. EGD showed mild gastritis and no active bleeding. Capsule endoscopy was also performed on [**2-13**] that showed a few mild erosions in the duodenum and proximal small bowel as well as a few nonbleeding redspots in the mid and distal small bowel. Since discharge from [**Hospital1 18**] the patient reports that he has had dark stools but has not had any BRBPR. On sunday night the patient developed a tightness in his abdomen which he describes as a knot. He also had some nausea, however denied abdominal pain, SOB, CP, or LH. Labs at his [**Hospital1 1501**] this morning showed Hct 20.1 (down from 27 on [**2-27**]) and he was sent to [**Hospital1 18**] for further workup. . In ED VS were T 97 HR 85 BP 96/53 86% TM. Rectal exam showed guaiac pos. black stool, no blood. He was given a total of 4L NS as well as 2 units RBCs. He also received protonix 40mg IV. On arrival to the ICU the patient reported feeling much better. he cont. to deny abdominal pain, SOB, CP. He had an additional black, guaiac pos. stool on arrival to the ICU. MEDICAL HISTORY: #congenital heart disease -s/p pulmonic valvulotomy in [**2160**] -s/p VSD repair [**2185**] -[**2199-12-24**]: redo sternotomy, PVR (porcine), MVR (porcine), VSD closure, PFO closure #CHF #s/p trach, open J-tube in [**1-10**] #DM #anxiety #depression #A fib #RBBB #RLE varicosities #s/p R hernia repair #s/p appy MEDICATION ON ADMISSION: 1. Atorvastatin 20 mg Daily 2. Ascorbic Acid 500 mg [**Hospital1 **] 3. Fluoxetine 20 mg DAILY 4. Docusate Sodium 50 mg/5 mL [**Hospital1 **] 5. Miconazole Nitrate 2 % Powder QID 6. Albuterol Sulfate 2.5 mg/3 mL Inhalation Q6H PRN 7. Ipratropium Bromide 0.02 % Solution Q6 PRN 8. Clonazepam 0.5 mg Tablet PO BID PRN 9. Lansoprazole 30 mg Tablet Daily 10. Aspirin 81 mg TabletDaily 11. Ferrous Sulfate 300 mg/5 mL Daily 12. Metoprolol Tartrate 25 mg Tablet PO twice a day. 13. Insulin Glargine Twenty (20) UNITS Subcutaneous at bedtime. ALLERGIES: Aldactone PHYSICAL EXAM: VS: Temp 98.0 98.0 113/51 97% trach. Gen - Alert, no acute distress HEENT - PERRL, extraocular motions intact, anicteric, mucous membranes moist, trach in place Neck - no JVD, no cervical lymphadenopathy Chest - [**Month (only) **]. BS at bases, otherwise clear to auscultation bilaterally CV - Irregular, III/VI SEM loudest at RUSB Abd - Soft, nontender, nondistended, with normoactive bowel sounds Extr - No clubbing, cyanosis, 2+ pitting edema b/l LE with chronic venous stasis changes Neuro - Alert and oriented x 3, cranial nerves [**1-14**] intact, upper and lower extremity strength 5/5 bilaterally, sensation grossly intact Skin - No rashes Rectal: guaiac positive stool FAMILY HISTORY: father had MI at age 55 SOCIAL HISTORY: disabled never used tobacco occasional ETOH ### Response: {'Hemorrhage of gastrointestinal tract, unspecified,Acute respiratory failure,Chronic systolic heart failure,Pneumonia due to other specified organism,Bacteremia,Acute kidney failure, unspecified,Delirium due to conditions classified elsewhere,Hyperosmolality and/or hypernatremia,Iron deficiency anemia secondary to blood loss (chronic),Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Foreign body in larynx,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other specified bacteria,Depressive disorder, not elsewhere classified,Anxiety state, unspecified,Heart valve replaced by transplant,Tracheostomy status,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction'}

CHIEF COMPLAINT: PRESENT ILLNESS: Mr. [**Known lastname 2470**] is an 84 year-old gentleman with an unknown past medical history as he has never seen a physician in the past who, on the day of admission, developed sudden onset of chest pain at rest. He described the pain as substernal chest pain radiating across his chest and between his shoulder blades. The patient denied associated shortness of breath, nausea, vomiting, lightheadedness, or dizziness. He states he has been in his usual state of health prior to the onset of chest pain. MEDICAL HISTORY: As previously stated the patient denies. MEDICATION ON ADMISSION: ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: The patient lives by himself. His wife suffers from dementia and lives in a nursing home. He visits her every day. The patient has remote smoking history describing that he smoked during World War II basically a pack per month. He denies ETOH use.

Acute myocardial infarction of other anterior wall, initial episode of care,Other complications due to other cardiac device, implant, and graft,Pneumonia, organism unspecified,Congestive heart failure, unspecified,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Hypotension, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Delirium due to conditions classified elsewhere

AMI anterior wall, init,Comp-oth cardiac device,Pneumonia, organism NOS,CHF NOS,Atrial fibrillation,Crnry athrscl natve vssl,Hypotension NOS,DMII wo cmp nt st uncntr,Delirium d/t other cond

Admission Date: [**2104-12-10**] Discharge Date: [**2104-12-14**] Service: CCU HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 2470**] is an 84 year-old gentleman with an unknown past medical history as he has never seen a physician in the past who, on the day of admission, developed sudden onset of chest pain at rest. He described the pain as substernal chest pain radiating across his chest and between his shoulder blades. The patient denied associated shortness of breath, nausea, vomiting, lightheadedness, or dizziness. He states he has been in his usual state of health prior to the onset of chest pain. He denied fevers or chills, congestion, cough, no GI symptoms. He denies prior history of chest pain as well. The patient also denied paroxysmal nocturnal dyspnea, orthopnea, dyspnea on exertion, or lower extremity edema. He states he walks three to four miles every day without symptoms. The patient arrived at an outside hospital Emergency Department approximately forty minutes after his chest pain began. The chest pain continued to radiate across his chest to his back. His pulse on admission was 92 with a blood pressure of 106/80. A CTA was done at the outside hospital that was negative for aortic injury, but the electrocardiogram showed anterior ST elevations, Qs in V1 and V2, right bundle branch block and left anterior vesicular block. The patient was given nitro drip, heparin intravenous, intravenous beta blocker and transferred to [**Hospital1 1444**] for cardiac catheterization. Electrocardiograms at the outside hospital involved to include ST elevation and both the anterior and lateral leads with peak ST elevations of 6 mm in leads V2 and V3. Initial cardiac enzymes were negative at the outside hospital. Of note, the patient's glucose is in the 400s when he was admitted. In the cardiac catheterization laboratory the patient was shown to have the following results on angiography. He had a right dominant system and left anterior descending coronary artery with a 95% thrombotic proximal and mid lesion involving the first diagonal and first septal branch. His left circumflex had an 80% mid lesion and his right coronary artery had a 40% mid and 60% posterolateral lesions. For intervention the patient had Angioject and stent to the left anterior descending coronary artery without complications. Hemodynamics in the cardiac laboratory showed a cardiac output suppressed at 3.10, a low index of 1.67, PA pressure of 31/18 with a wedge pressure of 22, the A wave being 23 and the V wave being 28, and a right ventricular pressure of 32/8. PAST MEDICAL HISTORY: As previously stated the patient denies. MEDICATIONS: The patient states he only takes one multivitamin every day at home. ALLERGIES: No known drug allergies. PAST SURGICAL HISTORY: The patient denies. SOCIAL HISTORY: The patient lives by himself. His wife suffers from dementia and lives in a nursing home. He visits her every day. The patient has remote smoking history describing that he smoked during World War II basically a pack per month. He denies ETOH use. PHYSICAL EXAMINATION: On admission the patient's temperature was 97.4. His heart rate was 92 and sinus. His blood pressure was 150/90. Sat 98% on a nonrebreather and then subsequently 93% on 8 liters nasal cannula. Respiratory rate 17. In general, he was anxious. He was alert, but not oriented. Per report the patient had been very anxious in the catheterization laboratory requiring heavy sedation with morphine and Haldol. Heart regular rate and rhythm. S1 and S2. Difficulty to hear over diffuse lung, rhonchi and crackles. Lungs diffuse crackles bilaterally. Abdomen soft, nontender, nondistended. Positive bowel sounds. No hepatosplenomegaly. Extremities no clubbing, cyanosis or edema. Good distal pulses with 2+ dorsalis pedis pulses bilaterally and 2+ posterior tibial pulses bilaterally. Neurological examination not oriented to time or place. Cranial nerves II through XII grossly intact. Strength grossly normal bilaterally, although examination limited as the patient has sheath in place. LABORATORY DATA: The patient's data from the outside hospital included a hematocrit of 47.4, white blood cell count 15.6, platelets 249. The CKs at the outside hospital included a CK of 143 with an MB of 3.8, MB index of 2.7 and an troponin I of 0.22. At [**Hospital1 69**] the patient's second CK came back at 6433 with an MB of 465 and MB index of 7.2 and a troponin greater then 50. The patient's chem 7 included sodium 134, K 4.8, chloride 98, bicarb 20, BUN 21, creatinine 1.1 and glucose of 412. HOSPITAL COURSE: 1. Cardiovascular: The patient had a very large anterior ST elevation myocardial infarction. He is status post stenting of his left anterior descending coronary artery. For management of his coronary artery disease he was started on aspirin, Plavix and he was placed on Integrilin for a total of 18 hours. He was empirically started on a statin. He was also started on a beta blocker and an ace inhibitor and his cardiac enzymes were cycled. The patient was started on Captopril 12.5 t.i.d. This was titrated up to 25 t.i.d., however, the patient had problems with hypotension and orthostasis, therefore this was decreased to 12.5 t.i.d. The patient tolerated Lopressor 25 b.i.d. He is also placed on Atorvastatin 20 q.h.s., Plavix 75 q.h.s. and aspirin 325 q.d. Post cardiac catheterization the patient's anterior and lateral ST elevations did resolve with flattening of the ST segment. After the CK peak of 6433 the patient's CK decreased to 2963 with an MB of 214. The next CK on [**2104-12-12**] was down to 1269. Pump function: The patient was noted on bed side echocardiogram after his cardiac catheterization to have severe increase in his ejection fraction with a estimated EF of 20% The patient had a formal echocardiogram on the [**5-10**] that showed an ejection fraction between 20 and 30%. The left ventricular wall thickness was seen to be normal. Left ventricular cavity size normal, overall left ventricular systolic function was said to be severely depressed. Right ventricular free wall is hypertrophied. Right ventricular chamber size normal. Focal hypokinesis of the apical free wall. Left ventricular cavity size was said to be normal with severely depressed severe hypokinesis of the anterior septum and anterior free wall, moderate hypokinesis of the inferior septum and lateral wall and akinesis of the apex. Based on these results the patient was started on intravenous heparin for the risk of left ventricular thrombus with such an akinetic ventricle including the apex. However, as it was discovered that the patient had baseline dementia per family report and he subsequently suffered from an episode of delirium it was felt that the atrial fibrillation did not outweigh the risk the patient had of falling. Therefore the intravenous heparin was stopped and the patient was placed on prophylactic subQ heparin. The patient was diuresed with 20 intravenous Lasix prn and responded nicely within the first 24 hours. His chest x-ray, which had initially showed failure cleared after diuresis and the patient required no further dosing of Lasix. Rhythm: With the patient's low EF and guard ventricular EP consult was considered for risk stratification. However, it was felt that with the patient's underlying medical conditions including delirium on top of dementia an EP consult would not benefit the patient at this time. Cardiac follow up: The patient was to be set up with a cardiologist in his area prior to discharge and to be set up with cardiac rehabilitation. 2. Diabetes: The patient presented with blood sugars in the 400s. His urine and serum were negative for ketones. The hemoglobin A1C was checked that came back at 12.7 indicating the patient had diabetes undiagnosed for quite some time. The patient was initially controlled with an intravenous insulin drip according to the [**Last Name (un) **] protocol and was then converted over to a sliding scale of regular insulin along with Glucophage 500 b.i.d. and NPH fixed doses. 3. Neurological: As stated previously the patient was noted to be severely agitated during cardiac catheterization and subsequently in the Coronary Care Unit and on the floor. He was initially managed with Haldol, which seemed to help with the patient's agitation and was therefore discontinued. A geriatric consult was obtained and they recommended that the patient be given Risperidone .5 mg b.i.d. on a prn basis only and this was done with control of the patient's agitation. To rule out causes of delirium the patient had blood cultures times two, urine cultures and analysis and a chest x-ray. All infectious workup was negative. The patient also had a TSH checked, which was within normal limits and a B-12 level checked. B-12 was within normal limits at 773. His TSH was within normal limits at 0.32. The patient's mental status cleared during his hospital course and was significantly cleared on [**2104-12-14**] at which time the patient was alert and oriented times three and was appropriate and cooperative. The patient had required a one to one sitter from the 9th until the 12th. The sitter was then discontinued on the [**5-14**]. It was concluded that the most likely cause of the patient's delirium on top of his baseline dementia were hypotension and hyperglycemia. Therefore as stated under Cardiovascular the patient's Captopril dose was decreased to prevent orthostasis and he was put on a tight glucose control regimen including Glucophage, NPH and regular insulin sliding scale. This is the end of the [**Hospital 228**] hospital course as of [**2104-12-14**]. The rest of the dictation will be completed by the intern taking over this service. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. Dictated By:[**Last Name (NamePattern1) 45275**] MEDQUIST36 D: [**2104-12-14**] 14:25 T: [**2104-12-16**] 11:26 JOB#: [**Job Number 45826**] Admission Date: [**2104-12-10**] Discharge Date: [**2104-12-16**] Service: CCU THIS DISCHARGE ADDENDUM COVERS THE HOSPITAL COURSE FOR DATES [**12-15**] TO [**2104-12-16**]: This is an 84-year-old male without prior medical care presenting with anterior ST segment elevation myocardial infarction, now status post left anterior descending stent this hospitalization. Decreased ejection fraction to 20%, new diagnosis diabetes mellitus and hospital course complicated by delirium on top of baseline dementia which is now resolved. 1. Cardiovascular: A. Coronary artery disease: Continued Plavix times nine months, aspirin, Toprol XL was started in exchange for Lopressor, statin was continued. B. Pump: Ejection fraction 20%, status post myocardial infarction. Continue the ACE. Lisinopril was started in exchange for Captopril. C. Electrophysiologic: Patient with a right bundle branch block in sinus tachycardia likely secondary to his depressed ejection fraction to maintain cardiac output. D. Blood pressure: Blood pressure 90-120 systolic on his ACE and beta-blocker. This is the desired range. 2. Psychiatry: Delirium now resolved. Does not require a sitter times 48 hours. Risperidone 0.5 mg prn can be given if acutely confused, though, this patient did not require this medication over the past three days. 3. Diabetes: Blood sugar is 180-280 on Lantus 16 units q.h.s. and metformin 500 b.i.d. and insulin sliding scale. Metformin increased to 1000 b.i.d. today. Patient's family should have diabetic teaching. 4. Fluid, electrolytes and nutrition: Diabetic diet. Electrolytes are stable. 5. Hematology: Hematocrit stable at 37. No anticoagulation for a depressed ejection fraction in this patient at risk for falls besides his aspirin and Plavix. DISPOSITION: To [**Hospital 3058**] rehabilitation. MEDICATIONS ON DISCHARGE: 1. Toprol XL 50 mg po q.d. 2. Lisinopril 5 mg po q.d. 3. Aspirin 325 mg po q.d. 4. Plavix 75 mg po q.d. 5. Metformin 1000 mg po q.d. 6. Lantus 16 units subcutaneous q.h.s. 7. Insulin sliding scale. 8. Atorvastatin 20 mg po q.d. 9. Colace 100 mg po b.i.d. 10. Pantoprazole 40 mg po q.d. DISCHARGE DIAGNOSES: 1. ST elevation myocardial infarction. 2. Diabetes mellitus. 3. Dementia. DISCHARGE FOLLOW-UP: Follow-up appointment Wednesday, [**2104-12-31**] at 2:45 p.m. with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], Cardiology [**Hospital 45827**] Medical Associates, [**Street Address(2) 45828**], [**Location (un) 1475**], [**Numeric Identifier 45829**]. Phone number [**Telephone/Fax (1) 3183**]. Follow-up with primary care physician in two weeks. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7169**] Dictated By:[**First Name3 (LF) 15581**] MEDQUIST36 D: [**2104-12-16**] 01:35 T: [**2104-12-16**] 13:39 JOB#: [**Job Number **] cc:[**Last Name (NamePattern1) 45830**] Name: [**Known lastname 8428**], [**Known firstname **] Unit No: [**Numeric Identifier 8429**] Admission Date: [**2104-12-17**] Discharge Date: [**2104-12-20**] Date of Birth: [**2020-4-9**] Sex: M Service: ADDENDUM: From [**2104-12-17**] to [**2104-12-20**]. Mr. [**Known lastname **] was to be discharged on [**2104-12-16**] to a [**Hospital 6777**] rehabilitation facility. That morning, he experienced 10/10 chest pain and was found to have anterior ST elevations on his EKG. He was taken to the Catheterization Laboratory within 30 minutes of the onset of his chest pain and was found to have a thrombosed LAD stent. This was reopened with suction of the clot and PTCA angioplasty of the stent. Mr. [**Known lastname **] [**Last Name (Titles) 8430**] did not bump his cardiac enzymes from this event. He remained stable status post this LAD stent rethrombosis. He was started on Lovenox 30 mg subcutaneously b.i.d. for two weeks which will end on [**2105-1-1**] to help prevent in-stent rethrombosis. His Lipitor was also discontinued and changed to pravastatin 40 mg p.o. q.d. which is not associated with decreasing the active levels of Plavix. 2. INFECTIOUS DISEASE: Mr. [**Known lastname **] was found to have a mild right upper lobe pneumonia which was found on chest x-ray after he spiked a fever to 101. He was begun on Levaquin 500 mg p.o. q.d. on [**2104-12-19**] and will complete a ten day course of this. Otherwise, his medications will be unchanged from the previous discharge summary addendum. [**First Name8 (NamePattern2) 577**] [**Last Name (NamePattern1) 578**], M.D. [**MD Number(2) 579**] Dictated By:[**Dictator Info **] MEDQUIST36 D: [**2104-12-20**] 02:58 T: [**2104-12-21**] 08:25 JOB#: [**Job Number 8431**] Name: [**Known lastname 8428**], [**Known firstname **] Unit No: [**Numeric Identifier 8429**] Admission Date: [**2104-12-10**] Discharge Date: [**2104-12-24**] Date of Birth: [**2020-4-9**] Sex: M Service: The patient was discharged to short term rehabilitation. MEDICATIONS ON DISCHARGE: 1. Toprol XL 50 mg p.o. once daily. 2. Lisinopril 5 mg p.o. once daily. 3. Aspirin 325 mg p.o. once daily. 4. Plavix 75 mg p.o. once daily. 5. Metformin 1000 mg p.o. once daily. 6. Lantus 16 subcutaneously q.h.s. 7. Insulin sliding scale. 8. Atorvastatin 20 mg p.o. once daily. 9. Colace 100 mg p.o. twice a day. 10. Pantoprazole 20 mg p.o. once daily. 11. Lovenox 30 mg subcutaneous twice a day will be continued for two weeks. 12. Levaquin 500 mg p.o. once daily for ten days. Lipitor was discontinued and changed to Pravastatin. FOLLOW-UP: As per previous discharge summary, the patient will follow-up Wednesday, Wednesday, [**2104-12-31**], with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Hospital 8439**] Medical Associates and follow-up with his primary care physician two weeks after discharge. DISCHARGE DIAGNOSES: 1. ST elevation myocardial infarction. 2. Congestive heart failure. 3. Dementia. CONDITION ON DISCHARGE: Stable. FOLLOW-UP: As above. [**First Name8 (NamePattern2) 577**] [**Last Name (NamePattern1) 578**], M.D. [**MD Number(2) 579**] Dictated By:[**Dictator Info **] MEDQUIST36 D: [**2105-3-7**] 20:50 T: [**2105-3-8**] 08:59 JOB#: [**Job Number 8440**]

410,996,486,428,427,414,458,250,293

{'Acute myocardial infarction of other anterior wall, initial episode of care,Other complications due to other cardiac device, implant, and graft,Pneumonia, organism unspecified,Congestive heart failure, unspecified,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Hypotension, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Delirium due to conditions classified elsewhere'}

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: Mr. [**Known lastname 2470**] is an 84 year-old gentleman with an unknown past medical history as he has never seen a physician in the past who, on the day of admission, developed sudden onset of chest pain at rest. He described the pain as substernal chest pain radiating across his chest and between his shoulder blades. The patient denied associated shortness of breath, nausea, vomiting, lightheadedness, or dizziness. He states he has been in his usual state of health prior to the onset of chest pain. MEDICAL HISTORY: As previously stated the patient denies. MEDICATION ON ADMISSION: ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: The patient lives by himself. His wife suffers from dementia and lives in a nursing home. He visits her every day. The patient has remote smoking history describing that he smoked during World War II basically a pack per month. He denies ETOH use. ### Response: {'Acute myocardial infarction of other anterior wall, initial episode of care,Other complications due to other cardiac device, implant, and graft,Pneumonia, organism unspecified,Congestive heart failure, unspecified,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Hypotension, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Delirium due to conditions classified elsewhere'}

CHIEF COMPLAINT: dyspnea/hypoxia PRESENT ILLNESS: 55 yo male with h/o cirrhosis (hep C v. autoimmune) transferred from [**Hospital1 **] with SOB x 1 week, pneumonia on CXR, elevated lactate and hypoxia. He notes worsening SOB for past week with pleuritic chest pain in R side. He also complains of fatigue and dysuria. He has some cough but only occasionally brings up sputum. He went to [**Hospital3 4107**] and was given ceftriaxone, azithro and solumedrol. He was also found to be in acute renal failure with Cr 4.9, K 5.7. Tox screen positive for opiates. He was transferred to [**Hospital1 18**] on NRB bc they did not have any ICU beds available. he denies fevers, chills. He does complain of itchy skin. . On arrival to [**Hospital1 18**] ED, his vital signs were T97.6 P104 BP105/57 R28 94% on NRB. He was given zosyn, vitamin K 10 mg SQ, kayexalate MEDICAL HISTORY: Cirrhosis: autoimmune v. Hep C with possibility of alcoholic hepatitis(s/p tx with interferon and ribiviron 18 mos ago with recurrence). Seen by Dr. [**Last Name (STitle) 10924**]. chronic hepatitis C diagnosed on routine blood work (genotype 3 and had a liver biopsy on [**2150-4-3**] noting grade [**7-8**] and stage [**3-2**]) Alcohol excess, quit 20 years ago Pancreatitis Hard of hearing, wears a hearing aid Splenic rupture secondary to a fall off a roof Bilateral lower leg edema Diverticulosis by history Left femur fx with ORIF Appendectomy MEDICATION ON ADMISSION: Meds Spironolactone 50 mg (for leg swelling) Lactulose (for constipation) Zyrtec Zoloft 200 mg Protonix 40 mg daily Prednisone 10 mg daily Ibuprofen prn Vicodin prn ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: VS: Tc 97.9 Tm 98.4 RR 62-75 BP 105-140/61-84 RR 14-31 O2Sat 95% on 5L Gen: WDWN man sitting in bed crying HEENT: Head-excoriations on head from scratching, PERRLA, EOMI, OP clear Neck: no JVD CV: RRR, nl s1, s2, no m/g/r Lungs: decreased R base breath sounds, crackles bilaterally midway up back Abd: BS+, soft, NT, ND, no hepatomegaly Ext: Bilateral 1+ pedal edema, + asterixis Pulses: 2+ radial and DP A/P 55 yo Male admitted with pneumonia on CXR w/ complicated effusion s/p chest tube placement on Vancomycin/Daptomycin. FAMILY HISTORY: Mother is living, age 77, macular degeneration Father is living, age 80, has glaucoma and DJD He has 4 brothers, 3 living, one deceased in [**2147**] from AIDS No sisters SOCIAL HISTORY: He is single, has a 29 year old son, is on disability, used to work as a roofer X 30 years He stopped smoking 20 years ago. No alcohol in 24 years.

Methicillin susceptible Staphylococcus aureus septicemia,Methicillin susceptible pneumonia due to Staphylococcus aureus,Alcoholic cirrhosis of liver,Bacteremia,Hepatic encephalopathy,Acute kidney failure, unspecified,Chronic hepatitis C without mention of hepatic coma,Unspecified pleural effusion,Hyposmolality and/or hyponatremia,Chronic airway obstruction, not elsewhere classified,Congestive heart failure, unspecified,Thrombocytopenia, unspecified,Other and unspecified alcohol dependence, in remission,Chronic pancreatitis,Unspecified deficiency anemia,Jaundice, unspecified, not of newborn,Unspecified disorder of stomach and duodenum,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Infection with microorganisms resistant to penicillins,Severe sepsis

Meth susc Staph aur sept,Meth sus pneum d/t Staph,Alcohol cirrhosis liver,Bacteremia,Hepatic encephalopathy,Acute kidney failure NOS,Chrnc hpt C wo hpat coma,Pleural effusion NOS,Hyposmolality,Chr airway obstruct NEC,CHF NOS,Thrombocytopenia NOS,Alcoh dep NEC/NOS-remiss,Chronic pancreatitis,Deficiency anemia NOS,Jaundice NOS,Gastroduodenal dis NOS,Gstr/ddnts NOS w/o hmrhg,Inf mcrg rstn pncllins,Severe sepsis

Admission Date: [**2150-9-4**] Discharge Date: [**2150-10-6**] Date of Birth: [**2095-2-5**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 348**] Chief Complaint: dyspnea/hypoxia Major Surgical or Invasive Procedure: chest tube insertion History of Present Illness: 55 yo male with h/o cirrhosis (hep C v. autoimmune) transferred from [**Hospital1 **] with SOB x 1 week, pneumonia on CXR, elevated lactate and hypoxia. He notes worsening SOB for past week with pleuritic chest pain in R side. He also complains of fatigue and dysuria. He has some cough but only occasionally brings up sputum. He went to [**Hospital3 4107**] and was given ceftriaxone, azithro and solumedrol. He was also found to be in acute renal failure with Cr 4.9, K 5.7. Tox screen positive for opiates. He was transferred to [**Hospital1 18**] on NRB bc they did not have any ICU beds available. he denies fevers, chills. He does complain of itchy skin. . On arrival to [**Hospital1 18**] ED, his vital signs were T97.6 P104 BP105/57 R28 94% on NRB. He was given zosyn, vitamin K 10 mg SQ, kayexalate Past Medical History: Cirrhosis: autoimmune v. Hep C with possibility of alcoholic hepatitis(s/p tx with interferon and ribiviron 18 mos ago with recurrence). Seen by Dr. [**Last Name (STitle) 10924**]. chronic hepatitis C diagnosed on routine blood work (genotype 3 and had a liver biopsy on [**2150-4-3**] noting grade [**7-8**] and stage [**3-2**]) Alcohol excess, quit 20 years ago Pancreatitis Hard of hearing, wears a hearing aid Splenic rupture secondary to a fall off a roof Bilateral lower leg edema Diverticulosis by history Left femur fx with ORIF Appendectomy Social History: He is single, has a 29 year old son, is on disability, used to work as a roofer X 30 years He stopped smoking 20 years ago. No alcohol in 24 years. Family History: Mother is living, age 77, macular degeneration Father is living, age 80, has glaucoma and DJD He has 4 brothers, 3 living, one deceased in [**2147**] from AIDS No sisters Physical Exam: VS: Tc 97.9 Tm 98.4 RR 62-75 BP 105-140/61-84 RR 14-31 O2Sat 95% on 5L Gen: WDWN man sitting in bed crying HEENT: Head-excoriations on head from scratching, PERRLA, EOMI, OP clear Neck: no JVD CV: RRR, nl s1, s2, no m/g/r Lungs: decreased R base breath sounds, crackles bilaterally midway up back Abd: BS+, soft, NT, ND, no hepatomegaly Ext: Bilateral 1+ pedal edema, + asterixis Pulses: 2+ radial and DP A/P 55 yo Male admitted with pneumonia on CXR w/ complicated effusion s/p chest tube placement on Vancomycin/Daptomycin. Pertinent Results: RADIOLOGY . US ABD LIMIT, SINGLE ORGAN [**2150-9-4**] 1. Slightly and coarse liver consistent with patient's known history of cirrhosis. 2. No intra- or extra-hepatic bile duct dilatation. 3. The gallbladder is not distended but the wall is edematous. These are most likely secondary to periportal hypertension. Clinical correlation is recommended. 4. Moderate-sized right pleural effusion. 5. No evidence of ascites. CHEST (PORTABLE AP) [**2150-9-4**] IMPRESSION: Moderate right pleural effusion. Right middle and lower lobe consolidation may represent pneumonia or compressive atelectasis. Left basilar atelectasis versus pneumonia. RENAL U.S. [**2150-9-7**] 3:09 PM Reason: MRSA BACTEREMIA ,EVAL FOR ABSCESS IMPRESSION: Normal-sized kidneys. Splenomegaly. No evidence of perirenal abscess. ************ CT PELVIS W/CONTRAST [**2150-9-9**] 4:15 PM 1. Interval placement of a right-sided chest tube. There is a small associated right pneumothorax. There has been interval decrease in the degree of atelectasis in the right lung. No definite empyema is identified. 2. Findings consistent with cirrhosis, including nodular liver, and ascites. No enhancing fluid collections within the liver or within the abdomen, to suggest the presence of an intra-abdominal source of infection. ***************** BONE SCAN [**2150-9-14**] Reason: 55 YR OLD MAN W/ HEP C CIRRHOSIS W/ MRSA PNEUMONIA W/ EMPYMA PLEASE EVAL FOR OSTEO L HIP IMPRESSION: No evidence for osteomyelitis. Small amount of increased uptake in the right anterior lower ribs suggests prior trauma. . CARDIOLOGY . ECHO Study Date of [**2150-9-8**] 1. The left atrium is moderately dilated. 2. The left ventricular cavity size is normal. Overall left ventricular systolic function cannot be reliably assessed. 3. The aortic valve leaflets are mildly thickened. The aortic valve is not well seen. Mild (1+) aortic regurgitation is seen. 4. No obvious evidence of endocarditis seen. . ECHO Study Date of [**2150-9-14**] Conclusions: The left atrium is dilated. No spontaneous echo contrast is seen in the body of the left atrium. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. No vegetation/mass is seen on the pulmonic valve. IMPRESSION: No valvular vegetations seen. CYTOLOGY . Cytology Report PLEURAL FLUID Procedure Date of [**2150-9-5**] NEGATIVE FOR MALIGNANT CELLS. Numerous neutrophils, scant reactive mesothelial cells and inflammatory cells. . Cytology Report PERITONEAL FLUID Procedure Date of [**2150-9-17**] NEGATIVE FOR MALIGNANT CELLS. Macrophages, mesothelial cells and blood. Brief Hospital Course: 55 yo male with h/o cirrhosis (hep C v. autoimmune) transferred from [**Hospital1 **] with SOB x 3 week and R sided chest pain, pneumonia on CXR, elevated lactate and hypoxia. He notes worsening SOB for past week with pleuritic chest pain in R side. He also complains of fatigue and dysuria. He has some cough but only occasionally brings up sputum. He went to [**Hospital3 4107**] and was given ceftriaxone, azithro and solumedrol. He was also found to be in acute renal failure with Cr 4.9, K 5.7. Tox screen positive for opiates. He was transferred to [**Hospital1 18**] on NRB bc they did not have any ICU beds available. He denied fevers, chills, but complained of itchy skin. In the MICU, he was started on Vanc, Levo and Ceftriaxone, which was eventually broadened to include flagyl. A noncontrast CT showed a RLL consolidation and R pleural effusion without evidence of loculation. Thoracic surgery was consulted and they placed a chest tube [**9-5**] with development of small basilar PTX --> small R lateral PTX [**9-7**], with drainage of ~1.2 L. Pleural fluid showed 51,500 WBC, 74% PMNs, 2% Bands, 23% monos, 16,900 RBC, TP 4.4, LDH 5108, Glucose 6, Amylase 21, Albumin 2.1 and grew out MRSA. Blood cultures and Urine cultures also grew out MRSA. Serial cultures have since been NGTD from [**9-6**] and [**9-7**]. His Abx regimen was changed to Vanc and Levo. His ARF was thought to be prerenal and he was gently hydrated with IVF with a CVP between [**9-9**] to keep CVP > 12. Urine eos were negative. A renal ultrasound was also ordered given MRSA in his urine to assess for renal abscess and was negative, revealing only trace ascites and an enlarged spleen. His BUN/Cr eventually improved from 85/4.2 to 65/1.2 Hepatology was called because of his hx of Hep C hepatitis vs. Autoimmune hepatitis with AST 79, ALT 71, Alk Phos 151, Bili 7.1 and believed that it was more likely an HCV flare with hepatic encephalopathy and cholestasis. They recommended lactulose TID to QID, volume resuscitation, holding aldactone until after IVF resuscitation and stress dose steroids as well as variceal screening once his respiratory status had improved (MELD 31). His Liver panel improved to AST 89, ALT 58, Alk Phos 130, Bili 4.6. He was started on labetalol and his aldactone was restarted. On [**9-7**], he was d/c'ed to the floor. 55yo man with history of cirrhosis likely secondary to hepatitis C presented with RML/RLL pneumonia, complicated parapneumonic effusion, and high grade MRSA bacteremia. # MRSA pneumonia This was heralded by progressive dyspnea, fever, pleuritic symptoms, and hypoxia. He was found to have RML and RLL pneumonia. Sputum cultures grew out MRSA. Additionally, he had a complicated parapneumonic effusion, which required the placement of a chest tube for drainage. Pleural fluid grew out MRSA as well. He was initially treated with vancomycin/levaquin/flagyl, which was tapered down to vanco/levaquin. He made progressive improvement and was weaned from NRB to 5L nasal canula. . # High grade MRSA bacteremia Initial blood cultures were significant for 4/4 bottles with MRSA. He was continued on vancomycin. TEE did not show any vegetations. He also had a renal US to rule out a perinephric abscess, as he had MRSA in the urine as well which is not uncommon with MRSA bacteremia. He was also started on Gentamycin and Daptomycin as his bacteremia did not clear with Vancomycin. Subsequently his Vanc was D/C'ed as patient responded to Daptomycin. Gentamycin was D/C'ed as patient developed acute renal failure most likely related to gentamycin toxicity. Daptomycin to be continued for 4 weeks after its initiation on [**2150-9-16**]. . # Acute renal failure: most likely ATN [**12-31**] Gent toxicity; urine sed showed brown muddy casts. FeNa intially did improve with hydration and so was thought to be prenal most likely Hepato-renal. However given the brown muddy casts and improving FeNa, most likely ATN. negative urine eos consistently. 25 g IV albumin given [**2150-9-17**]. Peak Creatinine was 6.6 which started trending down at the time of discharge. He did not have any signs of uremia or severe volume overload and so was not started on HD. Will need to check Creatinine every 3-4 days. . # [**Hospital **] Medical regimen was optimized with beta blocker for variceal bleeding prophylaxis, aldactone for diuresis, and lactulose titrated upward for encephalopathy. Liver team was following. Bilirubin peaked at 8.9. EGD negative for varices, but showed some gastritis - was on PPI. U/S [**9-7**] showed small amount of ascites --> CT [**9-9**] showed large amount of ascites --> diagnostic/therapeutic paracentesis removed 2 L with SAAG of -0.2. Hepatology of opinion that this was not unusual for bad cirrhosis. Vit K 10 mg SC x 3 days finished without improvement in INR. . # Hyponatremia: Sodium of 132 on admission, was likely [**12-31**] to portal hypertension from cirrhosis. Low albumin can cause dilutional effect . He was on free water fluid restriction at 1.5 L. . # Thrombocytopenia - Plt ct of 97 on admission. likely due to cirrhosis with secondary hypersplenism (large spleen on U/S). Was not on heparin gtt during this course of hospital admission. . # Anemia - HCT of 36.3 on admission, macrocytic anemia. Likely secondary to cirrhosis and anemia of chronic disease. Hemolysis labs [**9-11**] showed Indirect bili 4.2, Retic % 2.6% (RI 1.6 - inadequate), LDH 283 (slightly high), but Haptoglobin 110. Given splenomegaly - believe this to be hemolysis in spleen from cirrhosis. He was Guaiac negative. He was being transfused for hct < 24. . # COPD: continued on nebs . # Psych: He was occasionally agitated (likely component of hepatic encephalopathy) with labile mood and expressed feelings of hopelessness, depression. No active suicidal ideation, though expressed thoughts of "if only I just didn't wake up". No HI. Was continued on sertraline. . # Pruritus - Derm was consulted. Most likely from Hyperbilirubinemia, Uremia. Recommended sarna, hydroxyzine, (hydrocortisone tried for pruritus without much effect). Also had herpes II positive (back lesion) -> holding on Acyclovir as pt in renal failure. Did not consider increasing doxepine to 50 mg QHS (as recommended by derm) because of renal/hepatic toxicity. . # RLE slight warmth and swelling - mostly pitting edema. RLE U/S negative for DVT. Not on heparin because of thrombocytopenia. Continued on pneumoboots, heparin sq . # Diarrhea - likely from all of his lactulose, but given recent low grade fever and multiple Abx, a c diff was negative. . # PPX: PPI, pneumoboots, heparin sq Medications on Admission: Meds Spironolactone 50 mg (for leg swelling) Lactulose (for constipation) Zyrtec Zoloft 200 mg Protonix 40 mg daily Prednisone 10 mg daily Ibuprofen prn Vicodin prn Discharge Medications: 1. Albuterol Sulfate 0.083 % Solution Sig: [**11-30**] Inhalation Q6H (every 6 hours) as needed. 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Sertraline 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for agitation. 6. Lactulose (for Encephalopathy) 10 g/15 mL Solution Sig: Three Hundred (300) ML PO Q3-4H (Every 3 to 4 Hours) as needed. 7. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day). 8. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 11. Outpatient Lab Work Please check your Creatinine every 5 days and report it to your primary care physician or your kidney doctor. 12. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 14. Hydrocortisone 0.5 % Ointment Sig: One (1) Appl Topical TID (3 times a day) as needed. 15. Prochlorperazine 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 16. Doxepin 25 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 17. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 18. Terbinafine 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) for 4 weeks. 19. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1) Appl Rectal [**Hospital1 **] (2 times a day): Please apply to itching area. 20. Cholestyramine-Sucrose 4 g Packet Sig: One (1) Packet PO BID (2 times a day). 21. Ketoconazole 2 % Shampoo Sig: One (1) Appl Topical ASDIR (AS DIRECTED). 22. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 23. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 24. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 25. Clobetasol 0.05 % Cream Sig: One (1) Appl Topical TID (3 times a day). 26. Lactulose 10 g/15 mL Syrup Sig: Fifteen (15) ML PO BID (2 times a day). 27. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 28. Fluocinolone 0.01 % Solution Sig: One (1) Appl Topical TID (3 times a day) as needed for scalp itching. 29. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**11-30**] Sprays Nasal [**Hospital1 **] (2 times a day) as needed. 30. Pramoxine 1 % Lotion Sig: One (1) Topical QID (4 times a day). 31. Pramoxine-Hydrocortisone [**11-29**] % Cream Sig: One (1) Topical QID (4 times a day) as needed for pruritis. 32. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 33. Daptomycin 500 mg Recon Soln Sig: One (1) Intravenous once a day for 12 days. Discharge Disposition: Extended Care Facility: [**Location (un) **] healthcare center Discharge Diagnosis: 1. cirrhosis 2. MRSA pneumonia, complicated parapneumonic effusion 3. high grade MRSA bacteremia 4. hepatic encephalopathy 5. acute renal failure Discharge Condition: stable Discharge Instructions: 1. Continue to take your medications as prescribed 2. Call your doctor or return to the emergency room for any fever/chills/chest pain/cough/trouble breathing/ or any other concerning symptoms. 3. You should take your antibiotic for 4 weeks from [**9-16**]. 4. Please check your Creatinine every 5 days to monitor its trend and report it to your PCP or your kidney doctor. Followup Instructions: Please make an appointment to see your Primary Care physician [**Last Name (NamePattern4) **] [**1-1**] weeks. . For your chest tube drainage and collection: Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1533**],[**First Name3 (LF) **] [**Doctor First Name 25090**] MULTI-SPECIALTY THORACIC UNIT-CC9 Phone:[**0-0-**] Date/Time:[**2150-10-20**] 1:30 . Infectious Disease Specialist: Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] TAN Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2150-10-30**] 10:00 . Kidney Disease Specialist: Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D., PH.D. Date/Time:[**2150-11-19**] 3:00 . If you wish to see the Dermatologist, you can call [**Telephone/Fax (1) 250**] to make an appointment with Dr. [**First Name8 (NamePattern2) 62915**] [**Name (STitle) **] who saw you as an inpatient. Completed by:[**2150-10-6**]

038,482,571,790,572,584,070,511,276,496,428,287,303,577,281,782,537,535,V090,995

{'Methicillin susceptible Staphylococcus aureus septicemia,Methicillin susceptible pneumonia due to Staphylococcus aureus,Alcoholic cirrhosis of liver,Bacteremia,Hepatic encephalopathy,Acute kidney failure, unspecified,Chronic hepatitis C without mention of hepatic coma,Unspecified pleural effusion,Hyposmolality and/or hyponatremia,Chronic airway obstruction, not elsewhere classified,Congestive heart failure, unspecified,Thrombocytopenia, unspecified,Other and unspecified alcohol dependence, in remission,Chronic pancreatitis,Unspecified deficiency anemia,Jaundice, unspecified, not of newborn,Unspecified disorder of stomach and duodenum,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Infection with microorganisms resistant to penicillins,Severe sepsis'}

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: dyspnea/hypoxia PRESENT ILLNESS: 55 yo male with h/o cirrhosis (hep C v. autoimmune) transferred from [**Hospital1 **] with SOB x 1 week, pneumonia on CXR, elevated lactate and hypoxia. He notes worsening SOB for past week with pleuritic chest pain in R side. He also complains of fatigue and dysuria. He has some cough but only occasionally brings up sputum. He went to [**Hospital3 4107**] and was given ceftriaxone, azithro and solumedrol. He was also found to be in acute renal failure with Cr 4.9, K 5.7. Tox screen positive for opiates. He was transferred to [**Hospital1 18**] on NRB bc they did not have any ICU beds available. he denies fevers, chills. He does complain of itchy skin. . On arrival to [**Hospital1 18**] ED, his vital signs were T97.6 P104 BP105/57 R28 94% on NRB. He was given zosyn, vitamin K 10 mg SQ, kayexalate MEDICAL HISTORY: Cirrhosis: autoimmune v. Hep C with possibility of alcoholic hepatitis(s/p tx with interferon and ribiviron 18 mos ago with recurrence). Seen by Dr. [**Last Name (STitle) 10924**]. chronic hepatitis C diagnosed on routine blood work (genotype 3 and had a liver biopsy on [**2150-4-3**] noting grade [**7-8**] and stage [**3-2**]) Alcohol excess, quit 20 years ago Pancreatitis Hard of hearing, wears a hearing aid Splenic rupture secondary to a fall off a roof Bilateral lower leg edema Diverticulosis by history Left femur fx with ORIF Appendectomy MEDICATION ON ADMISSION: Meds Spironolactone 50 mg (for leg swelling) Lactulose (for constipation) Zyrtec Zoloft 200 mg Protonix 40 mg daily Prednisone 10 mg daily Ibuprofen prn Vicodin prn ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: VS: Tc 97.9 Tm 98.4 RR 62-75 BP 105-140/61-84 RR 14-31 O2Sat 95% on 5L Gen: WDWN man sitting in bed crying HEENT: Head-excoriations on head from scratching, PERRLA, EOMI, OP clear Neck: no JVD CV: RRR, nl s1, s2, no m/g/r Lungs: decreased R base breath sounds, crackles bilaterally midway up back Abd: BS+, soft, NT, ND, no hepatomegaly Ext: Bilateral 1+ pedal edema, + asterixis Pulses: 2+ radial and DP A/P 55 yo Male admitted with pneumonia on CXR w/ complicated effusion s/p chest tube placement on Vancomycin/Daptomycin. FAMILY HISTORY: Mother is living, age 77, macular degeneration Father is living, age 80, has glaucoma and DJD He has 4 brothers, 3 living, one deceased in [**2147**] from AIDS No sisters SOCIAL HISTORY: He is single, has a 29 year old son, is on disability, used to work as a roofer X 30 years He stopped smoking 20 years ago. No alcohol in 24 years. ### Response: {'Methicillin susceptible Staphylococcus aureus septicemia,Methicillin susceptible pneumonia due to Staphylococcus aureus,Alcoholic cirrhosis of liver,Bacteremia,Hepatic encephalopathy,Acute kidney failure, unspecified,Chronic hepatitis C without mention of hepatic coma,Unspecified pleural effusion,Hyposmolality and/or hyponatremia,Chronic airway obstruction, not elsewhere classified,Congestive heart failure, unspecified,Thrombocytopenia, unspecified,Other and unspecified alcohol dependence, in remission,Chronic pancreatitis,Unspecified deficiency anemia,Jaundice, unspecified, not of newborn,Unspecified disorder of stomach and duodenum,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Infection with microorganisms resistant to penicillins,Severe sepsis'}

CHIEF COMPLAINT: Unresponsive. PRESENT ILLNESS: The patient is a 73 year old woman with past medical history of hypertension, hypercholesterolemia, COPD, recent car accident 3 weeks ago with rib fractures and patellar fracture, dementia, who was transferred from [**Hospital3 3583**] after being unheard of from since Wednesday and subsequently being found down. MEDICAL HISTORY: 1. Hypertension 2. Hypercholesterolemia 3. Glaucoma 4. Dementia 5. COPD 6. Recent car accident with rib fracture and patellar fracture MEDICATION ON ADMISSION: 1. Levoxyl 2. Diovan 3. Atenolol 4. Evista 5. Aricept 6. Advair 7. Albuterol 8. KCLe Daughter is unsure of exact meds and will bring them in am. ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Gen: Intubated, recently received bolus of sedation. HEENT: Mucosa dry. Neck: In hard cervical collar. Lungs: CTA anterolaterally. No R/R/W. Cardiac: RRR. S1/S2. No M/R/G. Abd: Soft, NT, ND, +NABS. No rebound or guarding. No HSM. Extrem: Warm and well-perfused. No C/C/E. FAMILY HISTORY: No family history of neurological disease. SOCIAL HISTORY: Widowed. Lived alone and independent in ADLs per her daughter. [**Name (NI) **] term memory problems. Positive tobacco use. No alcohol, drug use. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 96842**] [**Telephone/Fax (1) 96843**].

Unspecified essential hypertension,Other persistent mental disorders due to conditions classified elsewhere,Cerebral artery occlusion, unspecified with cerebral infarction,Chronic airway obstruction, not elsewhere classified,Atrial fibrillation,Urinary tract infection, site not specified,Cellulitis and abscess of leg, except foot,Pure hypercholesterolemia

Hypertension NOS,Mental disor NEC oth dis,Crbl art ocl NOS w infrc,Chr airway obstruct NEC,Atrial fibrillation,Urin tract infection NOS,Cellulitis of leg,Pure hypercholesterolem

Admission Date: [**2133-5-9**] Discharge Date: [**2133-5-22**] Date of Birth: [**2060-4-11**] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 618**] Chief Complaint: Unresponsive. Major Surgical or Invasive Procedure: Intubation History of Present Illness: The patient is a 73 year old woman with past medical history of hypertension, hypercholesterolemia, COPD, recent car accident 3 weeks ago with rib fractures and patellar fracture, dementia, who was transferred from [**Hospital3 3583**] after being unheard of from since Wednesday and subsequently being found down. Per her daughter, she was last seen on Wednesday. When she wasn't heard from in several days, her daughter went to check on her tonight. Daughter found her lying on floor, in between couch and stable, soiled with urine and stool. She was not speaking and did not seem to understand what daughter was saying. Taken to [**Hospital3 **] and arrived at 21:45. Documentation limited but received several milligrams of Ativan, Dilantin 600 mg IV, and Labetalol for SBP of 242/122. Labs there remarkable for WBC 16.9, INRX 1.1, normal renal function, CK of 1566. Head CT with large left MCA infarction. Transferred to [**Hospital1 18**] for further evaluation. Past Medical History: 1. Hypertension 2. Hypercholesterolemia 3. Glaucoma 4. Dementia 5. COPD 6. Recent car accident with rib fracture and patellar fracture Social History: Widowed. Lived alone and independent in ADLs per her daughter. [**Name (NI) **] term memory problems. Positive tobacco use. No alcohol, drug use. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 96842**] [**Telephone/Fax (1) 96843**]. Family History: No family history of neurological disease. Physical Exam: Gen: Intubated, recently received bolus of sedation. HEENT: Mucosa dry. Neck: In hard cervical collar. Lungs: CTA anterolaterally. No R/R/W. Cardiac: RRR. S1/S2. No M/R/G. Abd: Soft, NT, ND, +NABS. No rebound or guarding. No HSM. Extrem: Warm and well-perfused. No C/C/E. Neuro: Mental status: Eyes closed. Does not open spontaneously. No verbal output. Not following commands. Cranial Nerves: I: Not tested II: Pupils are post surgical and fixed. Unable to appreciate fundi. III, IV, VI: No doll's due to collar. V, VII: Weak corneals bilaterally. VIII: Unable to assess. IX, X: +Gag. [**Doctor First Name 81**]: Unable to assess. XII: Tongue midline without fasciculations. Motor: Legs are extended, plantar flexed. Moves left leg, bending and withdrawing it. Right leg moves side to side on bed. Triple flexion response in right lower extremity. Slow extension response in right upper extremity. Sensation: Withdraws to noxious x4 Reflexes: Reflexes are brisk with several beats of clonus at her ankles. Toes are both upgoing. Coordination: Unable to assess. Gait: Unable to assess. Pertinent Results: [**2133-5-9**] 03:15AM BLOOD WBC-15.2* RBC-5.72* Hgb-14.8 Hct-46.2 MCV-81* MCH-25.8* MCHC-31.9 RDW-16.4* Plt Ct-265 [**2133-5-9**] 03:15AM BLOOD Neuts-85.4* Lymphs-6.7* Monos-7.5 Eos-0 Baso-0.4 [**2133-5-9**] 02:15AM BLOOD PT-14.4* PTT-26.7 INR(PT)-1.3* [**2133-5-9**] 02:15AM BLOOD Glucose-170* UreaN-20 Creat-0.7 Na-142 K-5.8* Cl-110* HCO3-18* AnGap-20 [**2133-5-9**] 02:15AM BLOOD CK(CPK)-5119* [**2133-5-9**] 07:21AM BLOOD ALT-37 AST-136* LD(LDH)-329* CK(CPK)-5067* AlkPhos-79 Amylase-343* TotBili-0.6 [**2133-5-11**] 10:23AM BLOOD CK(CPK)-1350* [**2133-5-9**] 02:15AM BLOOD CK-MB-52* MB Indx-1.0 cTropnT-<0.01 [**2133-5-9**] 02:15AM BLOOD Calcium-8.9 Phos-3.2 Mg-1.7 [**2133-5-9**] 07:21AM BLOOD %HbA1c-5.6 [Hgb]-DONE [A1c]-DONE [**2133-5-9**] 07:21AM BLOOD Triglyc-111 HDL-60 CHOL/HD-3.3 LDLcalc-114 [**2133-5-9**] 01:39PM BLOOD Phenyto-5.5* BRAIN MRI: The diffusion images demonstrate an acute infarct involving the left middle cerebral artery with mild mass effect on the left lateral ventricle. There are mild-to-moderate periventricular changes of small vessel disease seen. There is no midline shift or hydrocephalus. There is mild-to-moderate brain atrophy seen. There is evidence of increased signal seen in the pons indicative of small vessel disease. No definite slow diffusion seen in the pons to indicate pontine infarct. Note is made of absence of flow void in the left cavernous carotid artery, which could be due to occlusion in the neck. IMPRESSION: Acute left MCA infarct with mild mass effect on the left lateral ventricle. Absent flow void in the left carotid artery. MRA OF THE HEAD: The head MRA demonstrates absence of flow signal in the left internal carotid artery. The left MCA is faintly visualized on the source images, most likely secondary to collaterals from the anterior communicating and left posterior communicating artery. The right internal carotid, right middle cerebral, and both anterior cerebral arteries demonstrate normal flow signal. In the posterior circulation, distal left vertebral artery appears to be ending in posterior inferior cerebellar artery. The right distal vertebral, basilar, and both posterior cerebral arteries demonstrate normal flow signal. IMPRESSION: Non-visualization of the left internal carotid artery, likely secondary to occlusion in the neck. Faint flow signal indicating diminished flow is seen within the left middle cerebral artery. TTE: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Tissue velocity imaging demonstrates an E/e' <8 suggesting a normal left ventricular filling pressure. Right ventricular chamber size and free wall motion are normal. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. Moderate to severe [3+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Moderate to severe tricuspid regurgitation. Pulmonary artery systolic hypertension. EEG: This is an abnormal routine EEG due to the presence of sharp and sharp and slow wave discharges seen over the right frontal region and due to a slow and disorganized background rhythm with multifocal polymorphic slowing in the delta frequency range. Additionally, there is an increased voltage gradient over the left fronto-temporal region. The first abnormality suggests a cortical dysfunction in the right frontal region. The second abnormality represents a mild encephalopathy. There was no clear seizure activity recorded, however, and post-ictal events cannot be excluded. Brief Hospital Course: 1. Stroke: The pt was found to have aphasia and a right hemiparesis at an outside hospital. She was intubated and transferred here for further management. A head CT was obtained which showed a large left MCA distribution stroke. An MRI was then performed which showed the left MCA stroke as well as an occluded [**Doctor First Name 3098**] in the neck. This was felt to be an acute event which led to her stroke. As for the reason for the embolus, the patient had a TTE which showed LVH, but no thrombus or valvular lesions. She was monitored on telemetry and shown to have intermittent AF which was not previously known. This is likely the reason for her embolus. Carotid arteries were not evaluated with Doppler given the known [**Doctor First Name 3098**] occlusion and the fact that her source was almost certainly her heart. Given the large size of her stroke, she was not placed on coumadin/heparin. She was started on ASA 300 mg daily instead. She was also started on Lipitor. After several days, she was also started on heparin sq when this was deemed safe. She remained intubated and not attempting to answer questions while in the ICU. She had no spontaneous movement on the right and minimal movement to painful stimuli. This did not change while she was in the ICU. She opened her eyes spontaneously and would look ot her left, but it is unclear if this was in reaction to anything specific. She did not follow any commands, even on her right side which did move spontaneously at times. Multiple family meetings were held in which it was determined that the pt would not want a PEG and/or tracheostomy. This was clear from the beginning. She was kept intubated for 10 days and then extubated. She did well from a respiratory standpoint, but we had a high suspicion that she may aspirate given her inability to handle her own secretions. This was known by the family when she was extubated. As she was breathing well with minimal care required, she was transferred to the floor for further care. There she remained stable. Prior to transfer, another family meeting was held to reaffirm the pt's status as comfort measures only. 2. UTI:The patient had a UTI on admission that was treated well with 5 days of levofloxacin. 3. Cellulitis: The patient had a questionable cellulitis on her right ankle which was treated for 3 days with cefazolin. It improved significantly and this medication was stopped. It is unclear whether this was definitely cellutlitis or only a local skin irritation. Her legs seemed to cause her pain when it was touched. Given that she was found down, we did X-rays of her pelvis and hips to confirm no fracture. These films were normal. The pain seemed to resolve with the skin lesion. Medications on Admission: 1. Levoxyl 2. Diovan 3. Atenolol 4. Evista 5. Aricept 6. Advair 7. Albuterol 8. KCLe Daughter is unsure of exact meds and will bring them in am. Discharge Medications: 1. Scopolamine Base 1.5 mg Patch 72HR Sig: One (1) Patch 72HR Transdermal ONCE (Once) for 1 doses. 2. Acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal Q4H (every 4 hours) as needed for pain or fever. 3. Lorazepam 2 mg/mL Syringe Sig: [**12-4**] ml Injection Q4HPRN () as needed for agitation. 4. Morphine Concentrate 20 mg/mL Solution Sig: 5-20 mg PO Q1-2H () as needed for pain or discomfort. Discharge Disposition: Extended Care Facility: [**Location (un) 582**] at Silver [**Doctor Last Name **] Discharge Diagnosis: -left MCA territory stroke Discharge Condition: Comfort Measures Only Discharge Instructions: Please continue medications as prescribed, titrating for pt comfort. Followup Instructions: N/A [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]

401,294,434,496,427,599,682,272

{'Unspecified essential hypertension,Other persistent mental disorders due to conditions classified elsewhere,Cerebral artery occlusion, unspecified with cerebral infarction,Chronic airway obstruction, not elsewhere classified,Atrial fibrillation,Urinary tract infection, site not specified,Cellulitis and abscess of leg, except foot,Pure hypercholesterolemia'}

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: Unresponsive. PRESENT ILLNESS: The patient is a 73 year old woman with past medical history of hypertension, hypercholesterolemia, COPD, recent car accident 3 weeks ago with rib fractures and patellar fracture, dementia, who was transferred from [**Hospital3 3583**] after being unheard of from since Wednesday and subsequently being found down. MEDICAL HISTORY: 1. Hypertension 2. Hypercholesterolemia 3. Glaucoma 4. Dementia 5. COPD 6. Recent car accident with rib fracture and patellar fracture MEDICATION ON ADMISSION: 1. Levoxyl 2. Diovan 3. Atenolol 4. Evista 5. Aricept 6. Advair 7. Albuterol 8. KCLe Daughter is unsure of exact meds and will bring them in am. ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Gen: Intubated, recently received bolus of sedation. HEENT: Mucosa dry. Neck: In hard cervical collar. Lungs: CTA anterolaterally. No R/R/W. Cardiac: RRR. S1/S2. No M/R/G. Abd: Soft, NT, ND, +NABS. No rebound or guarding. No HSM. Extrem: Warm and well-perfused. No C/C/E. FAMILY HISTORY: No family history of neurological disease. SOCIAL HISTORY: Widowed. Lived alone and independent in ADLs per her daughter. [**Name (NI) **] term memory problems. Positive tobacco use. No alcohol, drug use. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 96842**] [**Telephone/Fax (1) 96843**]. ### Response: {'Unspecified essential hypertension,Other persistent mental disorders due to conditions classified elsewhere,Cerebral artery occlusion, unspecified with cerebral infarction,Chronic airway obstruction, not elsewhere classified,Atrial fibrillation,Urinary tract infection, site not specified,Cellulitis and abscess of leg, except foot,Pure hypercholesterolemia'}

CHIEF COMPLAINT: arsenic toxicity PRESENT ILLNESS: 49 y/o F w/ h/o HCV who presents from [**Hospital3 **] for a question of Gullian-[**Location (un) **] Syndrome. Patient states that she was in her USOH until 11 days PTA when she developed a productive cough. She also developed mild numbness in her fingertips and soles of her feet. The following day she developed a fever to 102. 7 days PTA she presented to OSH ED with these symptoms. She was prescribed a course of Azithromycin. She then developed nausea, vomiting, and diarrhea after taking the Azithromycin. She re-presented to the ED and was given IVFs and sent home. Over the next few days her numbness worsened with spread up her feet and then her legs. 4 days PTA she presented to her PCP with complaints of the numbness. She was instructed to go to the ED if the symptoms worsened. 2 days PTA she presented to [**Hospital **] with complaints of worsening numbness with spread into her abdomen and her back. She also complained of intermittent right-sided chest pressure. Initially she had no weakness or bowel or bladder symptoms. 1 day PTA she developed subjective weakness while ambulating to the bathroom, feeling as if her legs gave out from under her. She also had an episode of urinary incontinence. The numbness spread up her chest as well. She was seen by neurology and an MRI/MRA brain and LP was performed. MRI was unremarkable. LP revealed 1 WBC, 500 RBC, 27 protein, 70 glucose. Vital Capacity was 5.3 Liters and she denied SOB. Given concern for GBS she was sent to [**Hospital1 18**] fur further evaluation and possible plasmapheresis. . On arrival, she reported numbness as described above - from her fingers and toes up to her upper chest and also occassional tongue and peri-oral numbness. She denied shortness of breath or further nausea, vomiting, or diarrhea (GI symptoms resolved when she completed Z-pack course). She complained of weakness in her arms and legs. She has had no further fevers, cough, or SOB. MEDICAL HISTORY: HCV, s/p ribavirin treatment. Now normal liver tests per patient. Asthma prior IVDA MEDICATION ON ADMISSION: OutPt MEDS: Neurontin 25 HS Estrogen and Progestin Combination (Activella) Daily Prozac 40 Daily MEDs on Xfer: Norvasc 2.5 Daily Lopressor 50 [**Hospital1 **] Neurontin 25 HS Activella Ecotrin 81 Daily Prozac 40 Daily Protonix 40 Daily Nortriptyline 25 HS Ativan prn Q4 Ambien 5mg prn insomnia Morphine 2mg Q2 hrs prn SL Nitro prn chest pain NKDA ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Admission Exam: FAMILY HISTORY: Mother - breast cancer, uterine cancer, CAD Sister - breast cancer SOCIAL HISTORY: Prior IVDA. Quit 20 years ago. Denies ETOH. None since [**50**] yeas ago Prior tobacco. Quit in [**Month (only) 359**] Works as activity director at Alzheimer's unit Lives with husband

Toxic effect of arsenic and its compounds,Unspecified viral hepatitis C without hepatic coma,Accidental poisoning by arsenic and its compounds and fumes,Unspecified hereditary and idiopathic peripheral neuropathy,Unspecified essential hypertension

Toxic effect arsenic,Hpt C w/o hepat coma NOS,Acc poisoning-arsenic,Idio periph neurpthy NOS,Hypertension NOS

Admission Date: [**2137-5-9**] Discharge Date: [**2137-5-18**] Date of Birth: [**2088-5-6**] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5378**] Chief Complaint: arsenic toxicity Major Surgical or Invasive Procedure: lumbar puncture x 2 History of Present Illness: 49 y/o F w/ h/o HCV who presents from [**Hospital3 **] for a question of Gullian-[**Location (un) **] Syndrome. Patient states that she was in her USOH until 11 days PTA when she developed a productive cough. She also developed mild numbness in her fingertips and soles of her feet. The following day she developed a fever to 102. 7 days PTA she presented to OSH ED with these symptoms. She was prescribed a course of Azithromycin. She then developed nausea, vomiting, and diarrhea after taking the Azithromycin. She re-presented to the ED and was given IVFs and sent home. Over the next few days her numbness worsened with spread up her feet and then her legs. 4 days PTA she presented to her PCP with complaints of the numbness. She was instructed to go to the ED if the symptoms worsened. 2 days PTA she presented to [**Hospital **] with complaints of worsening numbness with spread into her abdomen and her back. She also complained of intermittent right-sided chest pressure. Initially she had no weakness or bowel or bladder symptoms. 1 day PTA she developed subjective weakness while ambulating to the bathroom, feeling as if her legs gave out from under her. She also had an episode of urinary incontinence. The numbness spread up her chest as well. She was seen by neurology and an MRI/MRA brain and LP was performed. MRI was unremarkable. LP revealed 1 WBC, 500 RBC, 27 protein, 70 glucose. Vital Capacity was 5.3 Liters and she denied SOB. Given concern for GBS she was sent to [**Hospital1 18**] fur further evaluation and possible plasmapheresis. . On arrival, she reported numbness as described above - from her fingers and toes up to her upper chest and also occassional tongue and peri-oral numbness. She denied shortness of breath or further nausea, vomiting, or diarrhea (GI symptoms resolved when she completed Z-pack course). She complained of weakness in her arms and legs. She has had no further fevers, cough, or SOB. Past Medical History: HCV, s/p ribavirin treatment. Now normal liver tests per patient. Asthma prior IVDA Social History: Prior IVDA. Quit 20 years ago. Denies ETOH. None since [**50**] yeas ago Prior tobacco. Quit in [**Month (only) 359**] Works as activity director at Alzheimer's unit Lives with husband Family History: Mother - breast cancer, uterine cancer, CAD Sister - breast cancer Physical Exam: Admission Exam: T 98.6 BP 100/46 HR 88 RR 15 98% RA GEN: pleasant female, overweight, NAD, no resp. distress HEENT: PERRL, EOMI, OP clear, MMM, anicteric Neck: supple, no LAD, non thyroidmegaly CV: RRR III/VI SM at apex, +S4 LUNGS: mild bibasilar crackles, o/w normal ABD: soft, NT, ND, +BS, obese, no HSM noted BACK: no vertebral tenderness, no CVAT EXT: no edema, 2+ pedal pulses Neuro: A/A Ox3, CN II-XII intact, normal bulk and tone, sensation to light touch/pinprick absent on bilateral lower extremity, abdomen, chest, and back. Sensation present on upper chest and back (above T3) and a segment of the lower back (about T10-L2). DTRs absent in patellar and achilles, present in upper extremities. Strength 4/5 hip flexors, finger abduction [**2-27**], otherwise strength intact. Upon discharge Delt Tri [**Hospital1 **] WE WF FE FF IP QD Ham DF RT: 4+ 4- 4+ 5 5 5 5 3 4+ 3- 3+ LEFT: 4+ 4- 4+ 5 5 5 5 3 4+ 3- 3+ Sensation: Patchy loss to pinprick in legs and trunk Reflexes: absent except 1+ in right bicep and brachioradialis Pertinent Results: DATA (OSH): . WBC 10.8-->8.4 HCT 44.2-> 41.0 PLT 368->323 BUN 10, Cr .8 LFTS WNL Trop neg TSH 1.4 HCG neg CHOL 205 LDL 147 HDL 37 TG 108 INR 1.3 PTT 34.4 . LP: 1 WBC 518 RBC glucose 70 protein 27.3 (15-45) gram stain: negative culture: no growth . CXR: no infiltrate . CTA Chest: no PE, slightly dilated ascending aorta (4.5 cm), 1.2 cm lung nodule in left upper lobe . CTV LE: no DVT . MRI Brain: mild mucosal thickening within left maxillary sinus, o/w unremarkable MRA Brain: normal flow . ECG: Sinus tachy at 100, normal axis, intervals, TWI III . Pan-MRI: No abnormal signal within the spinal cord. No evidence of cord compression. Possible vertebral hemangioma in the thoracic vertebra. EMG: Complex, abnormal study. The electrophysiologic findings are most consistent with a generalized, moderate, sensorimotor polyneuropathy, which is predominantly demyelinating in nature and of indeterminate chronicity. The reduced activation seen in multiple muscles of the right lower extremity may be due to patient effort, however a central nervous system contribution to the patient's weakness cannot be excluded Copper nl, Low MMA, MycoPNA: neg, EB CMV IgG positive, IgM neg. EBV IgG positive, IgM neg. No cryoglobulins LP:[**5-12**] 1 WBC 29 RBC glucose 60 protein 20 gram stain: negative culture: no growth no cells Arsenic: 23, nl is <23, 24hr urine collection (164.8 MCG/G CR, nl <50mgc/g CR) Brief Hospital Course: 49 y/o F with progressive numbess following recent infection concerning for Guillain-[**Location (un) **] syndrome. Currently no respiratory compromise. . 1) Numbness/weakness - pt was monitored for any evidence of respiratory insufficiency, however had good lung volumes and inspiratory force on initial evaluation in the ICU. MRI of her spine was obtained and was unrevealing. Work-up was initiated consisting of laboratory evaluation for vitamin B12 deficiency, syphillis, HIV, Hepatitis-related, Diabetes-related, thyroid, paraneoplastic (lung nodule on x-ray) which were all negative. The patient was transferred to neurology after being consulted. On transfer, the patient had a sensory level to about C5 on the abdomen, and asymmetric sensory findings on the back up to T10, paraparesis with radicular signs at C4,5, She also complained of gait ataxia, most likely due to sensory loss and areflexia. Initial though was a myelopathy with polyradiculopathy. GBS was a possible initail diagnosis, but because the patient had a level, other etiologies were explored. Other etiologies included cryglobulinemia because h/o HCV, mycoplasma (due to previous URI sx), lyme, EBV, or CMV, as well as a 24hr urine & blood heavy metal screen to look for arsenic. The patient had recently moved to a new house in early [**Month (only) 116**], two weeks prior to initial symptoms. Pt was CMV IgG positive and EBV IgG positive, but IgM levels were negative and MRI showed no signs of myelitis. She was negative for lyme and cryoglubulinemia. Throughout the course, the patient had progressive weakness of both IP/Hamstrings/TA [**1-27**], though weaker on the right compared to the left. SHe also had weak deltoids [**2-27**], biceps [**2-27**], though more weakness on the right than the left. SHe also had intermittent increased tone on the left foot. Repeat LP showed 1WBC 29RBC protein:20 glucose:69. EMG showed a moderate sensorimotor demyelination process, however there were some axonal features as well. Because the patient had progressive weakness, the patient was started on IVIG therapy. Initially the patient had improvement of symptoms with the IVIG with return of sensation to her fingers. She did have episodes of flushing with the IVIG which was treated with benadryl. She had four treatments of IVIG throughout her hospital course. On HD 7, the blood heavy metal screen showed borderline levels of arsenic (23, nl is <23). The suspicion for arsenic was confirmed with elevated levels in the 24hr urine collection (164.8 MCG/G CR, nl <50mgc/g CR). An addiontional random urine collection was made to determine if the elevated arsenic level was due to organic arsenic (found in shellfish) or inorganic arsenic (found in runoff/well water). The town of [**Location (un) 20756**] ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 67997**], [**Telephone/Fax (1) 67998**]) was notified about the patient, and inquired about levels of arsenic in their well water. [**Month (only) 547**] tests showed no elevated levels or arsenic, however no recent levels were taken, and they have begun their investigation. . 2) Lung nodule: CXR showed a LUL nodule, which chest CT showed a calcified LUL granuloma. She has a short smoking history, and denies and recent weight loss. . 3) HTN: No prior history of HTN. On Norvasc, Lopressor. BPs high/normal on presentation. The lopressor was continued through her hospital course. - Cont. Lopresor . 4) Chest pain: atypical pain. Relieved by morphine at OSH. CTA neg for PE, ECG not suggestive of ACS. Tylenol/NSAIDS did not relieve the chest pressure, ao she was placed on nitroglycerin PRN for the chest pressure she described. Subsequent ECGs showed no signs of ischemia. . 5) F/E/N: Low salt diet. Check lytes . 6) PPX: SQ heparin, bowel regimen 7) Disp: the patient was discharged to rehab with instructions to follow up in the outpatient neurology clinic. Medications on Admission: OutPt MEDS: Neurontin 25 HS Estrogen and Progestin Combination (Activella) Daily Prozac 40 Daily MEDs on Xfer: Norvasc 2.5 Daily Lopressor 50 [**Hospital1 **] Neurontin 25 HS Activella Ecotrin 81 Daily Prozac 40 Daily Protonix 40 Daily Nortriptyline 25 HS Ativan prn Q4 Ambien 5mg prn insomnia Morphine 2mg Q2 hrs prn SL Nitro prn chest pain NKDA Discharge Medications: 1. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 3. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 4. Albuterol Sulfate 0.083 % Solution Sig: 1-2 puffs Inhalation Q6H (every 6 hours) as needed. 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN (as needed). 10. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pressure. 11. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 12. Dolasetron 12.5 mg/0.625 mL Solution Sig: One (1) Intravenous Q8H (every 8 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) **] Discharge Diagnosis: polyneuropathy arsenic toxicity Discharge Condition: stable Discharge Instructions: Please call your primary care physician or return to the emergency room if you experience worsening weakness, increasing numbness, shortness of breath, visual changes, difficulty speaking, difficulty swallowing. Followup Instructions: Please call the neurology clinic at [**Hospital1 827**] for a follow up appointment in the next four to six weeks. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5379**] MD, [**MD Number(3) 5380**]

985,070,E866,356,401

{'Toxic effect of arsenic and its compounds,Unspecified viral hepatitis C without hepatic coma,Accidental poisoning by arsenic and its compounds and fumes,Unspecified hereditary and idiopathic peripheral neuropathy,Unspecified essential hypertension'}

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: arsenic toxicity PRESENT ILLNESS: 49 y/o F w/ h/o HCV who presents from [**Hospital3 **] for a question of Gullian-[**Location (un) **] Syndrome. Patient states that she was in her USOH until 11 days PTA when she developed a productive cough. She also developed mild numbness in her fingertips and soles of her feet. The following day she developed a fever to 102. 7 days PTA she presented to OSH ED with these symptoms. She was prescribed a course of Azithromycin. She then developed nausea, vomiting, and diarrhea after taking the Azithromycin. She re-presented to the ED and was given IVFs and sent home. Over the next few days her numbness worsened with spread up her feet and then her legs. 4 days PTA she presented to her PCP with complaints of the numbness. She was instructed to go to the ED if the symptoms worsened. 2 days PTA she presented to [**Hospital **] with complaints of worsening numbness with spread into her abdomen and her back. She also complained of intermittent right-sided chest pressure. Initially she had no weakness or bowel or bladder symptoms. 1 day PTA she developed subjective weakness while ambulating to the bathroom, feeling as if her legs gave out from under her. She also had an episode of urinary incontinence. The numbness spread up her chest as well. She was seen by neurology and an MRI/MRA brain and LP was performed. MRI was unremarkable. LP revealed 1 WBC, 500 RBC, 27 protein, 70 glucose. Vital Capacity was 5.3 Liters and she denied SOB. Given concern for GBS she was sent to [**Hospital1 18**] fur further evaluation and possible plasmapheresis. . On arrival, she reported numbness as described above - from her fingers and toes up to her upper chest and also occassional tongue and peri-oral numbness. She denied shortness of breath or further nausea, vomiting, or diarrhea (GI symptoms resolved when she completed Z-pack course). She complained of weakness in her arms and legs. She has had no further fevers, cough, or SOB. MEDICAL HISTORY: HCV, s/p ribavirin treatment. Now normal liver tests per patient. Asthma prior IVDA MEDICATION ON ADMISSION: OutPt MEDS: Neurontin 25 HS Estrogen and Progestin Combination (Activella) Daily Prozac 40 Daily MEDs on Xfer: Norvasc 2.5 Daily Lopressor 50 [**Hospital1 **] Neurontin 25 HS Activella Ecotrin 81 Daily Prozac 40 Daily Protonix 40 Daily Nortriptyline 25 HS Ativan prn Q4 Ambien 5mg prn insomnia Morphine 2mg Q2 hrs prn SL Nitro prn chest pain NKDA ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Admission Exam: FAMILY HISTORY: Mother - breast cancer, uterine cancer, CAD Sister - breast cancer SOCIAL HISTORY: Prior IVDA. Quit 20 years ago. Denies ETOH. None since [**50**] yeas ago Prior tobacco. Quit in [**Month (only) 359**] Works as activity director at Alzheimer's unit Lives with husband ### Response: {'Toxic effect of arsenic and its compounds,Unspecified viral hepatitis C without hepatic coma,Accidental poisoning by arsenic and its compounds and fumes,Unspecified hereditary and idiopathic peripheral neuropathy,Unspecified essential hypertension'}

CHIEF COMPLAINT: hematemesis PRESENT ILLNESS: 76-year-old gentleman is known to Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 468**], who performed a distal pancreatectomy on him 2-1/2 years ago for an early stage pancreatic cancer. Mr. [**Known lastname **] has subsequently developed myeloproliferative disease and has had numerous upper gastrointestinal ulcer events over this 2-year period; however, he has remained cancer-free. He was just admitted with upper GI bleed which was fairly mild. He received 2 units of packed red blood cells initially to recover his already low hematocrit. Upper GI endoscopy was futile on the first night of admission given a large amount of blood in the stomach. He was washed out over the next day, when he remained stable. He then had a follow-up endoscopy which revealed a bleeding ulcer in the antrum of the stomach just in a prepyloric position. This was coagulated and cauterized and epinephrine was administered to it. It appeared to be under control at this point in time. However, about 6 hours after, he burst forth with a massive and sudden upper gastrointestinal bleed. MEDICAL HISTORY: PMHx: Incisional Hernia CHF Pancreatic cancer - Adenocarcinoma, grade I, T3, [**3-12**] LN. s/p subtotal pancreatectomy [**2-19**], Xeloda, Cyberknife, XRT in [**6-20**]. Myelodysplastic syndrome s/p splenectomy - diagnosed 15 years ago, ringed sideroblastic anemia diagnosed via BM biopsy. Multiple GI bleeds [**2-15**] angioectasias from XRT. Anemia Squamous cell carcinoma in-situ T2DM BPH Gout Scarlet fever as a child Diverticulosis PSH: Lami '[**27**], TURP, knee '[**99**], Distal Panc/Splenectomy MEDICATION ON ADMISSION: Allopurinol 300 mg Tablet daily Amlodipine 5 mg [**Hospital1 **] Folic Acid 1 mg daily Furosemide 80 mg [**Hospital1 **] Glipizide 20 mg qAM and 1 tab q pm Hydralazine 25 mg TID Hydroxyurea 500 mg daily Lisinopril 10 mg daily Lorazepam 0.5 mg TID Metformin 1000 mg [**Hospital1 **] Metoprolol 125 mg TID Octreotide 200 mcg q month Pantoprazole 40 mg [**Hospital1 **] Sucralfate 1 gram QID Levitra 20 mg PRN Ambien 5 mg qhs prn Pyridoxine ALLERGIES: Nsaids PHYSICAL EXAM: on [**2155-9-24**] PHYSICAL EXAM: VITALS: 95.1, 84, 104/41, 97% RA GEN: Moderate distress. HEENT: Old blood in mouth. CV: RRR. No m/r/g. PULM: Clear anteriorly ABD: +BS. Moderate tenderness epigastrium. EXT: No c/c/e. FAMILY HISTORY: His sister died of congestive heart failure. SOCIAL HISTORY: The patient was married, had three children and quit tobacco in [**2122**]. Prior to that, he had a 30 pack year history. He used alcohol rarely. He worked as a tax attorney in [**Location (un) 86**]. He lived in [**Location (un) 745**].

Acute gastric ulcer with hemorrhage and perforation, without mention of obstruction,Acute kidney failure, unspecified,Defibrination syndrome,Acidosis,Acute and subacute necrosis of liver,Congestive heart failure, unspecified,Acute posthemorrhagic anemia,Rupture of artery,Myelodysplastic syndrome, unspecified,Gout, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Personal history of malignant neoplasm of other gastrointestinal tract

Ac stomac ulc w hem/perf,Acute kidney failure NOS,Defibrination syndrome,Acidosis,Acute necrosis of liver,CHF NOS,Ac posthemorrhag anemia,Rupture of artery,Myelodysplastic synd NOS,Gout NOS,DMII wo cmp nt st uncntr,BPH w/o urinary obs/LUTS,Hx of GI malignancy NEC

Admission Date: [**2155-9-24**] Discharge Date: [**2155-9-27**] Date of Birth: [**2079-7-7**] Sex: M Service: SURGERY Allergies: Nsaids Attending:[**First Name3 (LF) 148**] Chief Complaint: hematemesis Major Surgical or Invasive Procedure: 1. Exploratory laparotomy. 2. Gastrotomy with exploration and clot evacuation of the stomach and duodenum. 3. Antrectomy. 4. Arteriotomy repair of celiac axis with bovine pericardium. 5. [**Location (un) 5701**] bag closure for temporary abdominal domain control. History of Present Illness: 76-year-old gentleman is known to Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 468**], who performed a distal pancreatectomy on him 2-1/2 years ago for an early stage pancreatic cancer. Mr. [**Known lastname **] has subsequently developed myeloproliferative disease and has had numerous upper gastrointestinal ulcer events over this 2-year period; however, he has remained cancer-free. He was just admitted with upper GI bleed which was fairly mild. He received 2 units of packed red blood cells initially to recover his already low hematocrit. Upper GI endoscopy was futile on the first night of admission given a large amount of blood in the stomach. He was washed out over the next day, when he remained stable. He then had a follow-up endoscopy which revealed a bleeding ulcer in the antrum of the stomach just in a prepyloric position. This was coagulated and cauterized and epinephrine was administered to it. It appeared to be under control at this point in time. However, about 6 hours after, he burst forth with a massive and sudden upper gastrointestinal bleed. Past Medical History: PMHx: Incisional Hernia CHF Pancreatic cancer - Adenocarcinoma, grade I, T3, [**3-12**] LN. s/p subtotal pancreatectomy [**2-19**], Xeloda, Cyberknife, XRT in [**6-20**]. Myelodysplastic syndrome s/p splenectomy - diagnosed 15 years ago, ringed sideroblastic anemia diagnosed via BM biopsy. Multiple GI bleeds [**2-15**] angioectasias from XRT. Anemia Squamous cell carcinoma in-situ T2DM BPH Gout Scarlet fever as a child Diverticulosis PSH: Lami '[**27**], TURP, knee '[**99**], Distal Panc/Splenectomy Social History: The patient was married, had three children and quit tobacco in [**2122**]. Prior to that, he had a 30 pack year history. He used alcohol rarely. He worked as a tax attorney in [**Location (un) 86**]. He lived in [**Location (un) 745**]. Family History: His sister died of congestive heart failure. Physical Exam: on [**2155-9-24**] PHYSICAL EXAM: VITALS: 95.1, 84, 104/41, 97% RA GEN: Moderate distress. HEENT: Old blood in mouth. CV: RRR. No m/r/g. PULM: Clear anteriorly ABD: +BS. Moderate tenderness epigastrium. EXT: No c/c/e. At [**2155-9-27**]: On exam the patient did not respond to verbal or physical stimuli. Absent heart and breath sounds. Absent peripheral pulses. Pupils are fixed and dilated. Pertinent Results: [**2155-9-26**] 05:51PM BLOOD WBC-25.1* RBC-3.53* Hgb-10.6* Hct-29.8* MCV-84 MCH-30.1 MCHC-35.6* RDW-16.0* Plt Ct-36* [**2155-9-26**] 10:23PM BLOOD PT-22.1* PTT-64.7* INR(PT)-2.1* [**2155-9-26**] 10:23PM BLOOD Glucose-73 UreaN-44* Creat-2.1* Na-140 K-4.2 Cl-110* HCO3-10* AnGap-24* [**2155-9-26**] 10:23PM BLOOD ALT-971* AST-2078* CK(CPK)-774* AlkPhos-261* [**2155-9-26**] 10:23PM BLOOD Calcium-8.0* Phos-6.5* Mg-2.1 [**2155-9-26**] 11:33PM BLOOD Type-ART pO2-271* pCO2-33* pH-7.06* calTCO2-10* Base XS--20 [**2155-9-26**] 10:33PM BLOOD Lactate-13.8* EGD [**2155-9-25**]: Large 1 cm gastric ulcer with recent stigmata of bleeding. Successfully treated with epinephrine and cautery. Multiple patchy areas of ulceration in gastric body. Otherwise normal EGD to second part of the duodenum Brief Hospital Course: Admitted for hemoptysis, received 2 units pRBC in ED and admitted to MICU for treatment and evaluation of UGI bleed. Endoscopy attempted [**9-25**] but could not adequate assess due to excessive blood and clot in stomach. Pt. received additional 3U pRBC. O/N on [**9-25**] massive hemoptysis, received 10U pRBC, emergently intubated by anesthesia. On pressors, lactate 12.8, emergently brought to OR for antrectomy, repair of arteriotomy with bovine pericardial patch for upper gastrointestinal hemorrhage and boring ulcer of the posterior gastric wall directly into the celiac access. Intraoperatively the patient received 11 units of FFP, 11 packed red blood cells and 3 platelets. The abdomen was left open with [**Location (un) 5701**] bag in place, and returned to the ICU in critical condition. The patient had a brief post-operative course, experiencing multi organ system failure requiring pressors and ventilatory support in the setting of increasing lactic acidosis. A discussion with the family regarding the patient's poor prognosis led to making the patient CMO. Pressors were discontinued and the patient was extubated, expiring shortly thereafter. Medications on Admission: Allopurinol 300 mg Tablet daily Amlodipine 5 mg [**Hospital1 **] Folic Acid 1 mg daily Furosemide 80 mg [**Hospital1 **] Glipizide 20 mg qAM and 1 tab q pm Hydralazine 25 mg TID Hydroxyurea 500 mg daily Lisinopril 10 mg daily Lorazepam 0.5 mg TID Metformin 1000 mg [**Hospital1 **] Metoprolol 125 mg TID Octreotide 200 mcg q month Pantoprazole 40 mg [**Hospital1 **] Sucralfate 1 gram QID Levitra 20 mg PRN Ambien 5 mg qhs prn Pyridoxine Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: 1. Upper gastrointestinal hemorrhage. 2. Boring ulcer of the posterior gastric wall directly into the celiac access. 3. Multi-organ system failure Discharge Condition: Death Discharge Instructions: D/C to morgue Followup Instructions: Not applicable

531,584,286,276,570,428,285,447,238,274,250,600,V100

{'Acute gastric ulcer with hemorrhage and perforation, without mention of obstruction,Acute kidney failure, unspecified,Defibrination syndrome,Acidosis,Acute and subacute necrosis of liver,Congestive heart failure, unspecified,Acute posthemorrhagic anemia,Rupture of artery,Myelodysplastic syndrome, unspecified,Gout, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Personal history of malignant neoplasm of other gastrointestinal tract'}

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: hematemesis PRESENT ILLNESS: 76-year-old gentleman is known to Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 468**], who performed a distal pancreatectomy on him 2-1/2 years ago for an early stage pancreatic cancer. Mr. [**Known lastname **] has subsequently developed myeloproliferative disease and has had numerous upper gastrointestinal ulcer events over this 2-year period; however, he has remained cancer-free. He was just admitted with upper GI bleed which was fairly mild. He received 2 units of packed red blood cells initially to recover his already low hematocrit. Upper GI endoscopy was futile on the first night of admission given a large amount of blood in the stomach. He was washed out over the next day, when he remained stable. He then had a follow-up endoscopy which revealed a bleeding ulcer in the antrum of the stomach just in a prepyloric position. This was coagulated and cauterized and epinephrine was administered to it. It appeared to be under control at this point in time. However, about 6 hours after, he burst forth with a massive and sudden upper gastrointestinal bleed. MEDICAL HISTORY: PMHx: Incisional Hernia CHF Pancreatic cancer - Adenocarcinoma, grade I, T3, [**3-12**] LN. s/p subtotal pancreatectomy [**2-19**], Xeloda, Cyberknife, XRT in [**6-20**]. Myelodysplastic syndrome s/p splenectomy - diagnosed 15 years ago, ringed sideroblastic anemia diagnosed via BM biopsy. Multiple GI bleeds [**2-15**] angioectasias from XRT. Anemia Squamous cell carcinoma in-situ T2DM BPH Gout Scarlet fever as a child Diverticulosis PSH: Lami '[**27**], TURP, knee '[**99**], Distal Panc/Splenectomy MEDICATION ON ADMISSION: Allopurinol 300 mg Tablet daily Amlodipine 5 mg [**Hospital1 **] Folic Acid 1 mg daily Furosemide 80 mg [**Hospital1 **] Glipizide 20 mg qAM and 1 tab q pm Hydralazine 25 mg TID Hydroxyurea 500 mg daily Lisinopril 10 mg daily Lorazepam 0.5 mg TID Metformin 1000 mg [**Hospital1 **] Metoprolol 125 mg TID Octreotide 200 mcg q month Pantoprazole 40 mg [**Hospital1 **] Sucralfate 1 gram QID Levitra 20 mg PRN Ambien 5 mg qhs prn Pyridoxine ALLERGIES: Nsaids PHYSICAL EXAM: on [**2155-9-24**] PHYSICAL EXAM: VITALS: 95.1, 84, 104/41, 97% RA GEN: Moderate distress. HEENT: Old blood in mouth. CV: RRR. No m/r/g. PULM: Clear anteriorly ABD: +BS. Moderate tenderness epigastrium. EXT: No c/c/e. FAMILY HISTORY: His sister died of congestive heart failure. SOCIAL HISTORY: The patient was married, had three children and quit tobacco in [**2122**]. Prior to that, he had a 30 pack year history. He used alcohol rarely. He worked as a tax attorney in [**Location (un) 86**]. He lived in [**Location (un) 745**]. ### Response: {'Acute gastric ulcer with hemorrhage and perforation, without mention of obstruction,Acute kidney failure, unspecified,Defibrination syndrome,Acidosis,Acute and subacute necrosis of liver,Congestive heart failure, unspecified,Acute posthemorrhagic anemia,Rupture of artery,Myelodysplastic syndrome, unspecified,Gout, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Personal history of malignant neoplasm of other gastrointestinal tract'}

CHIEF COMPLAINT: Syncope, pauses PRESENT ILLNESS: Mr. [**Known firstname **] [**Known lastname **] is a 44 year-old male with no significant PMHx who presented to outside hospital after a syncopal episode occurring at work today. At 10AM patient was sitting at his desk, felt his heart "skip a beat" had associated lightheadedness but continued working. At noon, just after eating lunch the sensation of lightheadedness recurred for a few seconds and he woke up on the floor. He hit his head on a piece of heating equipment. His coworkers told him that he was unconscious for 20 seconds. They also reported some jerking movements when he initially passed out. When Mr. [**Known lastname **] [**Last Name (Titles) 5058**] he felt well. He was taken to the [**Location (un) 620**] ER for evaluation. MEDICAL HISTORY: R elbow bursitis Achilles tendon tear MEDICATION ON ADMISSION: ASA 162.5mg daily Ibuprofen 400-600mg daily Glucosamine Multivitamin ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: VS T97.3, BP 153/79, HR 85, RR 10-14, O2sat 97% on RA. Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. FAMILY HISTORY: There is no family history of premature coronary artery disease or sudden death. The patient's father had "enlarged valves" requiring replacements and atrial fibrillation at the age of 57. He also had a paternal uncle with arrhythmia. SOCIAL HISTORY: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. He drinks [**1-27**] drinks/day.

Sinoatrial node dysfunction,Subdural hemorrhage following injury without mention of open intracranial wound, with brief [less than one hour] loss of consciousness,Fall resulting in striking against other object

Sinoatrial node dysfunct,Subdural hem-brief coma,Fall striking object NEC

Admission Date: [**2113-3-29**] Discharge Date: [**2113-3-31**] Date of Birth: [**2068-7-11**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 425**] Chief Complaint: Syncope, pauses Major Surgical or Invasive Procedure: Metronic pacemaker placement History of Present Illness: Mr. [**Known firstname **] [**Known lastname **] is a 44 year-old male with no significant PMHx who presented to outside hospital after a syncopal episode occurring at work today. At 10AM patient was sitting at his desk, felt his heart "skip a beat" had associated lightheadedness but continued working. At noon, just after eating lunch the sensation of lightheadedness recurred for a few seconds and he woke up on the floor. He hit his head on a piece of heating equipment. His coworkers told him that he was unconscious for 20 seconds. They also reported some jerking movements when he initially passed out. When Mr. [**Known lastname **] [**Last Name (Titles) 5058**] he felt well. He was taken to the [**Location (un) 620**] ER for evaluation. At [**Location (un) 620**], he was found to have small bilateral subdural hematomas which were felt to be traumatic in nature. While in the [**Location (un) 620**] ED he was monitored on telemetry and had two additional syncopal episodes half hour apart. Both occurred when he was lying on the stretcher, were preceded by approximately 5 seconds of lightheadedness. He lost consciousness for 30 seconds each time. This time, unlike the prior episode he felt unwell afterwards. The second episode was witnessed by MDs at the hospital and telemetry revealed a 15 second pause. He was transferred to [**Hospital1 18**] for consideration of a pacemaker. Of note, at baseline he has had the sensation of "pauses" in his chest which last for 1 second 1-2x/month for the past year, however over the past two months this sensation has been occurring weekly. He went to see a primary care doctor and had holter monitor, echocardiogram and EKG all of which were reportedly normal. He exercises 1-2 times per week and has never had symptoms with exercise. He passed out 1 time years ago in the setting of being very ill with the flu. In the ED, initial vitals were T: 98.3 HR: 74 BP: 112/100 RR: 18 O2Sat: 100% on 3L. He was seen by Neurosurgery in the ED and was felt to be stable and not requiring neurosurgical intervention nor did they feel that dilantin was required On arrival to the CCU, the patient is feeling well and is without complaints. On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations. Syncope and presyncope as described in HPI. Past Medical History: R elbow bursitis Achilles tendon tear Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. He drinks [**1-27**] drinks/day. Family History: There is no family history of premature coronary artery disease or sudden death. The patient's father had "enlarged valves" requiring replacements and atrial fibrillation at the age of 57. He also had a paternal uncle with arrhythmia. Physical Exam: VS T97.3, BP 153/79, HR 85, RR 10-14, O2sat 97% on RA. Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP 6cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Warm and well perfused. Skin: Mild ecchymosis noted over left eyebrow. Neuro: Fluent speech, good comprehension. No dysarthria. CN II-XII intact. Motor exam with normal bulk and tone, [**5-30**] bilaterally in both upper and lower extremities. Sensation also intact throughout to light touch. Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: [**2113-3-29**] 04:47PM BLOOD WBC-12.9* RBC-4.48* Hgb-14.9 Hct-39.7* MCV-89 MCH-33.2* MCHC-37.4* RDW-13.7 Plt Ct-217 [**2113-3-31**] 07:00AM BLOOD WBC-7.3 RBC-4.72 Hgb-15.3 Hct-41.8 MCV-89 MCH-32.4* MCHC-36.5* RDW-12.8 Plt Ct-230 [**2113-3-29**] 04:47PM BLOOD Glucose-107* UreaN-23* Creat-1.1 Na-140 K-4.4 Cl-106 HCO3-26 AnGap-12 [**2113-3-31**] 07:00AM BLOOD Glucose-88 UreaN-21* Creat-0.9 Na-140 K-3.9 Cl-107 HCO3-26 AnGap-11 [**2113-3-29**] 04:47PM BLOOD cTropnT-<0.01 [**2113-3-30**] 04:53AM BLOOD CK-MB-4 cTropnT-<0.01 Urine cx: negative Lyme serology: negative CT Head ([**3-29**]): No change in tiny left inferior frontal subdural hematoma. EKG ([**3-30**]): NSR. TTE ([**3-30**]): No structural cardiac cause of syncope identified. Normal global and regional biventricular systolic function. CXR ([**3-31**]): The heart is normal in size and there is no evidence of vascular congestion. Blunting of what appears to be the right costophrenic angle posteriorly may reflect some pleural thickening. No evidence of acute focal pneumonia. A pacemaker device is now in place with the leads in the general area of the right atrium and apex of the right ventricle. No evidence of pneumothorax. Brief Hospital Course: 1) Loss of consciousness: Had 3 total episodes on day of admission. The episode in the OSH ED was seen on telemetry and showed a 15 second sinus arrest. Baseline EKG with some 1mm STE vs J point elevation diffusely, although history and CK not consistent with pericarditis. Telemetry monitoring showed occasional sinus pauses, but no sustained arrhythmias. The patient had no further lightheadedness or syncope. TTE was normal. A pacemaker was placed without complications and he was discharged in stable condition. 2) SDH: Small and likely traumatic in origin. Seen by neurosurgery in the ED, who signed off. Neuro exam remained within normal limits during his admission. Medications on Admission: ASA 162.5mg daily Ibuprofen 400-600mg daily Glucosamine Multivitamin Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 2. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 2 days. Disp:*8 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Sinus Arrest requiring pacemaker placement Subdural hematoma Discharge Condition: stable Discharge Instructions: You had long heart pauses that caused you to pass out and required a pacemaker. There were no complications with the procedure. Please do not raise your left arm over your head for 6 weeks, also avoid carrying more than 5 pounds with your left arm or tucking in your shirt with your left arm. No showers or baths for 1 week until you are seen in the device clinic. Keep the bandage clean and dry. You will take antibiotics for 48 hours to prevent a skin infection. You also have a tiny blood collection in the subdural part of your head that is stable. You do not need another CT scan unless you develop changes such as increasing headaches and light-headedness, confusion, fatigue or seizures. The blood will reabsorb with time. . New Medicines: 1. Cephalexin: an antibiotic to prevent skin infection 2. Tylenol to take as needed for pain. . Please call Dr. [**Last Name (STitle) **] if you have any increasing redness, pain or discharge at the pacer site. Also call with any increasing lightheadedness, fainting, trouble breathing, color changes or swelling in your left arm or any other unusual symptoms. Followup Instructions: DEVICE CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2113-4-11**] 2:30 [**Hospital Ward Name 23**] [**Location (un) **] Cardiology: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 62**] Date/Time: Friday [**6-2**] at 3:20PM. [**Hospital Ward Name 23**] clinical Center, [**Location (un) 436**]. . Primary Care: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Doctor Last Name **] Phone: [**Telephone/Fax (1) 3070**] Date/Time: [**4-17**] at 10:00pm. Please bring any medical records with you. Completed by:[**2113-3-31**]

427,852,E888

{'Sinoatrial node dysfunction,Subdural hemorrhage following injury without mention of open intracranial wound, with brief [less than one hour] loss of consciousness,Fall resulting in striking against other object'}

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: Syncope, pauses PRESENT ILLNESS: Mr. [**Known firstname **] [**Known lastname **] is a 44 year-old male with no significant PMHx who presented to outside hospital after a syncopal episode occurring at work today. At 10AM patient was sitting at his desk, felt his heart "skip a beat" had associated lightheadedness but continued working. At noon, just after eating lunch the sensation of lightheadedness recurred for a few seconds and he woke up on the floor. He hit his head on a piece of heating equipment. His coworkers told him that he was unconscious for 20 seconds. They also reported some jerking movements when he initially passed out. When Mr. [**Known lastname **] [**Last Name (Titles) 5058**] he felt well. He was taken to the [**Location (un) 620**] ER for evaluation. MEDICAL HISTORY: R elbow bursitis Achilles tendon tear MEDICATION ON ADMISSION: ASA 162.5mg daily Ibuprofen 400-600mg daily Glucosamine Multivitamin ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: VS T97.3, BP 153/79, HR 85, RR 10-14, O2sat 97% on RA. Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. FAMILY HISTORY: There is no family history of premature coronary artery disease or sudden death. The patient's father had "enlarged valves" requiring replacements and atrial fibrillation at the age of 57. He also had a paternal uncle with arrhythmia. SOCIAL HISTORY: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. He drinks [**1-27**] drinks/day. ### Response: {'Sinoatrial node dysfunction,Subdural hemorrhage following injury without mention of open intracranial wound, with brief [less than one hour] loss of consciousness,Fall resulting in striking against other object'}

CHIEF COMPLAINT: NSTEMI at OSH PRESENT ILLNESS: The patient is a 83 yo woman with h/o CAD s/o CABG in [**2150**], Hyperlipidemia, DM2, and hypertension, who presented from OSH with NSTEMI. Per the patient and her family, the patient developed shortness of breath, a productive cough, and increasing pain in her left arm last Tuesday. She presented to [**Hospital3 **] ED, where she was found to have a right lower lobe infiltrate and was admitted for pneumonia. She was started on Ceftriaxone and Azithromycin, yet continued to spike daily fevers, so Vancomycin was added on [**6-5**]. She admitted to increasing PND, orthopnea, and ankle edema over the past 6 months, so cardiology was consulted given concern for underlying CHF given her history of CAD. She had a TTE on [**6-4**], which showed concentric LVH with mild anteroseptal hyokinesis and 2+ MR. MEDICAL HISTORY: CABG: [**2150**] in [**State 108**]. SV to LAD, SV to RM, SV to distal circumflex marginal, SV to posterior descending artery.Diabetes Mellitus Dyslipidemia Hypertension Iron Deficiency Anemia Arthritis MEDICATION ON ADMISSION: Ibuprofen 400 mg [**Hospital1 **] Lisinopril 20 mg daily Lantus 50 Units daily Lipitor 10 mg daily Metformin 500 mg [**Hospital1 **] Nifedical XR 30 mg daily ALLERGIES: All drug allergies previously recorded have been deleted PHYSICAL EXAM: VS: T 98.0, BP 135/66, HR 96, RR 34, O2 sat 99% on NRB GENERAL: Elderly woman, pleasant, gregarious, in obvious respiratory distress. HEENT: PERRL, EOMI. Oropharynx clear and without exudate. Conjunctival pallor. No xanthalesma. NECK: Supple with JVP of 10 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. 2/6 systolic murmur. LUNGS: Poor inspiratory effort. Diffuse crackles, rhonchi, and expiratory wheezes. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ FAMILY HISTORY: The patient's son also had CAD s/p CABG. Her mother had DM2. SOCIAL HISTORY: The patient currently lives by herself in [**Hospital1 487**], MA. Her son lives in the same apartment complex, and she has VNA to help with ADLs. - Tobacco history: She smoked for 20 years but quit 30 years ago

Subendocardial infarction, initial episode of care,Pneumonia, organism unspecified,Acute on chronic systolic heart failure,Acute kidney failure, unspecified,Drug-induced delirium,Chronic total occlusion of coronary artery,Asthma, unspecified type, unspecified,Benzodiazepine-based tranquilizers causing adverse effects in therapeutic use,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Iron deficiency anemia, unspecified,Other and unspecified hyperlipidemia,Aortocoronary bypass status

Subendo infarct, initial,Pneumonia, organism NOS,Ac on chr syst hrt fail,Acute kidney failure NOS,Drug-induced delirium,Chr tot occlus cor artry,Asthma NOS,Adv eff benzodiaz tranq,Hypertension NOS,DMII wo cmp nt st uncntr,Iron defic anemia NOS,Hyperlipidemia NEC/NOS,Aortocoronary bypass

Admission Date: [**2162-6-6**] Discharge Date: [**2162-6-13**] Date of Birth: [**2079-4-6**] Sex: F Service: MEDICINE Allergies: All drug allergies previously recorded have been deleted Attending:[**First Name3 (LF) 2901**] Chief Complaint: NSTEMI at OSH Major Surgical or Invasive Procedure: Cardiac catheterization with bare metal stent to proximal left anterior descending artery History of Present Illness: The patient is a 83 yo woman with h/o CAD s/o CABG in [**2150**], Hyperlipidemia, DM2, and hypertension, who presented from OSH with NSTEMI. Per the patient and her family, the patient developed shortness of breath, a productive cough, and increasing pain in her left arm last Tuesday. She presented to [**Hospital3 **] ED, where she was found to have a right lower lobe infiltrate and was admitted for pneumonia. She was started on Ceftriaxone and Azithromycin, yet continued to spike daily fevers, so Vancomycin was added on [**6-5**]. She admitted to increasing PND, orthopnea, and ankle edema over the past 6 months, so cardiology was consulted given concern for underlying CHF given her history of CAD. She had a TTE on [**6-4**], which showed concentric LVH with mild anteroseptal hyokinesis and 2+ MR. On [**6-5**], the patient had an episode of [**6-4**], non-radiating, substernal chest pressure, which she states was reminiscent of the pain she experienced with her prior MI in [**2150**]. She had associated dizziness and diaphoresis. ECG showed ST depressions in II, III, and AVF as well as V4-V6. Cardiac enzymes were found to be elevated, so the patient was trasnferred to the CCU and started on [**Year (4 digits) **], Heparin gtt, [**Year (4 digits) **], and Integrilin. She had a stat repeat TTE, which showed global hypokinesis and a LVEF of 40%. She was then transferred to [**Hospital1 18**] for cardiac catheterization. On arrival to [**Wardname 13764**], the patient developed acute respiratory distress with O2 sats in the 80s. She received albuterol nebulizations x3, Atrovent x1, Lasix 40 mg IV, and was placed on a NRB. She was then transferred to the CCU for further evaluation and monitoring. In the CCU, the patient denies current chest pain and states that her breathing has improved. She continues to have a productive cough but feels more comfortable than prior. On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent chills or rigors. She denies exertional buttock or calf pain. She does endorse frequent constipation. Cardiac review of systems is notable for absence of palpitations, syncope or presyncope. Past Medical History: CABG: [**2150**] in [**State 108**]. SV to LAD, SV to RM, SV to distal circumflex marginal, SV to posterior descending artery.Diabetes Mellitus Dyslipidemia Hypertension Iron Deficiency Anemia Arthritis Social History: The patient currently lives by herself in [**Hospital1 487**], MA. Her son lives in the same apartment complex, and she has VNA to help with ADLs. - Tobacco history: She smoked for 20 years but quit 30 years ago - ETOH: Rare (doesn't like the taste of beer) - Illicit drugs: None Family History: The patient's son also had CAD s/p CABG. Her mother had DM2. Physical Exam: VS: T 98.0, BP 135/66, HR 96, RR 34, O2 sat 99% on NRB GENERAL: Elderly woman, pleasant, gregarious, in obvious respiratory distress. HEENT: PERRL, EOMI. Oropharynx clear and without exudate. Conjunctival pallor. No xanthalesma. NECK: Supple with JVP of 10 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. 2/6 systolic murmur. LUNGS: Poor inspiratory effort. Diffuse crackles, rhonchi, and expiratory wheezes. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ Pertinent Results: ADMISSION LABS/STUDIES: Cr: 1.4 Glucose: 193 CK: 1125, MB: 131, MBI: 11.6, Trop: 2.37 CBC: WBC 15.4, Hgb 10.3, Hct 31.2 Plt 330 PT: 14.4, PTT 53.4, INR 1.3 ABG: 7.38/36/124 Lactate: 1.9 From OSH: Cardiac enzymes (OSH): CK 919, CK-MB 191.5, Trop 15.66 Creatinine: 1.1 -> 1.2 Hct: 28.7 BNP: 275 U/A ([**6-6**]): 1+ leuk esterase, 0-2 WBC, 1+ bacteria Influenza A: Negative Legionella Ag: Negative Strep Pneumo Ag: Negative PERTINENT STUDIES: EKG (OSH on [**6-5**]): ST depressions in II, III, AVF, V4-V6. CXR (OSH on [**6-5**]): Right lower lobe infiltrate is essentially unchanged when compared to previous examination. The degree of cardiac silhouette enlargement s/o median sternotomy is unchanged. The left lung and pulmonary venous pattern have a normal appearance. No pleural effusions seen. TTE ([**6-4**]): Concentric LVH with mild anteroseptal hypokinesis. LVEF 50%. Trivial aortic stenosis ([**Location (un) 109**] 1.9 cm), 2+ MR. 3+ TR. STAT TTE ([**6-6**]): LVEF 40%, Global hypokinesis. Inferior wall hypokinesis v. akinesis. 4+ MR. CXR ([**6-6**]): RLL infiltrate, bilateral pleural effusions and pulmonary edema. Cardiac Cath ([**6-7**]): 1. Selective coronary angiography in this right dominant system demonstrated three vessel disease. The LMCA had no angiographically apparent disease. The LAD had a large clot in the proximal vessel which supplied a moderate sized diagonal. There was 70% mid-LAD stenosis proximal to the SVG-LAD touchdown and after the diagonal takeoff, as well as mild disease of the distal vessel. The LCx had a 50% occlusion at theorigin and OM1 and OM2 were 100% occluded. The native LCx only fills a small OM4. The distal AVG Cx is 100% occluded. The mid RCA had 100% occlusion. 2. Conduit angiography revealed the SVG-OM and SVG-Ramus to be totally occluded. The SVG to LAD and the SVG to RCA were widely patent. 3. Resting hemodynamics revealed elevated right sided filling pressure with RVEDP 18mmHg. There was moderate pulmonary arterial systolic hypertension with PASP of 42mmHg. The CI was preserved at 2.5 L/min/m2. 4. Successful thrombectomy (using Angiojet) of a large thrombus burden in the proximal LAD followed by PTCA and stenting with a 3.5x18 mm Driver BMS with improvement in distal flow (into a moderate size diag, otehr smaller branches) from TIMI 1 to TIMI 3. Final angiography showed no residual stenosis, dissection or distal emboli. Echo ([**6-8**]): The left atrium is elongated. The right atrial pressure is indeterminate. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is moderate regional left ventricular systolic dysfunction with anterior akinesis/hypokinesis with mild to moderate hypokinesis elsewhere. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is no pericardial effusion. Renal US with Dopplers([**6-10**]): 1. Atrophic left kidney with cortical thinning. No hydronephrosis bilaterally. 2. Some vascularity detected in the right kidney, but pulse wave Doppler ultrasound cannot be performed on this person, as she is unable to lie flat and unable to hold her breath. Doppler cannot be performed on a continual moving target. CXR ([**6-12**]): In comparison with the study of [**6-10**], there has been substantial decrease in the pulmonary vascular congestion. Cardiac silhouette remains enlarged. The right-sided pleural effusion has decreased. The area of possible consolidation in the right perihilar region is no longer seen, consistent with it having been a reflection of central pulmonary edema. Brief Hospital Course: # NSTEMI: The patient was originally admitted and thought to have demand ischemia in the setting of acute infection, as she had ST depressions in II, III, aVF, V4-V6 and elevated cardiac enzymes. She was given [**Last Name (LF) **], [**First Name3 (LF) **], Heparin gtt, Integrilin, Morphine, NTG SL, Metoprolol, and Nifedipine at OSH. At our hospital, she received a [**First Name3 (LF) **] load, continued the heparin gtt, and started an integrillin gtt. She was also started on metoprolol, lisinopril, and atorvastatin. The next morning she went for cardiac catheterization and was found to have a large clot in the proximal LAD, 50% occlusion of the LCx and 100% occlusion of OM1 and OM2. There was also 100% occlusion of the mid-RCA and 100% of the distal AVG Cx. She had elevated right-sided filling pressures and moderate pulmonary arterial systolic HTN. She received a BMS to the proximal LAD. There were no complications during the procedure. The next day, follow-up echo showed LV anterior akinesis/hypokinesis, moderate (2+) MR [**First Name (Titles) **] [**Last Name (Titles) **], and mild (1+) AR. Patient did not have a recurrence of chest pain during her stay. # Respiratory distress: On admission, the patient was found to be in respiratory distress. CXR at the time showed pulmonary edema and known RLL infiltrate (pneumonia was diagnosed at OSH). It was felt that she had flash pulmonary edema and she was treated with IV Lasix. Over the next 3 nights, patient had episodes of agitation and respiratory distress. During these episodes, her 02 sats would be approximately 90% on 4L, and her physical exam revealed diffuse wheezing with crackles and the lung bases. She was started on atrovent and albuterol nebulizers for possible reactive airway disease in the setting of resolving pneumonia. However, her crackles on lung exam and wheezing was concerning for recurrent flash pulmonary edema. Therefore, she was also diuresed with IV Lasix. However, as the episodes continued, it did not appear that the diuresis was helping her, and was therefore discontinued. She had a renal ultrasound to rule out renal artery stenosis causes transient high blood pressures and contributing to flash pulmonary edema. However, they were unable to evaluate for renal artery stenosis. It was decided that her respiratory distress was most likely due to reactive airways, and she was started on prednisone 60mg po daily and inhaled steroids. # Pneumonia: The patient presented to the OSH with dyspnea, productive cough, and fevers. She was found to have a RLL PNA. She was treated with Ceftriaxone, Azithromycin, and Vancomycin, and her WBC was trending down. On admission to our hospital, vancomycin was held and the patient completed a 7 day course of Ceftriaxone and Azithromycin for pneumonia. # Acute Kidney Injury: The patient's Cr on admission was 1.4, which was increased from her baseline of 1.1. Urine electrolytes were checked and she was felt to have a prerenal cause of her renal failure. Creatinine bumped to 1.9 during her stay, but decreased back to 1.6 by the time of discharge. Renal ultrasound showed some atrophy of the left kidney but was a poor study. Patient's BUN/Cr should be followed as an outpatient. Renal function should followed as an outpatient. # Diabetes Mellitus Type 2: The patient has a history of DM2, and was managed with glargine and sliding scale insulin. # Agitation: The patient with agitation on multiple occasions, most commonly related to respiratory distress. She became acutely delirious with administration of Ativan. During most of her agitation episodes, she responded to reorientation through an interpreter and one responded to IV morphine. This agitation decreased after patient was transfered to the floor. # Anemia: Patient with anemia throughout admission. It was thought to be secondary to iron deficiency and she was on iron sulfate as an outpatient. She was transfused 1 unit of blood during her stay in an effort to decrease her shortness of breath, as it was felt that anemia may be contributing to her dyspnea. During the stay a sample was not obtained and guaiaced. On discharge patient's HCT is stable at 29.7. Patient requesterd to be FULL CODE during this admission. Medications on Admission: Ibuprofen 400 mg [**Hospital1 **] Lisinopril 20 mg daily Lantus 50 Units daily Lipitor 10 mg daily Metformin 500 mg [**Hospital1 **] Nifedical XR 30 mg daily Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Take every day for one year. Disp:*30 Tablet(s)* Refills:*11* 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for Constipation. 4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 5. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual every 5 minutes for a total of three [**Hospital1 4319**] as needed for chest pain. 6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) vial Inhalation Q4H (every 4 hours) as needed for wheezing. 9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 11. Insulin Glargine 100 unit/mL Cartridge Sig: Fifty Four (54) Units Subcutaneous once a day. 12. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Humalog 100 unit/mL Cartridge Sig: as directed Units Subcutaneous four times a day: Please use according to sliding scale four times daily. Discharge Disposition: Extended Care Facility: [**Location (un) **] genesis healthcare Discharge Diagnosis: Primary: Right Lower Lobe Pneumonia Non ST Elevation Myocardial Infarction Delerium Acute blood loss anemia Acute on Chronic Systolic Congestive Heart Failure Discharge Condition: Good. The patient's VS are stable, and she is able to ambulate with assistance. Discharge Instructions: You had a pneumonia and a heart attack. A cardiac catheterization was done and we placed a bare metal stent in your left coronary artery. You had some weakness in your heart that caused some back up of fluid into your lungs. This was better after the catheterization but we continued to give you diuretics to remove the fluid. You had a lot of wheezes so you were started on prednisone. This medicine should be tapered off, not stopped suddenly. While you were here, we made the following changes to your medicines: 1. We decreased your Lisinopril dose to 2.5 mg daily 2. We increased you LANTUS dose to 54 Units daily 3. We INCREASED your LIPITOR dose to 80 mg daily 4. We DISCONTINUED your Nifedipine 5. We STARTED you on [**Location (un) **] to keep the stent open. Do not miss any [**Location (un) 4319**] or stop taking [**Location (un) 4532**] unless Dr. [**Last Name (STitle) 911**] tells you to. 6. We STARTED you on Aspirin: to take with the [**Last Name (STitle) **]. Do not stop taking or miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] unless Dr. [**Last Name (STitle) 911**] tells you to. 7. We STARTED you on Carvedilol to help your heart heal from the heart attack and lower your heart rate. 8. We STARTED you on Ipratropium and Albuterol nebulizations to helpt your breathing 9. We STARTED you on Nitroglycerine for your chest pain. 10. We DISCONTINUED your Ibuprofen, as your kidney function worsened during this admission. 11. We DISCONTINUED your Metformin in the setting of your acute renal failure. Please restart this when you Creatinine decreases less than 1.4. 12. We STARTED you on a Humalog insulin sliding scale until you can restart your Metformin. Please return to the ED or your health care provider if you experience shortness of breath, chest pain, confusion, increased fatigue, fevers, chills, or any other concerning symptoms. Please weigh yourself every morning, and call your doctor if your weight > 3 lbs in 1 day or 6 pounds in 3 days. Please adhere to a low Na (< 2 gm sodium/day) diet. . Please make an appt to see Dr. [**Last Name (STitle) 82847**] when you get out of the facility in [**Location 9583**]. Followup Instructions: Primary Care: Please follow up with your primary care physician within the next two weeks. [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 66039**] Cardiology: [**Last Name (NamePattern5) 7224**], NP (NP with Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**]) Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2162-7-8**] 2:30 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]

410,486,428,584,292,414,493,E939,401,250,280,272,V458

{'Subendocardial infarction, initial episode of care,Pneumonia, organism unspecified,Acute on chronic systolic heart failure,Acute kidney failure, unspecified,Drug-induced delirium,Chronic total occlusion of coronary artery,Asthma, unspecified type, unspecified,Benzodiazepine-based tranquilizers causing adverse effects in therapeutic use,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Iron deficiency anemia, unspecified,Other and unspecified hyperlipidemia,Aortocoronary bypass 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: NSTEMI at OSH PRESENT ILLNESS: The patient is a 83 yo woman with h/o CAD s/o CABG in [**2150**], Hyperlipidemia, DM2, and hypertension, who presented from OSH with NSTEMI. Per the patient and her family, the patient developed shortness of breath, a productive cough, and increasing pain in her left arm last Tuesday. She presented to [**Hospital3 **] ED, where she was found to have a right lower lobe infiltrate and was admitted for pneumonia. She was started on Ceftriaxone and Azithromycin, yet continued to spike daily fevers, so Vancomycin was added on [**6-5**]. She admitted to increasing PND, orthopnea, and ankle edema over the past 6 months, so cardiology was consulted given concern for underlying CHF given her history of CAD. She had a TTE on [**6-4**], which showed concentric LVH with mild anteroseptal hyokinesis and 2+ MR. MEDICAL HISTORY: CABG: [**2150**] in [**State 108**]. SV to LAD, SV to RM, SV to distal circumflex marginal, SV to posterior descending artery.Diabetes Mellitus Dyslipidemia Hypertension Iron Deficiency Anemia Arthritis MEDICATION ON ADMISSION: Ibuprofen 400 mg [**Hospital1 **] Lisinopril 20 mg daily Lantus 50 Units daily Lipitor 10 mg daily Metformin 500 mg [**Hospital1 **] Nifedical XR 30 mg daily ALLERGIES: All drug allergies previously recorded have been deleted PHYSICAL EXAM: VS: T 98.0, BP 135/66, HR 96, RR 34, O2 sat 99% on NRB GENERAL: Elderly woman, pleasant, gregarious, in obvious respiratory distress. HEENT: PERRL, EOMI. Oropharynx clear and without exudate. Conjunctival pallor. No xanthalesma. NECK: Supple with JVP of 10 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. 2/6 systolic murmur. LUNGS: Poor inspiratory effort. Diffuse crackles, rhonchi, and expiratory wheezes. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ FAMILY HISTORY: The patient's son also had CAD s/p CABG. Her mother had DM2. SOCIAL HISTORY: The patient currently lives by herself in [**Hospital1 487**], MA. Her son lives in the same apartment complex, and she has VNA to help with ADLs. - Tobacco history: She smoked for 20 years but quit 30 years ago ### Response: {'Subendocardial infarction, initial episode of care,Pneumonia, organism unspecified,Acute on chronic systolic heart failure,Acute kidney failure, unspecified,Drug-induced delirium,Chronic total occlusion of coronary artery,Asthma, unspecified type, unspecified,Benzodiazepine-based tranquilizers causing adverse effects in therapeutic use,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Iron deficiency anemia, unspecified,Other and unspecified hyperlipidemia,Aortocoronary bypass status'}

CHIEF COMPLAINT: nausea, vomiting PRESENT ILLNESS: 64 y/o Male with PMHx sig for Chronic diarrhea w/ hypoalbuminemia, h/o CVA, Hep B, Lymphoma, IDDM, HTN, recent hospitalization in [**Month (only) **] for pulmonary embolism w/ DVT who p/w 2 days of nausea, vomiting, diarrhea. MEDICAL HISTORY: 1. Acute left PICA territorial infarct involving the inferior aspect of the left cerebellar hemisphere, with thrombosis of the distal basilar artery [**2193-5-3**] 2. Reactivation Hepatitis B, on entecavir 3. Complex atheroma in descending aorta seen on TEE in [**2-11**]. 4. Left-to-right shunt across a small secundum atrial septal defect seen on TEE in [**2-11**]. 5. Central retinal artery occlusion in right eye - [**10-10**] likely an embolic event. 6. Lymphoma - lymphoplasmacytoid lymphoma; treated with fludaribine, five cycles in [**2187**]. Since then has been seen by Dr. [**Last Name (STitle) 410**] and has not required further therapy. 7. Insulin Dependent Diabetes - has had for many years. Treated with humalog-lente combination 16 u AM, 22 u PM. Has had multiple DM complications including left eye retinopathy, gastroparesis, peripheral neuropathy complicated by several bouts of LE cellulitis. Creatinine at baseline is 0.8-1.0 8. Low albumin - Unclear etiology, has ranged from 1.9-3.5 over last several years. Question of possible nephrotic syndrome; may be related to diabetes but unclear. 9. [**Name2 (NI) 167**] acoustic schwanoma - treated with gamma knife radiation. 10. Gastritis, duodenitis: significant UGI bleed after received lytics for recent embolic CVA [**97**]. Peripheral vascular disease status post right below knee amputation [**2-11**]. 12. Hypertension 13. Anemia that is a combination of iron deficiency and anemia of chronic inflammation. 14. Chronic malnutrition and 2 months of diarrhea, on TPN, multiple GI ulcers, no lymphoma seen on biopsies, but still undergoing work-up. 15. B12 deficiency on IM replacement 16. Depression MEDICATION ON ADMISSION: Lactinex 1 tab [**Hospital1 **] Anusol cream Vit C 500 mg ASA 81 daily Questran 0.4 mg [**Hospital1 **] Colchicine 0.6 daily Lomotil 2tabs daily Entecavir 0.5 mg daily Ferrous sulphate Regular insulin SS Prevacid 30 mg [**Hospital1 **] Remeron 30 mg QHS Vancomycin 1 gm IV daily (completed on [**2193-6-30**]) Coumadin 2 mg daily Zinc oxide Octreotide 100 mcg [**Hospital1 **] Infantis (Lactic acid prod org) Prednisone 5mg daily Ritalin 5 mg po 9am + 2pm Xenaderm daily to l heel Maalox Zofran PRN Simethicone ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Vitals: Temp 96.5, HR 108, BP 119/68, O2sat 95/3L NC Gen: appears confortable, AOx3 HEENT: Glossitis, PERLA, EOMI, MMM Neck: JVD not appreciable Skin: no cyanosis, rash, erythematous changes over knee joints Heart: ditant heart sounds, tachycardic, no murmurs appreciable Lungs: good bilat air movement, CTAB Abdomen: distended, tympanic w/ flank dullness, fluid thrill+, no hepatosplenomegaly appreciated, no caput medusae Ext: R BKA, 2+ pitting edema bilaterally upto knee, R>L GU: guaiac positive Neuro/Psych: mild right facial deviation, 3/5 strength in both UE/LE, mild tremors, mood appears normal . FAMILY HISTORY: Father died in [**2185**] after amputation for gangrene (unclear origin). Mother died [**2191**] unclear reason, had [**Name (NI) 11964**]. SOCIAL HISTORY: He is married with 2 children. Primary language is Russian. He has a remote 35 pack year smoking history. He drinks occasionally. He is a retired dentist.

Other pulmonary embolism and infarction,Bacteremia,Hemorrhage of gastrointestinal tract, unspecified,Acute kidney failure, unspecified,Disseminated candidiasis,Subendocardial infarction, initial episode of care,Acute posthemorrhagic anemia,Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta,Pneumonitis due to inhalation of food or vomitus,Congestive heart failure, unspecified,Abscess of lung,Hyperosmolality and/or hypernatremia,Unspecified protein-calorie malnutrition,Other suppurative peritonitis,Other specified intestinal malabsorption,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Personal history of other lymphatic and hematopoietic neoplasms,Hypotension, unspecified,Below knee amputation status

Pulm embol/infarct NEC,Bacteremia,Gastrointest hemorr NOS,Acute kidney failure NOS,Disseminated candidiasis,Subendo infarct, initial,Ac posthemorrhag anemia,Hpt B chrn wo cm wo dlta,Food/vomit pneumonitis,CHF NOS,Abscess of lung,Hyperosmolality,Protein-cal malnutr NOS,Suppurat peritonitis NEC,Intest malabsorption NEC,DMII neuro nt st uncntrl,Neuropathy in diabetes,Hx-lymphatic malign NEC,Hypotension NOS,Status amput below knee

Admission Date: [**2193-7-2**] Discharge Date: [**2193-7-26**] Date of Birth: [**2129-4-17**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 898**] Chief Complaint: nausea, vomiting Major Surgical or Invasive Procedure: Placement of PICC line Removal of PICC line History of Present Illness: 64 y/o Male with PMHx sig for Chronic diarrhea w/ hypoalbuminemia, h/o CVA, Hep B, Lymphoma, IDDM, HTN, recent hospitalization in [**Month (only) **] for pulmonary embolism w/ DVT who p/w 2 days of nausea, vomiting, diarrhea. Patient had a recent h/o left PICA infarct in [**2193-4-8**] after which he was started on anticoagulation. He then presented in [**2193-5-9**] with SOB and was found to have PE based on a high probability VQ scan w/ DVT within superficial femoral vein extending to common femoral origin. He was continued on anticoagulation and sent to [**Hospital1 **]. Patient then developed vomiting with nausea and continued intermittent diarrhea with cramping abdominal pain. He had [**12-10**] episode of vomiting in the weeks prior to admission with intermittent nausea which worsened 2 days prior to admission. There was no change in his frequency of diarrhea. Of note, the patient had been on TPN at [**Hospital1 **]. He did not have any hematemesis, [**Last Name (un) 15557**], hemactoschezia. He denied any chest pain, dizziness, shortness of breath, palpitations. He did have generalized weakness which he has had for several months now. He has a chronic history of diarrhea (likely some kind of protein losing enteropathy) with persistent hypoalbuminemia. Also he has small bowel enteroscopy which showed ersions in stomach/duodenum with ulcerations in jejunum and a mass in the distal bulb. Biopsy of the mass showed extensive gastric foveolar mucous cell metaplasia in duodenum but no evidence of lymphoma anywhere in the GI tract. In the ED, the patient was found to have a pulmonary embolism in the superior branch of the right main pulmonary artery. He also had trop elevation without significant EKG changes. He was given 325 mg Aspirin, started on a Heparin gtt and transferred to MICU. His vitals were stable on presentation to MICU. Past Medical History: 1. Acute left PICA territorial infarct involving the inferior aspect of the left cerebellar hemisphere, with thrombosis of the distal basilar artery [**2193-5-3**] 2. Reactivation Hepatitis B, on entecavir 3. Complex atheroma in descending aorta seen on TEE in [**2-11**]. 4. Left-to-right shunt across a small secundum atrial septal defect seen on TEE in [**2-11**]. 5. Central retinal artery occlusion in right eye - [**10-10**] likely an embolic event. 6. Lymphoma - lymphoplasmacytoid lymphoma; treated with fludaribine, five cycles in [**2187**]. Since then has been seen by Dr. [**Last Name (STitle) 410**] and has not required further therapy. 7. Insulin Dependent Diabetes - has had for many years. Treated with humalog-lente combination 16 u AM, 22 u PM. Has had multiple DM complications including left eye retinopathy, gastroparesis, peripheral neuropathy complicated by several bouts of LE cellulitis. Creatinine at baseline is 0.8-1.0 8. Low albumin - Unclear etiology, has ranged from 1.9-3.5 over last several years. Question of possible nephrotic syndrome; may be related to diabetes but unclear. 9. [**Name2 (NI) 167**] acoustic schwanoma - treated with gamma knife radiation. 10. Gastritis, duodenitis: significant UGI bleed after received lytics for recent embolic CVA [**97**]. Peripheral vascular disease status post right below knee amputation [**2-11**]. 12. Hypertension 13. Anemia that is a combination of iron deficiency and anemia of chronic inflammation. 14. Chronic malnutrition and 2 months of diarrhea, on TPN, multiple GI ulcers, no lymphoma seen on biopsies, but still undergoing work-up. 15. B12 deficiency on IM replacement 16. Depression Social History: He is married with 2 children. Primary language is Russian. He has a remote 35 pack year smoking history. He drinks occasionally. He is a retired dentist. Family History: Father died in [**2185**] after amputation for gangrene (unclear origin). Mother died [**2191**] unclear reason, had [**Name (NI) 11964**]. Physical Exam: Vitals: Temp 96.5, HR 108, BP 119/68, O2sat 95/3L NC Gen: appears confortable, AOx3 HEENT: Glossitis, PERLA, EOMI, MMM Neck: JVD not appreciable Skin: no cyanosis, rash, erythematous changes over knee joints Heart: ditant heart sounds, tachycardic, no murmurs appreciable Lungs: good bilat air movement, CTAB Abdomen: distended, tympanic w/ flank dullness, fluid thrill+, no hepatosplenomegaly appreciated, no caput medusae Ext: R BKA, 2+ pitting edema bilaterally upto knee, R>L GU: guaiac positive Neuro/Psych: mild right facial deviation, 3/5 strength in both UE/LE, mild tremors, mood appears normal . Pertinent Results: [**2193-7-1**] WBC-8.8 RBC-3.51* Hgb-10.1* Hct-30.1* MCV-86 MCH-28.8 MCHC-33.5 RDW-15.6* Plt Ct-252# Neuts-49.2* Bands-0 Lymphs-47.1* Monos-3.1 Eos-0.1 Baso-0.5 [**2193-7-2**] WBC-11.8* RBC-3.05* Hgb-8.8* Hct-25.7* MCV-84 MCH-28.8 MCHC-34.2 RDW-15.9* Plt Ct-258 Neuts-54 Bands-10* Lymphs-29 Monos-6 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1* [**2193-7-3**] 02:10AM BLOOD WBC-10.0 RBC-2.83* Hgb-8.1* Hct-24.1* MCV-85 MCH-28.7 MCHC-33.7 RDW-16.1* Plt Ct-238 Neuts-64 Bands-12* Lymphs-21 Monos-2 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 [**2193-7-4**] 01:38AM BLOOD WBC-9.0 RBC-2.30* Hgb-6.6* Hct-19.6* MCV-85 MCH-28.8 MCHC-33.8 RDW-15.8* Plt Ct-197 [**2193-7-4**] 04:37PM BLOOD WBC-16.7*# RBC-3.55*# Hgb-10.4*# Hct-29.5*# MCV-83 MCH-29.2 MCHC-35.1* RDW-15.6* Plt Ct-199 [**2193-7-5**] 03:45AM BLOOD WBC-11.0 RBC-3.47* Hgb-10.1* Hct-29.1* MCV-84 MCH-29.3 MCHC-34.8 RDW-15.7* Plt Ct-169 Neuts-66 Bands-8* Lymphs-21 Monos-4 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 [**2193-7-6**] 02:40AM BLOOD WBC-7.2 RBC-3.19* Hgb-9.4* Hct-26.6* MCV-84 MCH-29.6 MCHC-35.4* RDW-15.6* Plt Ct-135* [**2193-7-7**] 03:20AM BLOOD WBC-5.1 RBC-3.22* Hgb-9.3* Hct-27.3* MCV-85 MCH-28.8 MCHC-34.0 RDW-15.6* Plt Ct-136* [**2193-7-8**] 03:10AM BLOOD WBC-5.3 RBC-3.05* Hgb-8.7* Hct-25.9* MCV-85 MCH-28.6 MCHC-33.7 RDW-15.6* Plt Ct-139* [**2193-7-8**] 09:11PM BLOOD Hct-20* [**2193-7-9**] 05:00AM BLOOD WBC-8.0# RBC-3.33* Hgb-9.5* Hct-28.2*# MCV-85 MCH-28.4 MCHC-33.6 RDW-16.1* Plt Ct-146* [**2193-7-9**] 03:30PM BLOOD Hct-29.2* . [**2193-7-1**] 10:26PM BLOOD PT-12.8 PTT-27.7 INR(PT)-1.1 [**2193-7-7**] 03:20AM BLOOD PT-12.0 PTT-71.5* INR(PT)-1.0 [**2193-7-8**] 03:10AM BLOOD PT-12.5 PTT-67.5* INR(PT)-1.1 [**2193-7-9**] 05:00AM BLOOD PT-12.2 PTT-50.7* INR(PT)-1.0 . [**2193-7-1**] UreaN-62* Creat-0.7 Na-133 K-5.3* Cl-108 HCO3-19* AnGap-11 Albumin-1.4* Calcium-7.1* Phos-4.5 Mg-2.2 [**2193-7-9**] Glucose-109* UreaN-31* Creat-0.5 Na-139 K-4.0 Cl-111* HCO3-22 [**2193-7-2**] Glucose-109* UreaN-68* Creat-1.1 Na-135 K-5.7* Cl-110* HCO3-17* [**2193-7-4**] Glucose-125* UreaN-61* Creat-1.1 Na-136 K-4.6 Cl-109* HCO3-18* [**2193-7-9**] 05:00AM BLOOD Albumin-1.2* Calcium-7.8* Phos-2.9 Mg-1.9 . [**2193-7-1**] 02:15PM BLOOD ALT-20 AST-22 AlkPhos-172* Amylase-46 TotBili-0.1 [**2193-7-5**] 03:45AM BLOOD ALT-17 AST-24 LD(LDH)-327* AlkPhos-150* TotBili-0.2 [**2193-7-8**] 03:10AM BLOOD ALT-13 AST-18 LD(LDH)-210 AlkPhos-432* TotBili-0.2 [**2193-7-9**] 05:00AM BLOOD ALT-13 AST-16 LD(LDH)-221 AlkPhos-454* TotBili-0.2 . [**2193-7-1**] 02:15PM BLOOD CK-MB-11* MB Indx-33.3* cTropnT-0.15* [**2193-7-1**] 11:45PM BLOOD cTropnT-0.13* [**2193-7-2**] 06:45AM BLOOD CK-MB-11* MB Indx-23.9* cTropnT-0.17* [**2193-7-4**] 01:38AM BLOOD CK-MB-6 cTropnT-0.17* [**2193-7-4**] 04:37PM BLOOD CK-MB-NotDone cTropnT-0.12* . [**2193-7-2**] 06:45AM BLOOD Triglyc-125 HDL-22 CHOL/HD-4.9 LDLcalc-60 . [**2193-7-2**] 09:44PM BLOOD Type-ART Temp-37.0 FiO2-100 O2 Flow-15 pO2-27* pCO2-37 pH-7.32* calTCO2-20* Base XS--7 AADO2-666 REQ O2-100 Intubat-NOT INTUBA Comment-NEBULIZER . [**2193-7-1**] 02:25PM BLOOD Lactate-1.4 [**2193-7-4**] 11:17AM BLOOD Lactate-2.8* [**2193-7-5**] 12:20AM BLOOD Lactate-1.8 . KUB [**7-1**] SUPINE AND LATERAL ABDOMINAL RADIOGRAPHS: An NG tube is seen with the tip positioned in the stomach. Air can be seen within the stomach and colon, and scattered loops of small bowel, without any evidence of dilatation. The study is limited secondary to large body habitus; however, no definite free intraperitoneal air is identified. The soft tissue and osseous structures are stable. IMPRESSION: Air is seen within the stomach and colon, without definite evidence for small bowel obstruction. . [**7-1**] Abd/Pelvis CT: TECHNIQUE: MDCT acquired contiguous axial images were obtained from the lung bases to the pubic symphysis. Multiplanar reconstructions were obtained. CONTRAST: Oral contrast and 130 cc of IV Optiray contrast were administered due to the rapid rate of bolus injection required for this study. CT OF THE ABDOMEN WITH IV CONTRAST: Moderate-size bilateral pleural effusion, increased on the right, new on the left, is accompanied by a small pericardial effusion. Aside from associated relaxation atelectasis, the lungs are clear. A filling defect in the anterior branch of the right main pulmonary artery is a new, likely acute pulmonary embolus. A large amount of ascites and the nodular cirrhotic liver are unchanged. The portal vein is patent. The gallbladder, spleen, kidneys, adrenal glands, and atrophic pancreas are stable in appearance. The bowel is normal, without wall thickening or dilatation. No free intraperitoneal air is seen. Atherosclerotic calcification involves the aorta and its major branches. A stent has not migrated from the origin of the right common iliac artery. Scattered retroperitoneal and periaortic and aortocaval lymph nodes are not appreciably changed. CT OF THE PELVIS WITH IV CONTRAST: A large amount of free fluid is seen within the pelvis. Mild thickening of the sigmoid colon is stable. The bladder is normal. BONE WINDOWS: No suspicious lytic or sclerotic lesions are identified. There is spondylolysis of L5. CT RECONSTRUCTIONS: Multiplanar reconstructions were essential in delineating the anatomy and pathology. IMPRESSION: 1. Acute right upper lobe pulmonary embolus. 2. No bowel obstruction. 3. Increasing small to moderate pleural and small pericardial effusions probably due to cirrhosis and large volume of ascites. 4. Stable sigmoid colon wall edema or inflammation. . [**7-1**] CXR: Moderate sized pleural effusion with elevated hemidiaphragm and associated atelectasis. . [**7-2**] Bilateral Lower Extremity Ultrasound: BILATERAL LOWER EXTREMITY ULTRASOUND: Grayscale and Doppler son[**Name (NI) 867**] of the right and left common femoral, superficial femoral, and left popliteal vein was performed. There is occlusive thrombus, which is hypoechoic and expanding the right common femoral and superficial femoral vein throughout its course. On the left side, there is echogenic nonocclusive thrombus at the origin of the greater saphenous vein at this at the saphenofemoral junction. The left common femoral, superficial femoral, and popliteal veins are patent. IMPRESSION: 1. Occlusive thrombus, which appears acute, within the right common femoral and superficial femoral veins. 2. Nonocclusive thrombus at the origin of the left greater saphenous vein, at the saphenofemoral junction. . [**7-5**] CXR: 1. New right upper and right middle lobe consolidations, most probably aspiration and/or pneumonia. 2. Mild pulmonary edema, new. 3. Distended stomach. . [**7-19**] CT Chest 1) Necrotizing pneumonia in right upper lobe posteriorly with foci of gas and probable evolving abscess formation. 2) Moderate right pleural effusion, decreased in size from prior CT. 3) Marked ascites. 4) Resolution of left pleural effusion. 5) Persistent pericardial effusion. . [**7-20**] ECHO Conclusions: 1. The left atrium is mildly dilated. 2. The left ventricular cavity size is normal. Overall left ventricular systolic function is difficult to assess but is normal (LVEF>55%). 3. The aortic root is mildly dilated. 4. The aortic valve leaflets are mildly thickened. 5. The mitral valve leaflets are mildly thickened. 6. There is a small pericardial effusion. 7. No obvious vegetations are seen. 8. Compared with the prior study (images reviewed) of [**2193-7-2**], there is probably no significant change. . [**7-23**] IMPRESSION: AP chest compared to [**7-17**] through 13: Lung volumes remain low marked due to the markedly elevated diaphragm. Longstanding consolidation or atelectasis at the right lung apex and atelectasis at the right lung base are unchanged. Mild pulmonary edema has recurred. Heart size is normal. Mediastinal vascular engorgement is longstanding and stable. Tip of the right subclavian line projects over the junction of the right subclavian and jugular veins. No pneumothorax. Brief Hospital Course: 64 y/o Male with PMHx sig for Chronic diarrhea w/ hypoalbuminemia, recent h/o CVA, Hep B, Lymphoma, IDDM, HTN, recent hospitalization in [**Month (only) **] for pulmonary embolism w/ DVT who presented with 2 days of nausea and vomiting, found to have Pulmonary Embolism in Right main PA and troponin elevation likely in setting of PE. . Pulmonary Embolism: Mr. [**Known lastname 15558**] was at high risk for pulmonary embolism given his history of malignancy, prolonged immobilization, and recent PE w/ DVT. Although the patient was on Coumadin, his INR was subtherapeutic on admission. CT on admission shows PE in superior branch of R PA. He remained hemodynamically stable on presentation. He was placed on Heparin drip and coumadin was started on [**7-8**]. Bilateral lower extremity ultrasound showed DVT in right lower extremity. IVC filter was placed as pt had PE on anticoagulation. Coumadin and heparin were stopped and the patient was started on lovenox sc. He remained stable on this regimen and his INR trended down. . E coli bacteremia: The patient developed an elevated white count and fevers and blood cultures from [**7-3**] grew Escherichia coli. Possible sources include either spontaneous bacterial peritonitis vs a pulmonary source given an infiltrate seen in the RUL/RML (see below). Aspiration pneumonia was also considered. He was started on Cefepime on [**7-4**] and Flagyl on [**7-5**] (as concern for aspiration). Flagyl was stopped on [**7-6**] and Cefepime was changed to ceftriaxone. ID was consulted and the patient was restarted on vancomycin and cefepime. IV flagyl was also added for concern for aspiration as above. Patient also has ascites, thought possibly to have predisposed to SBP and subsequent E. Coli sepsis. Surveilance cutures since initial bacteremia have been negative for bacteria. Patient did not receive tap at that time [**1-10**] to anticoagulation. The patient was doing well and transferred from MICU to floor on [**7-11**]. . Fungemia: After being tranferred to the floor on [**7-11**]/2 blood cultures grew [**Female First Name (un) **] albicans in the setting of TPN, for which the patient was initially placed on Voriconazole, then ultimately fluconazole. His PICC line was d/c'd and tip cultures was negative, all subsequent cultures were negative and PICC line was replaced on [**7-16**]. A TTE was performed to r/o endocarditis and showed no vegtations. TEE was not pursued, instead antibiotics will be continued for a total of 4 weeks. Ophthalmology was consulted and found no evidence of fungal infection in the eyes. . Nosocomial PNA: A CXR revealed a necrotizing pneumonia with air fluid level in RUL confirmed by chest CT on [**7-19**]. He was seen by infectious disease and started on cefipime, vanco, flagyl, and was r/o'd for TB, by 3 negative AFB. Thoracic surgery evaluated him and felt there was not collection to be drained and recommended antibiotics and repeat imaging. . Hypotension: On the morning of transfer to the MICU, patient's SBP dropped to the 60s/40s. He did complain for some chest pain and SOB through the Russian interpreter and he was tachypeneic with ABG 7.51/23/71. He recieved 1 liter NS and appeared more comfortable, was mentating and BPs came up to 80's/50s and then denied CP or SOB. He was afebrile and satting 95-98% on 4.5 L NC. He was tranferred to the MICU for closer monitoring. On admission the patient had a lactate of 2.7 which decreased to 1.6 with volume resuscitation and ongoing abx. The etiology for the patient's hypotension was likely multifactorial including intrasvascular volume depletion given persistent hypoalbunemia and potential sepsis. The patient was noted to have a persistenly elevated white count despite broad spectrum antibiotics. C. Diff has been negative. Sputum cultures are AFB negative x 3. The patient's Hct decreased from 29.6 to 24 in the setting of volume resuscitation without evidence of acute bleeding. The patient was transfused 2U PRBCs to help oncotic pressure given decreased albumin. He reponded to the PRBC well and remained normo to hypertensive for the remainder of his hospitalization. He was transferred back to the floor prior to discharge. . # CVS: ** CAD: The patient has high risk for CAD, now with elevated Troponins and Ck-MB fraction. No EKG changes. The elevated troponin was likely in the setting of acute PE, due to demand. He was continued on medical management with ASA, restarted on Lipitor. His beta blocker was held after an episode of hypotension which sent him to the MICU. The beta blocker may be restarted once medically stable. . ** Rhythm: sinus Tachycardia, likely from PE . ** Pump: ECHO from [**2-11**] shows EF of 55%, mild sym LVH, no WMA. he seems intravscularly dry. SBP around high 90s. had SBP in 70s. was treated with fluid boluses. SBP responded and remained stable. . ** HTN: based on previous records, but not on any antihypertensives as outpatient, on [**Hospital1 **] metoprolol. BP normal and stable . # GI Bleed: The patient's MICU course was complicated by a GI bleed in the setting of Heparin gtt. The GI bleed resolved, although patient continues to be guaiac positive. likely chronic from stomach/duodenal erosion w/ jejunal ulceration, especially in the setting of anticoagulation. Grossly positive stools early in his hospitalization, but now guaiac positive brown stools. GI was consulted, but given the risks of EGD/colonoscopy in the setting of ulcerations and anticoagulation the decision was made to hold off on this for now. There was a thought to give him IVIg for the ulcerative jejunoileitis but was not given due to lack of enough evidence that it would benefit. The patient's hematocrit trends down slowly and will need to be followed closely. . Anemia: Anemia of chronic disease worsened by GIB. Patient received transfusions to maintain Hematocrit > 28. GI was consulted as above. . Chronic Diarrhea: Consulted GI, but still unclear as to the cause of this. TPN was continued. Albumin was monitored. Stool studies were sent and were negative. Stool negative for C.Diff toxin. TPN was altered to include branched chain amino acids. . Recent h/o line sepsis: Staph epi from [**6-15**] in [**12-10**] sets at [**Hospital1 **]. repeat Blood Cx from [**6-22**] w/ 1 set showing staph. Was started on IV Vanco 1 gm until [**7-1**]. PICC line changed from L to R arm on [**6-27**]. E. Coli bacteremia as above, but no further cultures growing staph. He was on ceftriaxone for a week and then stopped. was started on IV vanc and cefepime after the CT chest [**Last Name (un) **] developing abscess, as above. . ARF: Patient with Creatinine elevated to 1.1 over baseline. It was felt that patient was pre-renal and he was given IVF as needed. Creatinine improved to 0.6. Remained stable. . DM: RISS, tight glycemic control . Gout: Continued Colchicine . Hep B: Continued Entecavir . FEN: Nutrition was consulted for TPN recommendations which was continued during hospitalization. Patient was also taking small amount of PO food. He was evaluated by speech and swallow who felt that the patient was able to take soft solids with thickened liquids. Medications on Admission: Lactinex 1 tab [**Hospital1 **] Anusol cream Vit C 500 mg ASA 81 daily Questran 0.4 mg [**Hospital1 **] Colchicine 0.6 daily Lomotil 2tabs daily Entecavir 0.5 mg daily Ferrous sulphate Regular insulin SS Prevacid 30 mg [**Hospital1 **] Remeron 30 mg QHS Vancomycin 1 gm IV daily (completed on [**2193-6-30**]) Coumadin 2 mg daily Zinc oxide Octreotide 100 mcg [**Hospital1 **] Infantis (Lactic acid prod org) Prednisone 5mg daily Ritalin 5 mg po 9am + 2pm Xenaderm daily to l heel Maalox Zofran PRN Simethicone Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal [**Hospital1 **] (2 times a day). 3. Cholestyramine-Sucrose 4 g Packet Sig: One (1) Packet PO BID (2 times a day). 4. Entecavir 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Octreotide Acetate 100 mcg/mL Solution Sig: One (1) 100mcg Injection Q8H (every 8 hours). 7. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 8. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)). 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 11. Haloperidol 1-2 mg IV HS:PRN agitation 12. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 13. Morphine Sulfate 1-2 mg IV Q3-4H:PRN pain 14. Insulin Regular Human 100 unit/mL Solution Sig: One (1) per sliding scale Injection ASDIR (AS DIRECTED). 15. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed. 16. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 17. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed). 18. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for abdominal cramps. 19. Enoxaparin 80 mg/0.8 mL Syringe Sig: Eighty (80) mg Subcutaneous Q12H (every 12 hours). 20. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 21. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane QID (4 times a day) as needed. 22. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 23. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig: Five Hundred (500) mg Intravenous Q8H (every 8 hours) for 21 days. 24. Fluconazole in Normal Saline 400 mg/200 mL Piggyback Sig: Four Hundred (400) mg Intravenous Q24H (every 24 hours) for 21 days. 25. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 26. Cefepime 2 g Piggyback Sig: Two (2) grams Intravenous Q8H (every 8 hours) for 21 days. 27. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) g Intravenous Q 24H (Every 24 Hours) for 21 days. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary: pulmonary embolism deep venous thrombosis E.Coli bacteremia [**Female First Name (un) 564**] Albicans Fungemia Nosocomial pneumonia GI Bleed Acute renal failure Chronic diarrhea Secondary: PICA infarct Hepatitis B Lymphoma IDDM HTN Gastritis PVD Anemia Depression Discharge Condition: stable Discharge Instructions: Please take all the medications as prescribed. You have a fungus in your blood and a pneumonia which needs to be treated with antibiotics. You must complete the entire course of antibiotics. **You need to take 3 more weeks of Cefepime, Vancomycin, Flagyl, and Fluconazole. **You need to continue anticoagulation for the diagnosis of pulmonary embolism. Please keep all outpatient appointments as outlined below. Please call your primary care physician or return to the hospital if you experience chest pain, increasing shortness of breath, abdominal pain, fevers, numbness, weakness or other concerning symptoms. Followup Instructions: You have an appointment with Dr. [**Last Name (STitle) 8682**], [**Telephone/Fax (1) 133**], on [**Last Name (LF) 766**], [**7-29**]. Please be sure to follow up with infectious disease as an outpatient. You have an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**8-19**] at 9:30. She will help you to schedule a follow up CT chest at that time. Please follow the result of the anti-Tissue Transglutaminase Antibody, IgA test

415,790,578,584,112,410,285,070,507,428,513,276,263,567,579,250,357,V107,458,V497

{'Other pulmonary embolism and infarction,Bacteremia,Hemorrhage of gastrointestinal tract, unspecified,Acute kidney failure, unspecified,Disseminated candidiasis,Subendocardial infarction, initial episode of care,Acute posthemorrhagic anemia,Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta,Pneumonitis due to inhalation of food or vomitus,Congestive heart failure, unspecified,Abscess of lung,Hyperosmolality and/or hypernatremia,Unspecified protein-calorie malnutrition,Other suppurative peritonitis,Other specified intestinal malabsorption,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Personal history of other lymphatic and hematopoietic neoplasms,Hypotension, unspecified,Below knee amputation 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: nausea, vomiting PRESENT ILLNESS: 64 y/o Male with PMHx sig for Chronic diarrhea w/ hypoalbuminemia, h/o CVA, Hep B, Lymphoma, IDDM, HTN, recent hospitalization in [**Month (only) **] for pulmonary embolism w/ DVT who p/w 2 days of nausea, vomiting, diarrhea. MEDICAL HISTORY: 1. Acute left PICA territorial infarct involving the inferior aspect of the left cerebellar hemisphere, with thrombosis of the distal basilar artery [**2193-5-3**] 2. Reactivation Hepatitis B, on entecavir 3. Complex atheroma in descending aorta seen on TEE in [**2-11**]. 4. Left-to-right shunt across a small secundum atrial septal defect seen on TEE in [**2-11**]. 5. Central retinal artery occlusion in right eye - [**10-10**] likely an embolic event. 6. Lymphoma - lymphoplasmacytoid lymphoma; treated with fludaribine, five cycles in [**2187**]. Since then has been seen by Dr. [**Last Name (STitle) 410**] and has not required further therapy. 7. Insulin Dependent Diabetes - has had for many years. Treated with humalog-lente combination 16 u AM, 22 u PM. Has had multiple DM complications including left eye retinopathy, gastroparesis, peripheral neuropathy complicated by several bouts of LE cellulitis. Creatinine at baseline is 0.8-1.0 8. Low albumin - Unclear etiology, has ranged from 1.9-3.5 over last several years. Question of possible nephrotic syndrome; may be related to diabetes but unclear. 9. [**Name2 (NI) 167**] acoustic schwanoma - treated with gamma knife radiation. 10. Gastritis, duodenitis: significant UGI bleed after received lytics for recent embolic CVA [**97**]. Peripheral vascular disease status post right below knee amputation [**2-11**]. 12. Hypertension 13. Anemia that is a combination of iron deficiency and anemia of chronic inflammation. 14. Chronic malnutrition and 2 months of diarrhea, on TPN, multiple GI ulcers, no lymphoma seen on biopsies, but still undergoing work-up. 15. B12 deficiency on IM replacement 16. Depression MEDICATION ON ADMISSION: Lactinex 1 tab [**Hospital1 **] Anusol cream Vit C 500 mg ASA 81 daily Questran 0.4 mg [**Hospital1 **] Colchicine 0.6 daily Lomotil 2tabs daily Entecavir 0.5 mg daily Ferrous sulphate Regular insulin SS Prevacid 30 mg [**Hospital1 **] Remeron 30 mg QHS Vancomycin 1 gm IV daily (completed on [**2193-6-30**]) Coumadin 2 mg daily Zinc oxide Octreotide 100 mcg [**Hospital1 **] Infantis (Lactic acid prod org) Prednisone 5mg daily Ritalin 5 mg po 9am + 2pm Xenaderm daily to l heel Maalox Zofran PRN Simethicone ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Vitals: Temp 96.5, HR 108, BP 119/68, O2sat 95/3L NC Gen: appears confortable, AOx3 HEENT: Glossitis, PERLA, EOMI, MMM Neck: JVD not appreciable Skin: no cyanosis, rash, erythematous changes over knee joints Heart: ditant heart sounds, tachycardic, no murmurs appreciable Lungs: good bilat air movement, CTAB Abdomen: distended, tympanic w/ flank dullness, fluid thrill+, no hepatosplenomegaly appreciated, no caput medusae Ext: R BKA, 2+ pitting edema bilaterally upto knee, R>L GU: guaiac positive Neuro/Psych: mild right facial deviation, 3/5 strength in both UE/LE, mild tremors, mood appears normal . FAMILY HISTORY: Father died in [**2185**] after amputation for gangrene (unclear origin). Mother died [**2191**] unclear reason, had [**Name (NI) 11964**]. SOCIAL HISTORY: He is married with 2 children. Primary language is Russian. He has a remote 35 pack year smoking history. He drinks occasionally. He is a retired dentist. ### Response: {'Other pulmonary embolism and infarction,Bacteremia,Hemorrhage of gastrointestinal tract, unspecified,Acute kidney failure, unspecified,Disseminated candidiasis,Subendocardial infarction, initial episode of care,Acute posthemorrhagic anemia,Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta,Pneumonitis due to inhalation of food or vomitus,Congestive heart failure, unspecified,Abscess of lung,Hyperosmolality and/or hypernatremia,Unspecified protein-calorie malnutrition,Other suppurative peritonitis,Other specified intestinal malabsorption,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Personal history of other lymphatic and hematopoietic neoplasms,Hypotension, unspecified,Below knee amputation status'}

CHIEF COMPLAINT: PRESENT ILLNESS: This is a 51-year-old male patient with insulin dependent-diabetes mellitus. He is status post an inferior wall myocardial infarction in [**2162**], which was treated with thrombolytics as well as an angioplasty and a stent to the right coronary artery. He has had subsequent instent restenosis in [**2165**] and a subsequent angioplasty in [**2168**] for unstable angina. Routine stress test in [**Month (only) 956**] of this year was positive and the patient was referred for cardiac catheterization. This revealed left ventricular ejection fraction of 40%, left ventricular end diastolic pressure of 23, a 50% left main occlusion, as well as three-vessel coronary artery disease. Patient was referred for coronary artery bypass graft. MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. 3. Insulin dependent-diabetes mellitus. 4. Status post appendectomy. 5. Status post eye surgery. 6. Multiple angioplasties with stents as previously mentioned in history of present illness. 7. He has also advanced diabetic neuropathy. 8. Sleep apnea, and has been advised to use a CPAP mask at home, but does not use it on a regular basis. MEDICATION ON ADMISSION: ALLERGIES: PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

Coronary atherosclerosis of native coronary artery,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Pure hypercholesterolemia,Polyneuropathy in diabetes,Background diabetic retinopathy,Other and unspecified angina pectoris

Crnry athrscl natve vssl,DMII neuro nt st uncntrl,Hypertension NOS,Pure hypercholesterolem,Neuropathy in diabetes,Diabetic retinopathy NOS,Angina pectoris NEC/NOS

Admission Date: [**2172-3-5**] Discharge Date: [**2172-3-10**] Date of Birth: [**2120-11-28**] Sex: M Service: HISTORY OF PRESENT ILLNESS: This is a 51-year-old male patient with insulin dependent-diabetes mellitus. He is status post an inferior wall myocardial infarction in [**2162**], which was treated with thrombolytics as well as an angioplasty and a stent to the right coronary artery. He has had subsequent instent restenosis in [**2165**] and a subsequent angioplasty in [**2168**] for unstable angina. Routine stress test in [**Month (only) 956**] of this year was positive and the patient was referred for cardiac catheterization. This revealed left ventricular ejection fraction of 40%, left ventricular end diastolic pressure of 23, a 50% left main occlusion, as well as three-vessel coronary artery disease. Patient was referred for coronary artery bypass graft. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. 3. Insulin dependent-diabetes mellitus. 4. Status post appendectomy. 5. Status post eye surgery. 6. Multiple angioplasties with stents as previously mentioned in history of present illness. 7. He has also advanced diabetic neuropathy. 8. Sleep apnea, and has been advised to use a CPAP mask at home, but does not use it on a regular basis. PREOPERATIVE MEDICATIONS: 1. NovoLog insulin 70/30, 80 units in the morning and 50 units before dinner. 2. Aspirin 325 p.o. q.d. 3. Plavix 75 p.o. q.d. 4. Lopressor 75 mg p.o. b.i.d. 5. Lasix 40 mg p.o. q.d. 6. Folate 2 mg p.o. q.d. 7. Crestor 10 mg p.o. q.d. 8. Neurontin 600 mg p.o. b.i.d. 9. Diovan 320 mg p.o. q.d. 10. Vitamin C b.i.d. 11. Multivitamins once a day. 12. The patient was previously on antibiotics for an upper respiratory admission in [**Month (only) 956**] of this year. PHYSICAL EXAMINATION UPON ADMISSION TO THE HOSPITAL: Unremarkable. Patient was a same-day admission on [**2171-3-5**], and was taken to the operating room at that time with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**], where the patient underwent a coronary artery bypass graft x4 with a LIMA to the LAD, saphenous vein to the PDA, saphenous vein to OM-1, and saphenous vein to D1. Postoperatively, patient was phenylephrine and milrinone IV drips and was transported in stable condition from the operating room to the Cardiac Surgery Recovery room. By postoperative day one, the patient was weaned off his vasoactive drips. Was hemodynamically stable. Was in normal sinus rhythm and had been weaned from mechanical ventilation and extubated, and was beginning to progress with cardiac rehabilitation and physical therapy, and the patient was transferred to the telemetry floor on postoperative day one. On postoperative day two, the patient was begun with Physical Therapy and cardiac rehab, and began ambulation. Remained hemodynamically stable in normal sinus rhythm. [**Last Name (un) **] service was consulted to assist with diabetes management, and increasing his insulin doses according to his needs. Patient continued to progress over the next couple of days from a physical therapy standpoint. On postoperative day four, the patient was a little bit lightheaded with ambulation and although he did not drop his blood pressures significantly, he was a little unsteady on his feet. The Physical Therapy service did re-evaluate his ability to ambulate independently today. On postoperative day five, the patient states he feels much better and is anxious to go home. No longer complains of dizziness or lightheadedness and is able to climb the stairs asymptomatically. Patient's chest tubes had been discontinued on postoperative day two, and his epicardial pacing wires have also been discontinued. Patient remains hemodynamically stable and is ready to be discharged to home today on postoperative day five. PHYSICAL EXAMINATION: Neurologically: The patient is grossly intact with no apparent neurologic deficits. His lungs are clear to auscultation bilaterally, although has slightly decreased breath sounds in bilateral bases. Cardiac examination is regular rate and rhythm. Abdomen is soft, obese, and nontender. His sternum is stable with Steri-Strips intact. There is no erythema or drainage, and his leg incision is also clean and intact. DISCHARGE MEDICATIONS: 1. NovoLog 70/30 insulin 80 units q.a.m. and 50 units before dinner. 2. Aspirin 325 mg p.o. q.d. 3. Colace 100 mg p.o. b.i.d. 4. Ranitidine 150 mg p.o. b.i.d. 5. Metoprolol 75 mg p.o. b.i.d. 6. Lasix 40 mg p.o. q.12h. for one week. 7. Potassium chloride 20 mEq p.o. b.i.d. x1 week as well. 8. Crestor 10 mg p.o. q.d. 9. Neurontin 300 mg p.o. b.i.d. 10. The patient is to resume his vitamins as he was taking preoperatively. FOLLOW-UP INSTRUCTIONS: Patient is to followup with his primary cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Known lastname **] in [**1-28**] weeks. He is to followup with his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 6700**] in [**12-27**] weeks regarding his diabetes management, and the patient is to followup with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] in [**4-30**] weeks upon discharge from the hospital today. DISCHARGE CONDITION: Good. DISCHARGE DIAGNOSES: 1. Coronary artery disease status post coronary artery bypass graft. 2. Insulin dependent-diabetes mellitus. 3. Hypertension. 4. Hypercholesterolemia. 5. Sleep apnea. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Name8 (MD) 964**] MEDQUIST36 D: [**2172-3-10**] 10:19 T: [**2172-3-10**] 10:20 JOB#: [**Job Number 19343**] (cclist)

414,250,401,272,357,362,413

{'Coronary atherosclerosis of native coronary artery,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Pure hypercholesterolemia,Polyneuropathy in diabetes,Background diabetic retinopathy,Other and unspecified angina pectoris'}

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: This is a 51-year-old male patient with insulin dependent-diabetes mellitus. He is status post an inferior wall myocardial infarction in [**2162**], which was treated with thrombolytics as well as an angioplasty and a stent to the right coronary artery. He has had subsequent instent restenosis in [**2165**] and a subsequent angioplasty in [**2168**] for unstable angina. Routine stress test in [**Month (only) 956**] of this year was positive and the patient was referred for cardiac catheterization. This revealed left ventricular ejection fraction of 40%, left ventricular end diastolic pressure of 23, a 50% left main occlusion, as well as three-vessel coronary artery disease. Patient was referred for coronary artery bypass graft. MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. 3. Insulin dependent-diabetes mellitus. 4. Status post appendectomy. 5. Status post eye surgery. 6. Multiple angioplasties with stents as previously mentioned in history of present illness. 7. He has also advanced diabetic neuropathy. 8. Sleep apnea, and has been advised to use a CPAP mask at home, but does not use it on a regular basis. MEDICATION ON ADMISSION: ALLERGIES: PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: ### Response: {'Coronary atherosclerosis of native coronary artery,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Pure hypercholesterolemia,Polyneuropathy in diabetes,Background diabetic retinopathy,Other and unspecified angina pectoris'}

CHIEF COMPLAINT: Mental status changes PRESENT ILLNESS: 69 year old female with h/o metastatic melanoma originating on the right arm with mets to the lung was with her family for [**Holiday **] and she had a headache. She went to bed and woke up confused and her husband reported that she became unconscious. The family was able to catch her and help her to the ground so she did not hit her head. She was shaking on her right side, had loud respirations, and was intubated when EMS arrived. She went to the OSH where a CT scan revealed 2 brain lesions. She was given Ativan for presumed seizure and was loaded with 1 gram of phosphenytoin. She was also given 8 mg of decadron. She was then transferred to [**Hospital1 18**]. For transport she was on fentanyl and versed. Upon arrival to [**Hospital1 18**] she was started on propofol. Neurosurgery was consulted for the new brain lesions. The patient was seen this week by hem-onc for her melanoma and was waiting for tests to come back before possibly enrolling in a clinical trial. She had a brain MRI that was negative 2 months ago. MEDICAL HISTORY: metastatic melanoma - originated on right arm, now has lung mets MEDICATION ON ADMISSION: Simvastatin 20 mg each evening Lisinopril 10 mg daily Trimethoprim 100 mg - take [**1-26**] tablet QHS Paroxetine 20 mg daily Atenolol 50 mg daily Hydroxycholoquine 200 mg daily ALLERGIES: Phenytoin Sodium PHYSICAL EXAM: T:97.7 BP:155/73 HR:104 RR:16 O2Sats:100% vented Gen: Intubated, off sedation for exam. HEENT: Pupils: PERRL EOMs-unable to test Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Obese, Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Lethargic with brief eye opening. Does not follow FAMILY HISTORY: Noncontributory SOCIAL HISTORY: Lives in [**State 108**] with husband. Was in [**Location (un) 86**] for [**Holiday **].

Secondary malignant neoplasm of brain and spinal cord,Cerebral edema,Grand mal status,Secondary malignant neoplasm of lung,Personal history of malignant melanoma of skin,Coronary atherosclerosis of unspecified type of vessel, native or graft,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Lupus erythematosus,Old myocardial infarction,Polymyalgia rheumatica,Personal history of tobacco use

Sec mal neo brain/spine,Cerebral edema,Grand mal status,Secondary malig neo lung,Hx-malig skin melanoma,Cor ath unsp vsl ntv/gft,Hypertension NOS,Hyperlipidemia NEC/NOS,Lupus erythematosus,Old myocardial infarct,Polymyalgia rheumatica,History of tobacco use

Admission Date: [**2132-1-19**] Discharge Date: [**2132-1-21**] Date of Birth: [**2062-5-7**] Sex: F Service: NEUROSURGERY Allergies: Phenytoin Sodium Attending:[**First Name3 (LF) 1835**] Chief Complaint: Mental status changes Major Surgical or Invasive Procedure: None History of Present Illness: 69 year old female with h/o metastatic melanoma originating on the right arm with mets to the lung was with her family for [**Holiday **] and she had a headache. She went to bed and woke up confused and her husband reported that she became unconscious. The family was able to catch her and help her to the ground so she did not hit her head. She was shaking on her right side, had loud respirations, and was intubated when EMS arrived. She went to the OSH where a CT scan revealed 2 brain lesions. She was given Ativan for presumed seizure and was loaded with 1 gram of phosphenytoin. She was also given 8 mg of decadron. She was then transferred to [**Hospital1 18**]. For transport she was on fentanyl and versed. Upon arrival to [**Hospital1 18**] she was started on propofol. Neurosurgery was consulted for the new brain lesions. The patient was seen this week by hem-onc for her melanoma and was waiting for tests to come back before possibly enrolling in a clinical trial. She had a brain MRI that was negative 2 months ago. Past Medical History: metastatic melanoma - originated on right arm, now has lung mets Hypertension Hyperlipidemia Discoid lupus diagnosed 25 years ago based on a malar rash and a back rash, finger stiffness. Doesn't know [**Doctor First Name **] or dsDNA status. MI in [**2112**] with cardiac arrest, treated with TPA with full resolution, no residual damage per the patient. PMR 2-3 years ago, resolved with steroid course Social History: Lives in [**State 108**] with husband. Was in [**Location (un) 86**] for [**Holiday **]. Family History: Noncontributory Physical Exam: T:97.7 BP:155/73 HR:104 RR:16 O2Sats:100% vented Gen: Intubated, off sedation for exam. HEENT: Pupils: PERRL EOMs-unable to test Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Obese, Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Lethargic with brief eye opening. Does not follow commands. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 2 to 1 mm bilaterally. III, IV, VI: unable to test V-XII: unable to test Motor: Moves all 4 extremities to sternal rub. Localizes and is purposeful with both upper extremities. Briskly withdraws bilateral lower extremities. Sensation: unable to test Toes mute bilaterally Pertinent Results: [**2132-1-20**] 02:03AM BLOOD WBC-16.6* RBC-4.02* Hgb-11.6* Hct-34.4* MCV-85 MCH-28.9 MCHC-33.8 RDW-12.6 Plt Ct-248 [**2132-1-19**] 01:10AM BLOOD Neuts-94.9* Bands-0 Lymphs-3.3* Monos-1.6* Eos-0.1 Baso-0.2 [**2132-1-20**] 02:03AM BLOOD Glucose-162* UreaN-15 Creat-0.6 Na-139 K-4.4 Cl-108 HCO3-23 AnGap-12 [**2132-1-20**] 02:03AM BLOOD Calcium-8.0* Phos-3.2 Mg-1.9 [**2132-1-19**] 03:41AM BLOOD Phenyto-11.1 [**2132-1-19**] 05:38PM BLOOD Type-ART pO2-151* pCO2-40 pH-7.37 calTCO2-24 Base XS--1 Intubat-INTUBATED [**2132-1-19**] 05:38PM BLOOD Na-145 K-3.4* Imaging: MRI Head [**1-19**]: Wet Read: NPw SAT [**2132-1-19**] 3:20 PM Multiple lesions in the rbain- largest in the right parietal lobe with moderate surroudning edema. While most lesions are in the cerebral parenchyma, i is noted in the right superior colliculus and another one in the right cerebellar hemisphere. Leptomeningeal spread cannot be excluded- consider further work up. A tiny lesion is noted on the surface of left cerebellar hemisphere. (series 16, im 6) Wet Read Audit # 1 NPw SAT [**2132-1-19**] 3:18 PM Multiple lesions in the rbain- largest in the right parietal lobe with moderate surroudning edema. While most lesions are in the cerebral parenchyma, i is noted in the right superior colliculus and another one in the right cerebellar hemisphere. Leptomeningeal spread cannot be excluded Brief Hospital Course: Ms [**Known lastname 3321**] was admitted to the ICU started on Dilantin and Decadron. She underwent a MRI of her brain which showed multiple lesions in the right [**Last Name (un) **]- largest in the right parietal lobe with moderate surroudning edema. On hospital day one she was extubated and found to have a normal neurological exam. On hospital day two she was transfered to the surgical floor. Her case was discussed in the brain tumor conference on [**1-21**] it was decided that whole brain radiation would be the best treatment. She was transferred to the [**Hospital Ward Name **] where the planning session took place. She was discharged to home, with instructions to return on [**1-22**] to have radiation. Medications on Admission: Simvastatin 20 mg each evening Lisinopril 10 mg daily Trimethoprim 100 mg - take [**1-26**] tablet QHS Paroxetine 20 mg daily Atenolol 50 mg daily Hydroxycholoquine 200 mg daily Discharge Medications: 1. Trimethoprim 100 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 2. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for headache. 3. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO QPM (once a day (in the evening)). 5. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Atenolol 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*0* 9. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). Disp:*21 Tablet(s)* Refills:*0* 10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 11. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours. Disp:*25 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Brain masses presumed Metastatic Melanoma Discharge Condition: Neurologically Stable Discharge Instructions: ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. ?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**]. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: ??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**1-28**], at 11:30 am. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 5074**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your appointment, or require additional directions. ??????You will be having whole brain radiation to treat your brain masses on [**1-22**]. Please follow the instructions that were provided to you during your planning session. Completed by:[**2132-1-21**]

198,348,345,197,V108,414,401,272,695,412,725,V158

{'Secondary malignant neoplasm of brain and spinal cord,Cerebral edema,Grand mal status,Secondary malignant neoplasm of lung,Personal history of malignant melanoma of skin,Coronary atherosclerosis of unspecified type of vessel, native or graft,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Lupus erythematosus,Old myocardial infarction,Polymyalgia rheumatica,Personal history of tobacco use'}

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: Mental status changes PRESENT ILLNESS: 69 year old female with h/o metastatic melanoma originating on the right arm with mets to the lung was with her family for [**Holiday **] and she had a headache. She went to bed and woke up confused and her husband reported that she became unconscious. The family was able to catch her and help her to the ground so she did not hit her head. She was shaking on her right side, had loud respirations, and was intubated when EMS arrived. She went to the OSH where a CT scan revealed 2 brain lesions. She was given Ativan for presumed seizure and was loaded with 1 gram of phosphenytoin. She was also given 8 mg of decadron. She was then transferred to [**Hospital1 18**]. For transport she was on fentanyl and versed. Upon arrival to [**Hospital1 18**] she was started on propofol. Neurosurgery was consulted for the new brain lesions. The patient was seen this week by hem-onc for her melanoma and was waiting for tests to come back before possibly enrolling in a clinical trial. She had a brain MRI that was negative 2 months ago. MEDICAL HISTORY: metastatic melanoma - originated on right arm, now has lung mets MEDICATION ON ADMISSION: Simvastatin 20 mg each evening Lisinopril 10 mg daily Trimethoprim 100 mg - take [**1-26**] tablet QHS Paroxetine 20 mg daily Atenolol 50 mg daily Hydroxycholoquine 200 mg daily ALLERGIES: Phenytoin Sodium PHYSICAL EXAM: T:97.7 BP:155/73 HR:104 RR:16 O2Sats:100% vented Gen: Intubated, off sedation for exam. HEENT: Pupils: PERRL EOMs-unable to test Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Obese, Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Lethargic with brief eye opening. Does not follow FAMILY HISTORY: Noncontributory SOCIAL HISTORY: Lives in [**State 108**] with husband. Was in [**Location (un) 86**] for [**Holiday **]. ### Response: {'Secondary malignant neoplasm of brain and spinal cord,Cerebral edema,Grand mal status,Secondary malignant neoplasm of lung,Personal history of malignant melanoma of skin,Coronary atherosclerosis of unspecified type of vessel, native or graft,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Lupus erythematosus,Old myocardial infarction,Polymyalgia rheumatica,Personal history of tobacco use'}

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is a 39-year-old female with end-stage renal disease secondary to diabetes. She also has a history of hypertension, peripheral vascular disease, and hypothyroidism who presented with chest pain. MEDICAL HISTORY: (Her past medical history includes) 1. Type 1 diabetes with associated retinopathy and neuropathy. 2. Hypertension. 3. Peripheral vascular disease. 4. End-stage renal disease (hemodialysis dependent). Her hemodialysis schedule is on Monday, Wednesday, and Friday. 5. History of hypothyroidism. 6. Status post percutaneous transluminal coronary angioplasty of the bilateral lower extremities. 7. Status post amputation of her right foot. MEDICATION ON ADMISSION: (Her medications on admission included) 1. Plavix 75 mg by mouth once per day. 2. Atenolol 25 mg by mouth once per day. 3. NPH insulin 26 units subcutaneously in the morning with 16 units subcutaneously regular; in the evening 2 units subcutaneously of regular and 4 units subcutaneously of NPH. 4. Tums by mouth three times per day. 5. Epogen 13,000 units with each dialysis. 6. Iron. 7. Vitamin D. ALLERGIES: The patient has allergies to CLINDAMYCIN (which gives her diarrhea), LEVAQUIN (which gives her gastrointestinal upset), and ZEMPLAR (which gives her a rash). PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: The patient moved here from [**State 108**] and lives with her mother in [**Name (NI) 8**]. She does not smoke. She does not drink alcohol. She does not use intravenous drugs. She does ambulate with a cane.

Coronary atherosclerosis of native coronary artery,Intermediate coronary syndrome,Cellulitis and abscess of face,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Diabetes with renal manifestations, type I [juvenile type], not stated as uncontrolled,Unspecified protein-calorie malnutrition,Unspecified acquired hypothyroidism

Crnry athrscl natve vssl,Intermed coronary synd,Cellulitis of face,Hyp kid NOS w cr kid V,DMI renl nt st uncntrld,Protein-cal malnutr NOS,Hypothyroidism NOS

Admission Date: [**2140-11-5**] Discharge Date: [**2140-11-18**] Date of Birth: [**2101-3-21**] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 39-year-old female with end-stage renal disease secondary to diabetes. She also has a history of hypertension, peripheral vascular disease, and hypothyroidism who presented with chest pain. The patient felt chest pressure while walking and had associated shortness of breath and emesis. She did have relief with rest. On admission, she did also note that her blood sugars were running higher than normal. She did have a stress test five years ago as a possibility for transplant option which was normal. In the Emergency Department, the patient was given aspirin, ceftriaxone, Lopressor, and was chest pain free. PAST MEDICAL HISTORY: (Her past medical history includes) 1. Type 1 diabetes with associated retinopathy and neuropathy. 2. Hypertension. 3. Peripheral vascular disease. 4. End-stage renal disease (hemodialysis dependent). Her hemodialysis schedule is on Monday, Wednesday, and Friday. 5. History of hypothyroidism. 6. Status post percutaneous transluminal coronary angioplasty of the bilateral lower extremities. 7. Status post amputation of her right foot. SOCIAL HISTORY: The patient moved here from [**State 108**] and lives with her mother in [**Name (NI) 8**]. She does not smoke. She does not drink alcohol. She does not use intravenous drugs. She does ambulate with a cane. ALLERGIES: The patient has allergies to CLINDAMYCIN (which gives her diarrhea), LEVAQUIN (which gives her gastrointestinal upset), and ZEMPLAR (which gives her a rash). MEDICATIONS ON ADMISSION: (Her medications on admission included) 1. Plavix 75 mg by mouth once per day. 2. Atenolol 25 mg by mouth once per day. 3. NPH insulin 26 units subcutaneously in the morning with 16 units subcutaneously regular; in the evening 2 units subcutaneously of regular and 4 units subcutaneously of NPH. 4. Tums by mouth three times per day. 5. Epogen 13,000 units with each dialysis. 6. Iron. 7. Vitamin D. REVIEW OF SYSTEMS: The patient's review of systems was positive for diarrhea for four days. No hematochezia. No orthopnea. Positive for chest pain (as in History of Present Illness). Positive for a dry cough. PHYSICAL EXAMINATION ON PRESENTATION: The patient's physical examination revealed she was a pleasant female in no apparent distress; although she did look malnourished. The patient's vital signs revealed her temperature was 98.5 degrees Fahrenheit, her heart rate was 79, her blood pressure was 133/68, her respiratory rate was 16, and her oxygen saturation was 94% on room air. Head, eyes, ears, nose, and throat examination revealed multiple large cystic lesions on her face and under her chin that were confluent. There was no warmth, but there was positive pigmentation. The patient's pupils were equal and reactive. The oropharynx was clear. Her chest examination revealed the lungs were clear to auscultation bilaterally. Cardiovascular examination revealed a regular rate and rhythm. There was a 2/6 systolic murmur at the right upper sternal border. The abdomen was soft, nontender, and nondistended. There were positive bowel sounds. Extremity examination revealed no edema. Her right foot had a partial amputation. Her left foot had a dorsalis pedis pulse of 1+. She had good capillary refill on the right. Neurologic examination revealed her cranial nerves were intact. Her strength was grossly intact and symmetric. She did have decreased sensation in her lower extremities. PERTINENT LABORATORY VALUES ON PRESENTATION: The patient's laboratories on admission revealed her white blood cell count was 17.5, her hematocrit was 38.9%, and her platelet count was 344,000. The patient's sodium was 138, potassium was 3.8, chloride was 93, bicarbonate was 32, blood urea nitrogen was 23, creatinine was 6.3, and her blood glucose was 46. Her troponin was 0.3 and CK/MB was 2. PERTINENT RADIOLOGY/IMAGING: The patient's chest x-ray showed cardiomegaly with upper zone redistribution. No effusions or consolidations. The patient's electrocardiogram revealed 1-mm ST depressions in V4 through V6 and there were T wave inversions in leads I, V3, and V4 and minor changes. CONCISE SUMMARY OF HOSPITAL COURSE: The patient was admitted and eventually was sent for cardiac catheterization. The cardiac catheterization revealed an ejection fraction of 35% and 3-vessel disease (including 100% occlusion of the right, 80% left anterior descending artery, and 100% posterior descending artery). The patient was then referred to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for coronary artery bypass grafting. While awaiting surgery, the patient's Plavix was held and had no complications. On [**2140-11-10**] the patient underwent coronary artery bypass grafting times three with left internal mammary artery to left anterior descending artery, saphenous vein graft to the distal left anterior descending artery, and a saphenous vein graft to the posterior descending artery. The surgery was performed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] with Dr. [**Last Name (STitle) 3111**] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (PA-C) as assistants. The surgery was performed under general endotracheal anesthesia with a cardiopulmonary bypass time of 91 minutes and a cross-clamp time of 64 minutes. The patient tolerated the procedure well and was transferred to the Intensive Care Unit with two atrial and two ventricular pacing wires with one left pleural chest tube and dobutamine, Levophed, and propofol drips. The patient was in a normal sinus rhythm. Over the postoperative night, the patient was extubated without complications. She remained on her dobutamine drip, and the Levophed drip was weaned as tolerated. By postoperative day one, the patient was to have hemodialysis and her Plavix restarted. Following dialysis, her chest tubes were discontinued without incident. The patient's dobutamine was weaned off over this day. By postoperative day two, the patient was started back on her beta blocker. Throughout the early postoperative period (over the first two days postoperatively), the patient was on an insulin drip for tighter control of her blood sugars. On postoperative day five, the patient was finally off of her insulin drip and her blood sugars were maintained with NPH and sliding-scale. The patient continued during that time to receive regular hemodialysis at the bedside. On postoperative day six, the patient was transferred to the regular floor and was continued on vancomycin and gentamicin; especially for the lesions on her face. By postoperative day seven, the patient was switched to by mouth medications for the pustule lesions on her face; this medication was Keflex. She had her pacing wires discontinued without incident on this day, and the plan was for her to be discharged to rehabilitation the following day. On postoperative day eight, the patient was doing well. She did receive an additional course of hemodialysis on this day. It was felt that she was ready and stable to be discharged to rehabilitation for further continuation and recovery from her cardiac surgery. PHYSICAL EXAMINATION ON DISCHARGE: The patient's discharge examination revealed her vital signs to be stable with a temperature of 97.8 degrees Fahrenheit, her heart rate was 96, her blood pressure was 140/67, her respiratory rate was 20, and her oxygen saturation was 100% on room air. In general, the patient was alert and oriented times three. In no apparent distress. Cardiovascular examination revealed a regular rate and rhythm. Her wounds were clean, dry, and intact. The lungs were clear to auscultation bilaterally. Her abdomen was soft, nontender, and nondistended. The patient's legs revealed no clubbing, cyanosis, or edema. Her wounds were clean, dry, and intact. PERTINENT LABORATORY VALUES ON DISCHARGE: The patient's laboratories on discharge revealed her white blood cell count was 15,000. Her hematocrit was 29.3%, and her platelet count was 370,000. The patient's sodium was 132, potassium was 4.9, chloride was 94, bicarbonate was 28, blood urea nitrogen was 40, creatinine was 7, and her blood glucose was 113. PERTINENT RADIOLOGY/IMAGING ON DISCHARGE: A chest x-ray showed very small bilateral pleural effusions, but no signs of infiltrate. DISCHARGE DISPOSITION: The patient was to be discharged to rehabilitation today ([**11-18**]). CONDITION AT DISCHARGE: The patient's condition on discharge was good. MEDICATIONS ON DISCHARGE: (Discharge medications included) 1. Colace 100 mg by mouth twice per day. 2. Aspirin 325 mg by mouth once per day. 3. Percocet one to two tablets by mouth q.4h. as needed (for pain). 4. Atenolol 25 mg by mouth once per day. 5. Keflex 500 mg by mouth once per day (for 10 days). 6. Plavix 75 mg by mouth once per day. 7. Renagel 800 mg by mouth three times per day. 8. Protonix 40 mg by mouth once per day. 9. Multivitamin one tablet by mouth once per day. 10. Epogen 13,000 units subcutaneously with each hemodialysis. 11. Calcium carbonate antacid 500-mg tablets one tablet by mouth three times per day. 12. NPH insulin 26 units subcutaneously in the morning and NPH 6 units subcutaneously in the evening. 13. Humalog insulin sliding-scale which varies depending during the day. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was instructed to follow up with her primary care physician (Dr. [**Last Name (STitle) 3112**] in one to two weeks. 2. The patient was instructed to follow up with her cardiologist in two to three weeks. 3. The patient had several appointments; the first of which was on [**2140-12-8**] with a physician at the [**Name9 (PRE) **] Clinic at 4 p.m. 4. The patient was instructed to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in four weeks. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Dictator Info 3114**] MEDQUIST36 D: [**2140-11-18**] 11:03 T: [**2140-11-18**] 11:17 JOB#: [**Job Number 3115**]

414,411,682,403,250,263,244

{'Coronary atherosclerosis of native coronary artery,Intermediate coronary syndrome,Cellulitis and abscess of face,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Diabetes with renal manifestations, type I [juvenile type], not stated as uncontrolled,Unspecified protein-calorie malnutrition,Unspecified acquired hypothyroidism'}

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 39-year-old female with end-stage renal disease secondary to diabetes. She also has a history of hypertension, peripheral vascular disease, and hypothyroidism who presented with chest pain. MEDICAL HISTORY: (Her past medical history includes) 1. Type 1 diabetes with associated retinopathy and neuropathy. 2. Hypertension. 3. Peripheral vascular disease. 4. End-stage renal disease (hemodialysis dependent). Her hemodialysis schedule is on Monday, Wednesday, and Friday. 5. History of hypothyroidism. 6. Status post percutaneous transluminal coronary angioplasty of the bilateral lower extremities. 7. Status post amputation of her right foot. MEDICATION ON ADMISSION: (Her medications on admission included) 1. Plavix 75 mg by mouth once per day. 2. Atenolol 25 mg by mouth once per day. 3. NPH insulin 26 units subcutaneously in the morning with 16 units subcutaneously regular; in the evening 2 units subcutaneously of regular and 4 units subcutaneously of NPH. 4. Tums by mouth three times per day. 5. Epogen 13,000 units with each dialysis. 6. Iron. 7. Vitamin D. ALLERGIES: The patient has allergies to CLINDAMYCIN (which gives her diarrhea), LEVAQUIN (which gives her gastrointestinal upset), and ZEMPLAR (which gives her a rash). PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: The patient moved here from [**State 108**] and lives with her mother in [**Name (NI) 8**]. She does not smoke. She does not drink alcohol. She does not use intravenous drugs. She does ambulate with a cane. ### Response: {'Coronary atherosclerosis of native coronary artery,Intermediate coronary syndrome,Cellulitis and abscess of face,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Diabetes with renal manifestations, type I [juvenile type], not stated as uncontrolled,Unspecified protein-calorie malnutrition,Unspecified acquired hypothyroidism'}

CHIEF COMPLAINT: Transferred with small bowel obstruction and septic shock PRESENT ILLNESS: This 72-year-old woman was seen at the request of Dr. [**Last Name (STitle) 2696**] for abdominal pain and vomiting. The patient was evaluated at outside hospital and found to have a several-day history of abdominal pain and vomiting with a lactate of 7.7 and a marked left shift. She was transferred here for further management. She has had several abdominal procedures including an appendectomy, cholecystectomy, cesarean section and TAH-BSO, and had one prior small bowel obstruction that required a laparotomy. She had a recent admission for what was thought to be a large bowel obstruction with what was thought to be a transition point of the hepatic flexure. She resolved spontaneously and then had a colonoscopy, which showed some congested mucosa at the hepatic flexure and the proximal transverse colon and terminal ileum. Biopsies were negative, and the patient was discharged. CEA at that time was negative. She was thought perhaps to have a venous ischemia. Hypercoagulable workup was performed with a phospholipid antibody found. She then developed the above-mentioned syndrome with nausea, vomiting and acute weakness. She was transferred here and was agitated and in respiratory distress and was intubated. Her labs at the outside hospital showed a white blood cell count of 8000 with 53% bands, lactate of 7.7, creatinine of 2.5. MEDICAL HISTORY: Her past medical history is notable for diabetes, hypertension, hypothyroidism, gastroesophageal reflux, morbid obesity, hyperlipidemia, arthritis. MEDICATION ON ADMISSION: lisinopril 10, lopressor 25'', synthroid 100, NPH 6'', zantac 150'', lipitor 20, prilosec 20, metformin 500''', propoxyphene 65 prn, januvia i, ativan 1 prn ALLERGIES: Heparin Agents PHYSICAL EXAM: GENERAL: She is an overweight woman who is intubated. VITAL SIGNS: Temperature is 99 degrees, blood pressure is 100/60, on Levophed drip. Pulse rate of 99. NECK: The neck is somewhat plethoric. CHEST: Breath sounds are diminished on both sides. HEART: The heart rate is regular without murmurs or gallops. ABDOMEN: The abdomen is obese and there is no particular tenderness and the examination done before intubation did not show a great deal of tenderness but there was distention. EXTREMITIES: Extremities were somewhat pale. FAMILY HISTORY: Non-contributory SOCIAL HISTORY: Lives with spouse and son. The patient is a former smoker and drinks one drink per day.

Streptococcal septicemia,Septic shock,Volvulus,Other and unspecified coagulation defects,Pneumonia due to Klebsiella pneumoniae,Acute and subacute necrosis of liver,Pressure ulcer, buttock,Other pulmonary insufficiency, not elsewhere classified,Severe sepsis,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Esophageal reflux,Other and unspecified hyperlipidemia,Oliguria and anuria,Morbid obesity,Personal history of tobacco use,Foreign body in larynx,Candidiasis of skin and nails,Unspecified acquired hypothyroidism

Streptococcal septicemia,Septic shock,Volvulus of intestine,Coagulat defect NEC/NOS,K. pneumoniae pneumonia,Acute necrosis of liver,Pressure ulcer, buttock,Other pulmonary insuff,Severe sepsis,DMII wo cmp nt st uncntr,Hypertension NOS,Esophageal reflux,Hyperlipidemia NEC/NOS,Oliguria & anuria,Morbid obesity,History of tobacco use,Foreign body in larynx,Cutaneous candidiasis,Hypothyroidism NOS

Admission Date: [**2193-11-22**] Discharge Date: [**2193-12-11**] Date of Birth: [**2121-6-9**] Sex: F Service: SURGERY Allergies: Heparin Agents Attending:[**First Name3 (LF) 1481**] Chief Complaint: Transferred with small bowel obstruction and septic shock Major Surgical or Invasive Procedure: . Exploratory laparotomy. 2. Lysis of adhesions. 3. Decompression of the colon and small intestine. 4. PICC placement History of Present Illness: This 72-year-old woman was seen at the request of Dr. [**Last Name (STitle) 2696**] for abdominal pain and vomiting. The patient was evaluated at outside hospital and found to have a several-day history of abdominal pain and vomiting with a lactate of 7.7 and a marked left shift. She was transferred here for further management. She has had several abdominal procedures including an appendectomy, cholecystectomy, cesarean section and TAH-BSO, and had one prior small bowel obstruction that required a laparotomy. She had a recent admission for what was thought to be a large bowel obstruction with what was thought to be a transition point of the hepatic flexure. She resolved spontaneously and then had a colonoscopy, which showed some congested mucosa at the hepatic flexure and the proximal transverse colon and terminal ileum. Biopsies were negative, and the patient was discharged. CEA at that time was negative. She was thought perhaps to have a venous ischemia. Hypercoagulable workup was performed with a phospholipid antibody found. She then developed the above-mentioned syndrome with nausea, vomiting and acute weakness. She was transferred here and was agitated and in respiratory distress and was intubated. Her labs at the outside hospital showed a white blood cell count of 8000 with 53% bands, lactate of 7.7, creatinine of 2.5. Past Medical History: Her past medical history is notable for diabetes, hypertension, hypothyroidism, gastroesophageal reflux, morbid obesity, hyperlipidemia, arthritis. Social History: Lives with spouse and son. The patient is a former smoker and drinks one drink per day. Family History: Non-contributory Physical Exam: GENERAL: She is an overweight woman who is intubated. VITAL SIGNS: Temperature is 99 degrees, blood pressure is 100/60, on Levophed drip. Pulse rate of 99. NECK: The neck is somewhat plethoric. CHEST: Breath sounds are diminished on both sides. HEART: The heart rate is regular without murmurs or gallops. ABDOMEN: The abdomen is obese and there is no particular tenderness and the examination done before intubation did not show a great deal of tenderness but there was distention. EXTREMITIES: Extremities were somewhat pale. Pertinent Results: [**2193-11-22**] 07:45PM URINE HYALINE-[**2-12**]* [**2193-11-22**] 07:45PM URINE RBC-0-2 WBC-0-2 BACTERIA-MOD YEAST-NONE EPI-[**2-12**] RENAL EPI-0-2 [**2193-11-22**] 07:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-250 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2193-11-22**] 07:45PM URINE COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]-1.022 [**2193-11-22**] 07:45PM PLT COUNT-306 CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST IMPRESSION: 1. High grade large bowel obstruction with transition point at the proximal to mid transverse colon. No CT findings to suggest ischemic bowel. Findings may be secondary to adhesive disease, less likely cecal volvulus. 2. Segment VI hepatic lesion, likely represents a hemangioma. 3. Left lower lobe [**Last Name (LF) 26646**], [**First Name3 (LF) **] represent aspiration and/or atelectasis. Brief Hospital Course: The patient was admitted to the SICU upon transfer from the referring hospital. She was intubated and maintained on antibiotics. Given her clinical condition she was taken emergently to the operating room for exploratory laparotomy. Please see the operative report for details. Post-operatively she was transferred back to the SICU. The rest of her hospital course is outlined by systems below: Neuro: The patient was kept intubated and sedated postoperatively. The sedation was weaned on HD 8 and she slowly became alert. On discharge she was alert and oriented x3 Pulm: The patient remained intubated until POD #9. The ventilator was then slowly weaned and she was able to be extubated on POD#11. During her intubation she required bronchoscopy which revealed a mucus plug. She also required diuresis to improve her oxygenation. She was eventually weaned off oxygen and was saturating in the high 90's on RA upon discharge ID: The patient arrived to the hospital in septic shock. Her blood cultures eventually grew ENTEROCOCCUS FAECALIS and LACTOBACILLUS SPECIES and her sputum culture grew klebsiella and mold. She was started on antibiotics including vancomycin, Flagyl, fluconazole. Antibiotics were continued for a total of 14 days. On discharge she was afebrile with a normal white count. She was also given Xigris during her hospitalization for treatment of her sepsis. Heme: The patient was noted to have a low platelet count in the SICU. Heparin induced thrombocytopenia was diagnosed by labs. All heparin products were stopped and the patient was started on Arixtra for anticoagulation. The anticoagulation was stopped once the patient was out of bed. She was maintained on pneumoboots throughout her hospitalization. A PICC line was placed for antibiotics. GI: The patient remained NPO while in the SICU. A swallow evaluation was obtained and they recommended soft diet with no straws initially. On discharge she was tolerating a regular diet. While in the SICU she was maintained on tube feeds via and NG tube. The tube feeds were stopped once the patient was tolerating a regular diet. GU: The patient had a Foley catheter which was removed when she came out of the SICU. The catheter was replaced however because the patient was incontinent and it was thought this was worsening her decubitus ulcers. On discharge the patient was tolerating a regular diet, her pain was controlled on oral medications and she was voiding via a Foley catheter. She is being discharged to acute rehab in stable condition for further care. She will be sent with a Foley catheter. Medications on Admission: lisinopril 10, lopressor 25'', synthroid 100, NPH 6'', zantac 150'', lipitor 20, prilosec 20, metformin 500''', propoxyphene 65 prn, januvia i, ativan 1 prn Discharge Medications: 1. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-11**] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 2. Nystatin-Triamcinolone 100,000-0.1 unit/g-% Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 3. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation Q4H (every 4 hours) as needed. 4. Insulin NPH & Regular Human Subcutaneous 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. 10. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q6H (every 6 hours). 14. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Cecal Volvulous Sepsis Heparin induced thrombocytopenia Pressure ulcers Discharge Condition: Stable to rehab Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomitting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomitting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to amubulate several times per day. Incision Care: -Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] in [**12-11**] weeks. Please call ([**Telephone/Fax (1) 1483**] to schedule an appointment.

038,785,560,286,482,570,707,518,995,250,401,530,272,788,278,V158,933,112,244

{'Streptococcal septicemia,Septic shock,Volvulus,Other and unspecified coagulation defects,Pneumonia due to Klebsiella pneumoniae,Acute and subacute necrosis of liver,Pressure ulcer, buttock,Other pulmonary insufficiency, not elsewhere classified,Severe sepsis,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Esophageal reflux,Other and unspecified hyperlipidemia,Oliguria and anuria,Morbid obesity,Personal history of tobacco use,Foreign body in larynx,Candidiasis of skin and nails,Unspecified acquired hypothyroidism'}

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: Transferred with small bowel obstruction and septic shock PRESENT ILLNESS: This 72-year-old woman was seen at the request of Dr. [**Last Name (STitle) 2696**] for abdominal pain and vomiting. The patient was evaluated at outside hospital and found to have a several-day history of abdominal pain and vomiting with a lactate of 7.7 and a marked left shift. She was transferred here for further management. She has had several abdominal procedures including an appendectomy, cholecystectomy, cesarean section and TAH-BSO, and had one prior small bowel obstruction that required a laparotomy. She had a recent admission for what was thought to be a large bowel obstruction with what was thought to be a transition point of the hepatic flexure. She resolved spontaneously and then had a colonoscopy, which showed some congested mucosa at the hepatic flexure and the proximal transverse colon and terminal ileum. Biopsies were negative, and the patient was discharged. CEA at that time was negative. She was thought perhaps to have a venous ischemia. Hypercoagulable workup was performed with a phospholipid antibody found. She then developed the above-mentioned syndrome with nausea, vomiting and acute weakness. She was transferred here and was agitated and in respiratory distress and was intubated. Her labs at the outside hospital showed a white blood cell count of 8000 with 53% bands, lactate of 7.7, creatinine of 2.5. MEDICAL HISTORY: Her past medical history is notable for diabetes, hypertension, hypothyroidism, gastroesophageal reflux, morbid obesity, hyperlipidemia, arthritis. MEDICATION ON ADMISSION: lisinopril 10, lopressor 25'', synthroid 100, NPH 6'', zantac 150'', lipitor 20, prilosec 20, metformin 500''', propoxyphene 65 prn, januvia i, ativan 1 prn ALLERGIES: Heparin Agents PHYSICAL EXAM: GENERAL: She is an overweight woman who is intubated. VITAL SIGNS: Temperature is 99 degrees, blood pressure is 100/60, on Levophed drip. Pulse rate of 99. NECK: The neck is somewhat plethoric. CHEST: Breath sounds are diminished on both sides. HEART: The heart rate is regular without murmurs or gallops. ABDOMEN: The abdomen is obese and there is no particular tenderness and the examination done before intubation did not show a great deal of tenderness but there was distention. EXTREMITIES: Extremities were somewhat pale. FAMILY HISTORY: Non-contributory SOCIAL HISTORY: Lives with spouse and son. The patient is a former smoker and drinks one drink per day. ### Response: {'Streptococcal septicemia,Septic shock,Volvulus,Other and unspecified coagulation defects,Pneumonia due to Klebsiella pneumoniae,Acute and subacute necrosis of liver,Pressure ulcer, buttock,Other pulmonary insufficiency, not elsewhere classified,Severe sepsis,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Esophageal reflux,Other and unspecified hyperlipidemia,Oliguria and anuria,Morbid obesity,Personal history of tobacco use,Foreign body in larynx,Candidiasis of skin and nails,Unspecified acquired hypothyroidism'}

CHIEF COMPLAINT: Altered Mental Status PRESENT ILLNESS: Mr. [**Known lastname **] is a 62 year old male with a h/o bipolar disorder, and recent need for a hip replacement who initially presented to his PCP for [**Name9 (PRE) **] evaluation and altered mental status. Per his wife one week prior to admission he was falling/syncopizing at home and was also experiencing a fine tremor. Per his wife when he had these episodes she saw him just fall with no prodrome, and hit his head on one occasion with a brief loss of consciousness. His family also noted that he was having difficulty with confusion over the past 2-3 months, with worsening short term memory. His wife also noted a shuffling gait, resting tremor and recently was found pouring milk into soup on the stove and kept pouring until the milk overflowed. With these symptoms his wife brought him to his PCP for evaluation, at that appointment he was noted to be confused, hypotensive to the 70's, not oriented to the day and then had a syncopal episode so his PCP referred him to the ER for evaluation of his altered mental status and for further work up prior to his hip replacement. In the ER at the OSH his vital signs had stabilized, his he said that he remembered falling but otherwise felt well. Denied any chest pain, palpitations, shortness of breath, orthopnea, PND, abdominal pain, vomiting or diarrhea. He was then admitted to [**Hospital3 417**] for a syncope work up. . During his hospital stay he was seen by neurology and cardiology for further evaluation of his syncope and mental status changes. He was seen by psychiatry, neurology and cardiology in consultation. Given the report of hs shuffling gait, and cognitive decline there was concern about early Parkinson's though he had no cogwheeling or rigidity on exam. For further evaluation it was felt that he should undergo an MRI/MRA of his head, prior to these studies he received ativan for sedation. The ativan caused a paradoxical reaction and he became extremely agitated. At that time he was given large amounts of haldol, a total of 17mg and required 4 point leather restraints and an eventual transfer to the ICU. In the ICU after receiving the large amounts of sedating medications he became apneic and was intubated. He had an EEG which showed diffuse slowing, there was also concern for a possible neuroleptic malignant syndrome vs. serotonin syndrome given his rigidity so he was given 1 dose of dantrolene, there was also concern about OSA and the need for CPAP, however they had difficulty weaning sedation. On the day of transfer he became febrile, in the setting of his AMS there was concern about possible meningitis vs. encephalitis so an LP was done. The LP showed 1WBC (100%lymphs), 1RBC, glucose of 76, protein of 99, Gram stain and culture pending at the time of transfer. With his multiple problems and difficulty weaning sedation he was transferred to [**Hospital1 18**] for further management. . On the floor, his initial VS were: 101.6, 72, 147/63, 20, 97% on CMV 500x14, PEEP of 5, 40% FiO2. MEDICAL HISTORY: Hypertension Hyperlipidemia Bipolar Disorder SVT Osteoarthritis MEDICATION ON ADMISSION: Home Medications: Toprol XL 50mg daily Terazosin 5mg daily Klor-Con 20meq daily Zocor 40mg QHS Wellbutrin 450mg daily Cymbalta 60mg daily Lamictal 100mg [**Hospital1 **] Percocet prn . Medications on Transfer: Acyclovir 400mg IV Q8H Fentanyl gtt Midazolam gtt Propofol gtt Lamotrigine 100mg [**Hospital1 **] Lisinopril 5mg daily Cyanocobalamin 1000mcg daily Folic Acid 1mg daily Heparin SQ 5000units TID Metoprolol Tartrate 5mg IV Q6h Pantoprazole 40mg IV daily Acetaminophen 650mg Q4h prn Maalox 30ml q4h prn Docusate 100mg [**Hospital1 **] prn Magnesium Hydroxide 10ml QHS prn Diphenhydramine 25mg IM q4h prn Fentanyl 25mcg Q2h prn ALLERGIES: Ativan PHYSICAL EXAM: Admission: Gen: intubated, sedated, opens eyes to voice, follows commands HEENT: PERRLA 2mm->1mm CV: nl S1/S2, no m/r/g, RRR Chest: anterior vent sounds with rhonchi Abd: soft, NT/ND, BS+, no grimace to deep palpation Ext: 1+ upper ext edema L>R, no leg edema Skin: erythematous macular rash on back diffusely, small petechhiae appearing lesions on legs Neuro: PERRLA, moves all extremities spontaneously, withdraws to deep pain, no increased tone or cogwheel rigidity FAMILY HISTORY: Father with dementia at age [**Age over 90 **] Mother with dementia at age [**Age over 90 **] SOCIAL HISTORY: Lives with his wife, have a 30 y/o special needs daughter at home. He used to work as a firefighter. - Tobacco: denies - Alcohol: drinks one drink per day - Illicits: denies

Ventilator associated pneumonia,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Hyperosmolality and/or hypernatremia,Encephalopathy, unspecified,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Dementia with lewy bodies,Dementia in conditions classified elsewhere without behavioral disturbance,Physical restraints status,Bipolar disorder, unspecified,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Obstructive sleep apnea (adult)(pediatric),Dermatitis due to drugs and medicines taken internally,Penicillins causing adverse effects in therapeutic use,Other specified cardiac dysrhythmias,Retention of urine, unspecified

Ventltr assoc pneumonia,Food/vomit pneumonitis,Acute respiratry failure,Hyperosmolality,Encephalopathy NOS,Mth sus Stph aur els/NOS,Dementia w Lewy bodies,Dementia w/o behav dist,Physical restrain status,Bipolar disorder NOS,Hypertension NOS,Hyperlipidemia NEC/NOS,Obstructive sleep apnea,Drug dermatitis NOS,Adv eff penicillins,Cardiac dysrhythmias NEC,Retention urine NOS

Admission Date: [**2193-7-7**] Discharge Date: [**2193-7-22**] Date of Birth: [**2131-5-21**] Sex: M Service: MEDICINE Allergies: Ativan Attending:[**First Name3 (LF) 4891**] Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: Intubation History of Present Illness: Mr. [**Known lastname **] is a 62 year old male with a h/o bipolar disorder, and recent need for a hip replacement who initially presented to his PCP for [**Name9 (PRE) **] evaluation and altered mental status. Per his wife one week prior to admission he was falling/syncopizing at home and was also experiencing a fine tremor. Per his wife when he had these episodes she saw him just fall with no prodrome, and hit his head on one occasion with a brief loss of consciousness. His family also noted that he was having difficulty with confusion over the past 2-3 months, with worsening short term memory. His wife also noted a shuffling gait, resting tremor and recently was found pouring milk into soup on the stove and kept pouring until the milk overflowed. With these symptoms his wife brought him to his PCP for evaluation, at that appointment he was noted to be confused, hypotensive to the 70's, not oriented to the day and then had a syncopal episode so his PCP referred him to the ER for evaluation of his altered mental status and for further work up prior to his hip replacement. In the ER at the OSH his vital signs had stabilized, his he said that he remembered falling but otherwise felt well. Denied any chest pain, palpitations, shortness of breath, orthopnea, PND, abdominal pain, vomiting or diarrhea. He was then admitted to [**Hospital3 417**] for a syncope work up. . During his hospital stay he was seen by neurology and cardiology for further evaluation of his syncope and mental status changes. He was seen by psychiatry, neurology and cardiology in consultation. Given the report of hs shuffling gait, and cognitive decline there was concern about early Parkinson's though he had no cogwheeling or rigidity on exam. For further evaluation it was felt that he should undergo an MRI/MRA of his head, prior to these studies he received ativan for sedation. The ativan caused a paradoxical reaction and he became extremely agitated. At that time he was given large amounts of haldol, a total of 17mg and required 4 point leather restraints and an eventual transfer to the ICU. In the ICU after receiving the large amounts of sedating medications he became apneic and was intubated. He had an EEG which showed diffuse slowing, there was also concern for a possible neuroleptic malignant syndrome vs. serotonin syndrome given his rigidity so he was given 1 dose of dantrolene, there was also concern about OSA and the need for CPAP, however they had difficulty weaning sedation. On the day of transfer he became febrile, in the setting of his AMS there was concern about possible meningitis vs. encephalitis so an LP was done. The LP showed 1WBC (100%lymphs), 1RBC, glucose of 76, protein of 99, Gram stain and culture pending at the time of transfer. With his multiple problems and difficulty weaning sedation he was transferred to [**Hospital1 18**] for further management. . On the floor, his initial VS were: 101.6, 72, 147/63, 20, 97% on CMV 500x14, PEEP of 5, 40% FiO2. Past Medical History: Hypertension Hyperlipidemia Bipolar Disorder SVT Osteoarthritis Social History: Lives with his wife, have a 30 y/o special needs daughter at home. He used to work as a firefighter. - Tobacco: denies - Alcohol: drinks one drink per day - Illicits: denies Family History: Father with dementia at age [**Age over 90 **] Mother with dementia at age [**Age over 90 **] Physical Exam: Admission: Gen: intubated, sedated, opens eyes to voice, follows commands HEENT: PERRLA 2mm->1mm CV: nl S1/S2, no m/r/g, RRR Chest: anterior vent sounds with rhonchi Abd: soft, NT/ND, BS+, no grimace to deep palpation Ext: 1+ upper ext edema L>R, no leg edema Skin: erythematous macular rash on back diffusely, small petechhiae appearing lesions on legs Neuro: PERRLA, moves all extremities spontaneously, withdraws to deep pain, no increased tone or cogwheel rigidity Discharge: AF, VSS GA: pleasant, well appearing male in NAD, AAOx3, coherent, speaking in full sentences, logical, asking appropriate questions. HEENT: PERRLA. MMM. no LAD. no JVD. neck supple. Cards: RRR S1/S2 heard. no murmurs/gallops/rubs. Pulm: CTAB no crackles or wheezes Abd: soft, NT, +BS. no g/rt. neg HSM. neg [**Doctor Last Name 515**] sign. Extremities: wwp, no edema. DPs, PTs 2+. Skin: large black lesion with irregular border in upper mid back Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities. DTRs 2+ BL (biceps, achilles, patellar). sensation intact to LT. gait WNL. Pertinent Results: ADMISSION LABS: ================ [**2193-7-7**] 09:34PM BLOOD WBC-10.2 RBC-3.21* Hgb-10.3* Hct-30.6* MCV-95 MCH-32.0 MCHC-33.6 RDW-13.9 Plt Ct-198 [**2193-7-7**] 09:34PM BLOOD Neuts-87.8* Lymphs-7.1* Monos-3.8 Eos-1.0 Baso-0.3 [**2193-7-7**] 09:34PM BLOOD PT-15.0* PTT-32.1 INR(PT)-1.3* [**2193-7-7**] 09:34PM BLOOD Glucose-109* UreaN-24* Creat-1.0 Na-151* K-4.2 Cl-117* HCO3-26 AnGap-12 [**2193-7-8**] 03:27AM BLOOD ALT-22 AST-19 CK(CPK)-449* AlkPhos-63 TotBili-0.6 [**2193-7-7**] 09:34PM BLOOD Calcium-8.6 Phos-3.1 Mg-2.2 [**2193-7-8**] 05:03PM BLOOD Type-ART pO2-86 pCO2-40 pH-7.46* calTCO2-29 Base XS-4 . DISCHARGE LABS: =============== [**2193-7-21**] 04:56AM BLOOD WBC-5.8 RBC-3.40* Hgb-10.7* Hct-31.2* MCV-92 MCH-31.5 MCHC-34.4 RDW-14.5 Plt Ct-655* [**2193-7-22**] 06:05AM BLOOD Glucose-101* UreaN-10 Creat-0.9 Na-144 K-4.4 Cl-108 HCO3-25 AnGap-15 [**2193-7-18**] 09:49PM BLOOD ALT-27 AST-30 CK(CPK)-184 AlkPhos-88 TotBili-0.5 [**2193-7-22**] 06:05AM BLOOD Calcium-8.6 Phos-3.4 Mg-2.0 . . . MICROBIOLOGY: ============= OSH CSF: WBC-1, 100% lymphs, negative gram stain and culture, negative HSV PCR and VDRL . [**2193-7-7**] 9:40 pm SPUTUM Source: Endotracheal. **FINAL REPORT [**2193-7-12**]** GRAM STAIN (Final [**2193-7-8**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [**2193-7-12**]): MODERATE GROWTH Commensal Respiratory Flora. STAPH AUREUS COAG +. MODERATE GROWTH. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. STAPH AUREUS COAG +. MODERATE GROWTH. SECOND MORPHOLOGY. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | STAPH AUREUS COAG + | | CLINDAMYCIN-----------<=0.25 S <=0.25 S ERYTHROMYCIN----------<=0.25 S <=0.25 S GENTAMICIN------------ <=0.5 S <=0.5 S LEVOFLOXACIN---------- 0.25 S 0.25 S OXACILLIN------------- 0.5 S 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S <=0.5 S . . IMAGING: ======== TTE [**7-8**]: Poor image quality. The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. There is no aortic valve stenosis. No aortic regurgitation is seen. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . MRI [**7-8**]: FINDINGS: There is no evidence of acute intracranial hemorrhage, mass, mass effect or shifting of the normally midline structures. Few scattered foci of high signal intensity are demonstrated on T2 and FLAIR, distributed in the subcortical and periventricular white matter, more significant on the right side, which are nonspecific and may reflect chronic microvascular ischemic disease. There is no evidence of abnormal enhancement. No diffusion abnormalities are detected. Normal flow void signal is maintained at the major arterial vascular structures. The orbits are unremarkable, bilateral mucosal thickening is identified at the maxillary, ethmoidal, frontal and sphenoid sinus, new since the prior examination, likely indicating an ongoing inflammatory process, there is also bilateral patchy mucosal thickening at the mastoid air cells. IMPRESSION: There is no evidence of acute intracranial pathology or significant intracranial changese since the prior MRI study dated [**2193-7-5**]. Few scattered foci of high signal intensity are demonstrated in the subcortical white matter, more significant on the right side, which are nonspecific and may reflect chronic microvascular ischemic disease. No diffusion abnormalities are detected, there is no evidence of abnormal enhancement. Pansinusitis and also bilateral mastoid mucosal thickening, new since the prior examination. . [**7-11**] UE U/S: No evidence of deep vein thrombosis in the left arm. CXR [**2193-7-20**]: FINDINGS: In comparison with the study of [**7-18**], there is no longer any evidence of pulmonary vascular congestion. No pneumonia, pleural effusion, or other abnormality. Brief Hospital Course: Mr. [**Known lastname **] is a 62 year old gentleman with a h/o bipolar d/o, HTN, HL and osteoarthritis, who was admitted to an OSH with AMS, intubated for apnea post large doses of haldol/ativan, now transferred with fever and difficulty weaning the ventilator. He recovered from his VAP and is mental status improved by the time of discharge. #) Altered Mental Status: initial cause is unclear, however given wife's report and documentation from the OSH there was concern for early onset Parkinson's and possible [**Last Name (un) 309**] Body Dementia, additionally his paradoxical reaction to ativan is concerning for an underlying dementia. CSF was negative for signs of infection. MRI was also negative for any acute intracranial process. Neurology was consulted and felt that his mental status changes were secondary to receiving benzodiazapines in the substrate of [**Last Name (un) 309**] Body Dementia. He was sedated on propofol while intubated, and switched to presedex around the time of extubation. Also while intubated, required several doses of seroquel for agitation. Once extubated, patient was oriented to only person, and after speaking with family, seemed to be at baseline. His confusioin became severe 24 hours later, with difficult to control agitation. Recevied quetiapine, olanzapine, risperidone, haldol, trazodone with no improvement of agitation. Required placement back on Precedex gtt for sedation. Sent to floors with readmission to ICU for acute agitation. Required Precedex gtt again for control of acute agitation. Removed all antipsychotics. Weaned off Precedex. Return to nonagitated, pleasant state within 36 hours of ICU admission. Had EEG that was non-suggestive of seizure. He will need full neurpsych and cognitive testing once his acute delerium resolves. Continued on lamotrigine, which may need uptitration. Seroquel for agitation has been suggested although not required for last 24 hours of admission. #) Respiratory Failure: Patient initially intubated at OSH for altered mental status in the setting of recieving large amounts of haldol. Failed extubation attempt on [**7-8**] and was reintubated. CXR showed both pneumonia/aspiration pneumonitis and pulmonary edema. Patient was emperically started on vancomycin and zosyn. Sputum cultures grew MSSA, and patient was initially started on nafcillin, then swtiched to cefazolin after he developed drug rash. Total course will be 7 days, Day 1 = [**7-12**]. He was eventually extubated on [**7-14**] once his mental status improved, pneumonia improved on CXR, and diuresis with IV Lasix. He tolerated the extubation well. #. SVT: On [**7-17**], patient flipped into SVT at 180, which resolved with carotid massage. Likely AVRT or AVNRT. Upon readmission to ICU, had sinus tachycardia and hypertension thought to be from agitation. Started metoprolol 25 mg [**Hospital1 **] with good control. #. Urinary Retention: Patient on terzosin at home. He was switched to flomax secondary to hypotension and required intermittent straight caths while in the unit. #) Hypertension: Patient on lisinopril and metoprolol at home. While intubated, these medications were held. SBPs > 200 when patient was agitated. He was started on a labetolol drip and BPs improved. Once patient's sedation was changed to presedex, labetolol gtt was weaned off. After extubation, his home BP medications were restarted, and on transfer to the floor, he was on metoprolol and lisinopril. #) Bipolar Disorder: While patient was intubated, he was unable to take his home lamotrigine, cymbalta and wellbutrin as currently unable to get an NG or OG tube. Lamotrigine was restarted as above. #Sleep Apnea: found to have episodes of apnea with desaturations into the mid to low 80's. Will need a sleep evaluation. TRANSITION OF CARE: - Recommend outpatient dermatology follow-up for dark lesion on mid-upper back. - Recommend sleep study for episodes of sleep apnea. Medications on Admission: Home Medications: Toprol XL 50mg daily Terazosin 5mg daily Klor-Con 20meq daily Zocor 40mg QHS Wellbutrin 450mg daily Cymbalta 60mg daily Lamictal 100mg [**Hospital1 **] Percocet prn . Medications on Transfer: Acyclovir 400mg IV Q8H Fentanyl gtt Midazolam gtt Propofol gtt Lamotrigine 100mg [**Hospital1 **] Lisinopril 5mg daily Cyanocobalamin 1000mcg daily Folic Acid 1mg daily Heparin SQ 5000units TID Metoprolol Tartrate 5mg IV Q6h Pantoprazole 40mg IV daily Acetaminophen 650mg Q4h prn Maalox 30ml q4h prn Docusate 100mg [**Hospital1 **] prn Magnesium Hydroxide 10ml QHS prn Diphenhydramine 25mg IM q4h prn Fentanyl 25mcg Q2h prn Discharge Medications: 1. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. lamotrigine 25 mg Tablet Sig: see below Tablet PO 1 tab in the morning; 2 tabs at night . Disp:*90 Tablet(s)* Refills:*0* 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 5. quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for severe agitation. Disp:*30 Tablet(s)* Refills:*0* 6. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO at bedtime. Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Primary: Altered Mental Status Secondary: Bipolar disorder Hypertension Supraventricular Tachycardia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname **], You were brought to the hospital because of behavior changes at home. You became very agitated at the outside hospital and you required multiple medications for sedation and eventually needed to be intubated. Your intubation was complicated by a pneumonia and you were transferred to [**Hospital1 18**] for further management of your pneumonia and your mental status changes. You were treated with a 7 day course of antibiotics for your pneumonia and you improved. You were seen by psychiatry and neurology. You again became very agitated and required IV sedation to control your agitation. You then improved without additional medications. The following changes were made to your medications: - STOPPED Wellbutrin, Cymbalta, tamsulosin, Klor-Con, Percocet - DECREASED Lamictal from 100 mg twice a day to 25 mg in the morning, 50 mg in the evening - STARTED Seroquel 25 mg by mouth twice a day as needed for severe agitation - STARTED Tamsulosin 0.4 mg by mouth at night (used for urinary retention) Followup Instructions: Please keep the following appointments: Name: [**Last Name (LF) **], [**First Name3 (LF) **] Location: [**Hospital3 15290**] Counseling Address: [**Street Address(2) **] [**Location (un) 38**], [**Numeric Identifier 89129**] Phone: [**Telephone/Fax (1) 89130**] Appointment: Tuesday [**7-30**] at 4PM Name: [**Last Name (LF) **],[**First Name3 (LF) **] M. Location: [**Hospital1 **] HEALTHCARE - [**Hospital1 **] Address: ONE PEARL ST, [**Apartment Address(1) 12836**], [**Hospital1 **],[**Numeric Identifier 9647**] Phone: [**Telephone/Fax (1) 17919**] Appointment: Wednesday [**7-31**] at 3:15PM Department: ORTHOPEDICS When: FRIDAY [**2193-8-30**] at 1:55 PM With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: ORTHOPEDICS When: FRIDAY [**2193-8-30**] at 2:15 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10486**], MD [**Telephone/Fax (1) 1228**] Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: COGNITIVE NEUROLOGY UNIT When: THURSDAY [**2193-9-5**] at 2:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6403**], MD [**Telephone/Fax (1) 1690**] Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage

997,507,518,276,348,041,331,294,V498,296,401,272,327,693,E930,427,788

{'Ventilator associated pneumonia,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Hyperosmolality and/or hypernatremia,Encephalopathy, unspecified,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Dementia with lewy bodies,Dementia in conditions classified elsewhere without behavioral disturbance,Physical restraints status,Bipolar disorder, unspecified,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Obstructive sleep apnea (adult)(pediatric),Dermatitis due to drugs and medicines taken internally,Penicillins causing adverse effects in therapeutic use,Other specified cardiac dysrhythmias,Retention of urine, 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: Altered Mental Status PRESENT ILLNESS: Mr. [**Known lastname **] is a 62 year old male with a h/o bipolar disorder, and recent need for a hip replacement who initially presented to his PCP for [**Name9 (PRE) **] evaluation and altered mental status. Per his wife one week prior to admission he was falling/syncopizing at home and was also experiencing a fine tremor. Per his wife when he had these episodes she saw him just fall with no prodrome, and hit his head on one occasion with a brief loss of consciousness. His family also noted that he was having difficulty with confusion over the past 2-3 months, with worsening short term memory. His wife also noted a shuffling gait, resting tremor and recently was found pouring milk into soup on the stove and kept pouring until the milk overflowed. With these symptoms his wife brought him to his PCP for evaluation, at that appointment he was noted to be confused, hypotensive to the 70's, not oriented to the day and then had a syncopal episode so his PCP referred him to the ER for evaluation of his altered mental status and for further work up prior to his hip replacement. In the ER at the OSH his vital signs had stabilized, his he said that he remembered falling but otherwise felt well. Denied any chest pain, palpitations, shortness of breath, orthopnea, PND, abdominal pain, vomiting or diarrhea. He was then admitted to [**Hospital3 417**] for a syncope work up. . During his hospital stay he was seen by neurology and cardiology for further evaluation of his syncope and mental status changes. He was seen by psychiatry, neurology and cardiology in consultation. Given the report of hs shuffling gait, and cognitive decline there was concern about early Parkinson's though he had no cogwheeling or rigidity on exam. For further evaluation it was felt that he should undergo an MRI/MRA of his head, prior to these studies he received ativan for sedation. The ativan caused a paradoxical reaction and he became extremely agitated. At that time he was given large amounts of haldol, a total of 17mg and required 4 point leather restraints and an eventual transfer to the ICU. In the ICU after receiving the large amounts of sedating medications he became apneic and was intubated. He had an EEG which showed diffuse slowing, there was also concern for a possible neuroleptic malignant syndrome vs. serotonin syndrome given his rigidity so he was given 1 dose of dantrolene, there was also concern about OSA and the need for CPAP, however they had difficulty weaning sedation. On the day of transfer he became febrile, in the setting of his AMS there was concern about possible meningitis vs. encephalitis so an LP was done. The LP showed 1WBC (100%lymphs), 1RBC, glucose of 76, protein of 99, Gram stain and culture pending at the time of transfer. With his multiple problems and difficulty weaning sedation he was transferred to [**Hospital1 18**] for further management. . On the floor, his initial VS were: 101.6, 72, 147/63, 20, 97% on CMV 500x14, PEEP of 5, 40% FiO2. MEDICAL HISTORY: Hypertension Hyperlipidemia Bipolar Disorder SVT Osteoarthritis MEDICATION ON ADMISSION: Home Medications: Toprol XL 50mg daily Terazosin 5mg daily Klor-Con 20meq daily Zocor 40mg QHS Wellbutrin 450mg daily Cymbalta 60mg daily Lamictal 100mg [**Hospital1 **] Percocet prn . Medications on Transfer: Acyclovir 400mg IV Q8H Fentanyl gtt Midazolam gtt Propofol gtt Lamotrigine 100mg [**Hospital1 **] Lisinopril 5mg daily Cyanocobalamin 1000mcg daily Folic Acid 1mg daily Heparin SQ 5000units TID Metoprolol Tartrate 5mg IV Q6h Pantoprazole 40mg IV daily Acetaminophen 650mg Q4h prn Maalox 30ml q4h prn Docusate 100mg [**Hospital1 **] prn Magnesium Hydroxide 10ml QHS prn Diphenhydramine 25mg IM q4h prn Fentanyl 25mcg Q2h prn ALLERGIES: Ativan PHYSICAL EXAM: Admission: Gen: intubated, sedated, opens eyes to voice, follows commands HEENT: PERRLA 2mm->1mm CV: nl S1/S2, no m/r/g, RRR Chest: anterior vent sounds with rhonchi Abd: soft, NT/ND, BS+, no grimace to deep palpation Ext: 1+ upper ext edema L>R, no leg edema Skin: erythematous macular rash on back diffusely, small petechhiae appearing lesions on legs Neuro: PERRLA, moves all extremities spontaneously, withdraws to deep pain, no increased tone or cogwheel rigidity FAMILY HISTORY: Father with dementia at age [**Age over 90 **] Mother with dementia at age [**Age over 90 **] SOCIAL HISTORY: Lives with his wife, have a 30 y/o special needs daughter at home. He used to work as a firefighter. - Tobacco: denies - Alcohol: drinks one drink per day - Illicits: denies ### Response: {'Ventilator associated pneumonia,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Hyperosmolality and/or hypernatremia,Encephalopathy, unspecified,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Dementia with lewy bodies,Dementia in conditions classified elsewhere without behavioral disturbance,Physical restraints status,Bipolar disorder, unspecified,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Obstructive sleep apnea (adult)(pediatric),Dermatitis due to drugs and medicines taken internally,Penicillins causing adverse effects in therapeutic use,Other specified cardiac dysrhythmias,Retention of urine, unspecified'}

CHIEF COMPLAINT: Dehydration. PRESENT ILLNESS: Mr. [**Known lastname **] is a 61 year old man with metastatic esophageal cancer to liver and lung presents from clinic with dehydration and severe mucositis. He is s/p initiation of cycle 1 of ECX (epirubicin, cisplatin, and xeloda) on [**5-20**]. Since his treatment, he has been feeling fatigued and developed a sore throat and mouth sores. He has been able to eat and drink although drinking sometimes makes him nauseated. He was prescribed magic mouthwash and did not noticed much improvement. Patietn also states that he feels confused sometims and with a slow mind. He had dairrhea in the morning with normal color, but watery stool. He denies any sick contacts or exposure to people in nursing homes, children or other infectious agents. . He had planned on coming into the outpatient treatment area for IVFs, but because he has been feeling so unwell, he presented in clinic today for evaluation. . In clinic, he was found to be orthostatic and appeared dehydrated on exam. He was noted to have oral thrush. He was given 2L NS, zofran 8 mg IV and nystatin 5 cc as well as diflucan 200 mg. he was seen by Dr. [**Last Name (STitle) **]. He is now being admitted for rehydration and treatment of his mucositis and thrush. MEDICAL HISTORY: PAST ONCOLOGIC HISTORY: ====================== He initially presented in [**11/2142**] due to dysphagia and weight loss. At that time, he had a barium swallow, which showed a pinpoint narrowing of his distal esophagus. He had endoscopy and underwent dilatation of this stricture. He did not have much improvement with the dilatation and in [**Month (only) 116**] of this year underwent a second dilatation once again with no improvement. He had motility tests, which were most consistent with achalasia. In [**Month (only) **], he underwent a Botox injection to the narrowing in order to help to release it. He had a CT scan after this which showed a 1.5 cm gastrohepatic lymph node. On [**2143-8-28**] he underwent an upper endoscopy on which they saw distal esophageal narrowing. They also performed multiple biopsies of the area of narrowing. Of note, they saw some ulceration in the GE junction and a thick abnormal fold concerning for esophageal or gastric cardia cancer. The biopsy showed moderate to poorly differentiated adenocarcinoma. After this he underwent endoscopic ultrasound, however, they were unable to pass the ultrasound probe beyond the stricture. He has had a port, g-tube, and esophageal stent placed. He started treatment with 5-FU and Cisplatin on [**2143-10-10**] with concurrent radiation therapy. Radiation was completed on [**2143-11-26**]. He was admitted from [**2143-11-26**] to the [**2143-12-3**] with febrile neutropenia and dehydration. He underwent an esophagectomy on [**2144-1-20**]. Pathology from this showed a metastatic adenocarcinoma with 4/6 perigastric lymph nodes positive, and a separate foci of tumor in the adjacent adipose tissue. He completed treatment in [**2144-1-4**]. He had liver lesions noted on a CT scan [**2145-1-16**]. He had these biopsied on [**2145-1-27**] and the pathology came back as consistent with metastasis from esophageal cancer. . PAST MEDICAL HISTORY: ==================== - Esophageal cancer- moderate to poorly differentiated adenocarcinoma; Rec'd 5-FU/cisplatin with concurrent XRT in [**10-11**], now s/p minimally invasive esophagectomy [**1-10**]. - h/o atrial fibrillation - h/o S. viridans bacteremia - Sinusitis, status post surgery - Hypertension - Vocal cord paralysis MEDICATION ON ADMISSION: Emend 125mg day 1, 80mg days [**3-9**] Xeloda 2g [**Hospital1 **] (days [**2-17**]) Dexamethasone 4mg (days [**3-10**]) Magic mouthwash tid prn Lorazepam 0.5-1mg q4-6h prn Megestrol 100mg/10ml susp daily Metoclopramide 5mg tid Metoprolol 100mg [**Hospital1 **] Ondansetron 8mg q8h prn (? GI upset) Gelclair tid Oxycodone 5-10mg q4-6h prn Prochlorperazine 10mg q6-8h prn Ranitidine 150mg [**Hospital1 **] Sucralfate 1g tid Zolpidem 10mg hs prn ALLERGIES: Penicillins PHYSICAL EXAM: Vitals - T: 98.1 BP: 104/74 HR: 67 RR: 16 02 sat: 100% on RA . GENERAL: NAD, very pelasant gentleman, hoarse, very french accent SKIN: warm and well perfused, no excoriations or lesions, no rashes HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva, patent nares, MMM, good dentition, nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, no mrg LUNG: CTAB ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly M/S: moving all extremities well, no cyanosis, clubbing or edema, no obvious deformities PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact, strenght [**6-8**] in upper and lower extremities, DTRs [**6-8**], [**Name2 (NI) 73082**] 27 FAMILY HISTORY: He has a father with pancreatic cancer who died at the age of 70. SOCIAL HISTORY: He originally moved from [**Country 6171**] 17 years ago. Married, 2 children. Teaches French and Spanish. He used to smoke a pack a day, but quit 15 years ago. He used to drink a couple of glasses of wine with dinner each night, but not since diagnosis.

Drug induced neutropenia,Pneumonia, organism unspecified,Malignant neoplasm of liver, secondary,Candidiasis of mouth,Acute kidney failure, unspecified,Malignant neoplasm of other specified part of esophagus,Bacteremia,Dehydration,Anemia, unspecified,Atrial fibrillation,Other stomatitis and mucositis (ulcerative),Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Diarrhea,Pneumococcus infection in conditions classified elsewhere and of unspecified site,Unilateral paralysis of vocal cords or larynx, partial,Unspecified essential hypertension,Other and unspecified noninfectious gastroenteritis and colitis

Drug induced neutropenia,Pneumonia, organism NOS,Second malig neo liver,Thrush,Acute kidney failure NOS,Mal neo esophagus NEC,Bacteremia,Dehydration,Anemia NOS,Atrial fibrillation,Stomatits & mucosits NEC,Adv eff antineoplastic,Diarrhea,Pneumococcus infect NOS,Vocal paral unilat part,Hypertension NOS,Noninf gastroenterit NEC

Admission Date: [**2145-5-28**] Discharge Date: [**2145-6-18**] Date of Birth: [**2084-3-2**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 5552**] Chief Complaint: Dehydration. Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname **] is a 61 year old man with metastatic esophageal cancer to liver and lung presents from clinic with dehydration and severe mucositis. He is s/p initiation of cycle 1 of ECX (epirubicin, cisplatin, and xeloda) on [**5-20**]. Since his treatment, he has been feeling fatigued and developed a sore throat and mouth sores. He has been able to eat and drink although drinking sometimes makes him nauseated. He was prescribed magic mouthwash and did not noticed much improvement. Patietn also states that he feels confused sometims and with a slow mind. He had dairrhea in the morning with normal color, but watery stool. He denies any sick contacts or exposure to people in nursing homes, children or other infectious agents. . He had planned on coming into the outpatient treatment area for IVFs, but because he has been feeling so unwell, he presented in clinic today for evaluation. . In clinic, he was found to be orthostatic and appeared dehydrated on exam. He was noted to have oral thrush. He was given 2L NS, zofran 8 mg IV and nystatin 5 cc as well as diflucan 200 mg. he was seen by Dr. [**Last Name (STitle) **]. He is now being admitted for rehydration and treatment of his mucositis and thrush. Past Medical History: PAST ONCOLOGIC HISTORY: ====================== He initially presented in [**11/2142**] due to dysphagia and weight loss. At that time, he had a barium swallow, which showed a pinpoint narrowing of his distal esophagus. He had endoscopy and underwent dilatation of this stricture. He did not have much improvement with the dilatation and in [**Month (only) 116**] of this year underwent a second dilatation once again with no improvement. He had motility tests, which were most consistent with achalasia. In [**Month (only) **], he underwent a Botox injection to the narrowing in order to help to release it. He had a CT scan after this which showed a 1.5 cm gastrohepatic lymph node. On [**2143-8-28**] he underwent an upper endoscopy on which they saw distal esophageal narrowing. They also performed multiple biopsies of the area of narrowing. Of note, they saw some ulceration in the GE junction and a thick abnormal fold concerning for esophageal or gastric cardia cancer. The biopsy showed moderate to poorly differentiated adenocarcinoma. After this he underwent endoscopic ultrasound, however, they were unable to pass the ultrasound probe beyond the stricture. He has had a port, g-tube, and esophageal stent placed. He started treatment with 5-FU and Cisplatin on [**2143-10-10**] with concurrent radiation therapy. Radiation was completed on [**2143-11-26**]. He was admitted from [**2143-11-26**] to the [**2143-12-3**] with febrile neutropenia and dehydration. He underwent an esophagectomy on [**2144-1-20**]. Pathology from this showed a metastatic adenocarcinoma with 4/6 perigastric lymph nodes positive, and a separate foci of tumor in the adjacent adipose tissue. He completed treatment in [**2144-1-4**]. He had liver lesions noted on a CT scan [**2145-1-16**]. He had these biopsied on [**2145-1-27**] and the pathology came back as consistent with metastasis from esophageal cancer. . PAST MEDICAL HISTORY: ==================== - Esophageal cancer- moderate to poorly differentiated adenocarcinoma; Rec'd 5-FU/cisplatin with concurrent XRT in [**10-11**], now s/p minimally invasive esophagectomy [**1-10**]. - h/o atrial fibrillation - h/o S. viridans bacteremia - Sinusitis, status post surgery - Hypertension - Vocal cord paralysis Social History: He originally moved from [**Country 6171**] 17 years ago. Married, 2 children. Teaches French and Spanish. He used to smoke a pack a day, but quit 15 years ago. He used to drink a couple of glasses of wine with dinner each night, but not since diagnosis. Family History: He has a father with pancreatic cancer who died at the age of 70. Physical Exam: Vitals - T: 98.1 BP: 104/74 HR: 67 RR: 16 02 sat: 100% on RA . GENERAL: NAD, very pelasant gentleman, hoarse, very french accent SKIN: warm and well perfused, no excoriations or lesions, no rashes HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva, patent nares, MMM, good dentition, nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, no mrg LUNG: CTAB ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly M/S: moving all extremities well, no cyanosis, clubbing or edema, no obvious deformities PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact, strenght [**6-8**] in upper and lower extremities, DTRs [**6-8**], [**Name2 (NI) 73082**] 27 Pertinent Results: On Admission: [**2145-5-28**] 10:00AM WBC-2.9*# RBC-4.84 HGB-15.0 HCT-43.9 MCV-91 MCH-30.9 MCHC-34.1 RDW-13.8 [**2145-5-28**] 10:00AM PLT SMR-VERY LOW PLT COUNT-35*# [**2145-5-28**] 10:00AM GRAN CT-2240 [**2145-5-28**] 10:00AM ALT(SGPT)-100* AST(SGOT)-51* ALK PHOS-75 TOT BILI-1.4 DIR BILI-0.3 INDIR BIL-1.1 [**2145-5-28**] 10:00AM ALBUMIN-3.5 PHOSPHATE-3.5 MAGNESIUM-2.2 [**2145-5-28**] 10:00AM UREA N-36* CREAT-1.0 SODIUM-138 POTASSIUM-3.6 CHLORIDE-102 TOTAL CO2-27 ANION GAP-13 [**2145-5-28**] 10:00AM GRAN CT-2240 Pertinent Interim/Discharge Labs [**2145-6-18**] 12:23AM BLOOD WBC-12.3* RBC-3.46* Hgb-10.7* Hct-30.5* MCV-88 MCH-31.0 MCHC-35.2* RDW-18.6* Plt Ct-228 [**2145-6-14**] 12:00AM BLOOD WBC-19.3* RBC-3.03* Hgb-9.4* Hct-28.2* MCV-93 MCH-30.9 MCHC-33.2 RDW-17.9* Plt Ct-98* [**2145-6-13**] 12:00AM BLOOD PT-15.5* INR(PT)-1.4* [**2145-6-8**] 09:36AM BLOOD PT-28.0* PTT-31.1 INR(PT)-2.8* [**2145-6-6**] 12:00AM BLOOD Gran Ct-253* [**2145-6-7**] 12:00AM BLOOD Gran Ct-704* [**2145-6-9**] 12:00AM BLOOD Gran Ct-7521 [**2145-6-18**] 12:23AM BLOOD Glucose-91 UreaN-19 Creat-0.5 Na-134 K-4.4 Cl-103 HCO3-24 AnGap-11 [**2145-6-15**] 12:00AM BLOOD ALT-27 AST-32 LD(LDH)-292* AlkPhos-160* TotBili-2.1* [**2145-6-18**] 12:23AM BLOOD Calcium-7.0* Phos-3.5 Mg-1.9 [**2145-6-15**] 12:00AM BLOOD Albumin-2.0* Calcium-6.9* Phos-3.1 Mg-1.9 CT abdomen/pelvis [**5-30**]: 1. No evidence of diverticulitis, abscess, or any acute pathology to explain LLQ pain. 2. New wedge-shaped hypodensities within the spleen, likely infarcts given relatively rapid appearance from the prior study. 3. Although incompletely assessed due to collapsed bowel, apparent wall thickening of the ascending colon which may represent bowel wall edema. No secondary signs of inflammation (ie no fat stranding). CXR [**6-3**]: As compared to the previous radiograph, there is increasing opacity at the left lung base, combined with a newly appeared blunting of the left costophrenic sinus, presumably due to effusion. The size of the cardiac silhouette is unchanged. Unchanged normal right lung, unchanged Port-A-Cath system. CT chest [**6-4**]: 1. New diffuse transverse colon wall thickening and surrounding inflammatory change consistent with colitis, only partially visualized. Further evaluation with dedicated CT enterography of the abdomen and pelvis may be obtained for further evaluation. 2. New, small left, and trace right, pleural effusions. 3. New tree-in-[**Male First Name (un) 239**] opacities in the right lower lobe with mild improvement in right upper lobe tree-in-[**Male First Name (un) 239**] opacities. These findings may be due to aspiration. TTE [**6-8**]: No vegetations seen (suboptimal-quality study). Mild mitral regurgitation. Normal global and regional biventricular systolic function. RUE U/S [**6-8**]: DVT involving the right distal brachial vein, as well as the cephalic vein. CXR [**6-9**]: Compared to [**6-3**], there is more opacification in the left lower lobe, which could be worsening atelectasis or pneumonia particularly due to recent aspiration. There has also been increase in diameter of the cardiac silhouette and the azygos vein which may indicate volume overload but there is no pulmonary edema. MICRO [**6-1**] blood cx: Strep Pneumoniae Brief Hospital Course: 1. Pneumococcal infection: While the patient was neutropenic, he was febrile once. Cultures were sent and he was started on empiric cefepime. Imaging suggested a LLL pneumonia, and blood cultures grew GPC, for which vancomycin was added. The GPC were speciated as S. pneumoniae. TTE showed no vegetations. No further blood cultures were positive, and his antibiotics were eventually narrowed to ceftriaxone alone for a 14 day course, starting at the resolution of neutropenia. For easier dosing at home, he was changed to Cefpodoxine to finish course after discharge. 2. Mucositis: Unable to tolerate PO and was resuscitated with IVF. He was started on oral lidocaine and gelclairm as well as oral fluconazole and nystatin for [**Female First Name (un) 564**]. He was later taken off the fluconazole as it elevated his transaminases and changed to micafungin. However, this was also stopped as it elevated his bilirubin. IV morphine was used for pain control and he briefly required a PCA pump. Once his neutropenia resolved, his mucositis began to improve. However, the resultant increase in secretions caused respiratory distress and hypoxia, requiring ICU transfer for frequent deep suctioning and nebulizers. This resolved rapidly and he returned to the floor. Mucositis subsequently improved. 3. Acute renal failure: Despite normal creatinine at 1.0, this essentially doubled from low baseline of 0.4-0.7 and BUN/creatinine 36. Likely in the setting of poor PO. He was agressively hydrated with IVF and creatinine improved. 4. Neutropenia: Secondary to chemotherapy. His ANC continued to trend down during admission until he became severely neutropenic. He was started on filgrastim and eventually his ANC completely recovered. 5. Thrombocytopenia: Also secondary to chemotherapy. Early in the admission, he had some hematochezia, so was transfused plts to keep his count over 30,000. 6. Right UE DVT: Found on U/S in the setting of arm swelling. He was started on enoxaparin. 7. Colitis: Early on, paient complained of LLQ pain, associated with hematochezia and then dark stools. He required 2 units RBCs for this, but endoscopy could not be done due to his neutropenia and thrombocytopenia. Stool studies were negative. CT abdomen showed some bowel edema, but no diverticulitis. A CT chest done a few days later noted some transverse colitis, although he was asymptomatic. Metronidazole was empirically started and continued for 5 days. Later on, in the setting of starting enoxaparin for DVT, he had dark guaiac positive stools. GI was consulted and felt bleeding was related to mucositis vs colitis/inflammation in setting of anticoagulation and did not feel there was indication for scope as an inpatient. His hematocrit was stable prior to discharge. 8. Esophageal cancer: On admission, he was day 9 status post chemotherapy. He received no further treatments as an inpatient, and he will follow up with his oncologist as an outpatient. 9. Nutrition: Due to poor POs, PPN was started as there was not enough access for TPN in the patient's chest port due to antibiotics and IV fluids. Once his antibiotics were weaned, TPN was initiated via his port. He also had an elevated INR that was likely nutritional, and improved with vitamin K. Medications on Admission: Emend 125mg day 1, 80mg days [**3-9**] Xeloda 2g [**Hospital1 **] (days [**2-17**]) Dexamethasone 4mg (days [**3-10**]) Magic mouthwash tid prn Lorazepam 0.5-1mg q4-6h prn Megestrol 100mg/10ml susp daily Metoclopramide 5mg tid Metoprolol 100mg [**Hospital1 **] Ondansetron 8mg q8h prn (? GI upset) Gelclair tid Oxycodone 5-10mg q4-6h prn Prochlorperazine 10mg q6-8h prn Ranitidine 150mg [**Hospital1 **] Sucralfate 1g tid Zolpidem 10mg hs prn Discharge Medications: 1. Flushes Saline flush 10cc SASH and prn heparin flush 10U/ml 5cc SASH and prn Heparin 100U/ml 5cc deaccess port 2. Lidocaine HCl 2 % Solution Sig: Fifteen (15) ML Mucous membrane TID (3 times a day) as needed. Disp:*1 bottle* Refills:*0* 3. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for anxiety or nausea. 4. Megestrol 400 mg/10 mL Suspension Sig: 100mg/10ml suspension PO once a day. 5. Reglan 5 mg Tablet Sig: One (1) Tablet PO three times a day. 6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. ZOFRAN ODT 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. 8. Oral Wound Care Products Gel in Packet Sig: One (1) ML Mucous membrane TID (3 times a day) as needed. 9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 10. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea or vomit. 11. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO three times a day. 12. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 13. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe Subcutaneous Q12H (every 12 hours). Disp:*60 syringe* Refills:*0* 14. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 3 days. Disp:*12 Tablet(s)* Refills:*0* 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 16. Outpatient Lab Work Please do weekly lab work and fax to [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) 18971**] [**Telephone/Fax (1) 55043**] to monito while on TPN. Check CBC, BUN, Cr, electrolytes, albumin, LFTs. Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: Primary: Chemotherapy induced diarrhea and mucositis Pneumococcal bacteremia Pneumonia Deep venous thrombosis Secondary: Esophageal cancer Hypertension Discharge Condition: hemodynamically stable, afebrile, shortnes of breath and cough improved Discharge Instructions: You were admitted to [**Hospital1 18**] with dehydration, diarrhea, and inflammation of the mucous membranes (mucositis). We gave you IV fluids and started TPN, a form of nutrition given through the veins. We also treated you with antibiotics for a bloodstream infection and a pneumonia. We also started enoxaparin (Lovenox), a blood thinner, due to a blood clot found in your arm veins. Once your white blood cells recovered from your chemotherapy, your mucositis continued to improve. We changed your ranitidine to pantopraxole. Please take all medications as prescribed and go to all follow up appointments. If you experience fevers, chills, vomiting, diarrhea, abdominal pain, worsening mouth/throat pain, bloody stools, or any other concerning symptoms, please seek medical attention or come to the ER immediately. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **]. Call [**Telephone/Fax (1) 6568**] for an appointment in [**2-5**] weeks.

288,486,197,112,584,150,790,276,285,427,528,E933,787,041,478,401,558

{'Drug induced neutropenia,Pneumonia, organism unspecified,Malignant neoplasm of liver, secondary,Candidiasis of mouth,Acute kidney failure, unspecified,Malignant neoplasm of other specified part of esophagus,Bacteremia,Dehydration,Anemia, unspecified,Atrial fibrillation,Other stomatitis and mucositis (ulcerative),Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Diarrhea,Pneumococcus infection in conditions classified elsewhere and of unspecified site,Unilateral paralysis of vocal cords or larynx, partial,Unspecified essential hypertension,Other and unspecified noninfectious gastroenteritis and colitis'}

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: Dehydration. PRESENT ILLNESS: Mr. [**Known lastname **] is a 61 year old man with metastatic esophageal cancer to liver and lung presents from clinic with dehydration and severe mucositis. He is s/p initiation of cycle 1 of ECX (epirubicin, cisplatin, and xeloda) on [**5-20**]. Since his treatment, he has been feeling fatigued and developed a sore throat and mouth sores. He has been able to eat and drink although drinking sometimes makes him nauseated. He was prescribed magic mouthwash and did not noticed much improvement. Patietn also states that he feels confused sometims and with a slow mind. He had dairrhea in the morning with normal color, but watery stool. He denies any sick contacts or exposure to people in nursing homes, children or other infectious agents. . He had planned on coming into the outpatient treatment area for IVFs, but because he has been feeling so unwell, he presented in clinic today for evaluation. . In clinic, he was found to be orthostatic and appeared dehydrated on exam. He was noted to have oral thrush. He was given 2L NS, zofran 8 mg IV and nystatin 5 cc as well as diflucan 200 mg. he was seen by Dr. [**Last Name (STitle) **]. He is now being admitted for rehydration and treatment of his mucositis and thrush. MEDICAL HISTORY: PAST ONCOLOGIC HISTORY: ====================== He initially presented in [**11/2142**] due to dysphagia and weight loss. At that time, he had a barium swallow, which showed a pinpoint narrowing of his distal esophagus. He had endoscopy and underwent dilatation of this stricture. He did not have much improvement with the dilatation and in [**Month (only) 116**] of this year underwent a second dilatation once again with no improvement. He had motility tests, which were most consistent with achalasia. In [**Month (only) **], he underwent a Botox injection to the narrowing in order to help to release it. He had a CT scan after this which showed a 1.5 cm gastrohepatic lymph node. On [**2143-8-28**] he underwent an upper endoscopy on which they saw distal esophageal narrowing. They also performed multiple biopsies of the area of narrowing. Of note, they saw some ulceration in the GE junction and a thick abnormal fold concerning for esophageal or gastric cardia cancer. The biopsy showed moderate to poorly differentiated adenocarcinoma. After this he underwent endoscopic ultrasound, however, they were unable to pass the ultrasound probe beyond the stricture. He has had a port, g-tube, and esophageal stent placed. He started treatment with 5-FU and Cisplatin on [**2143-10-10**] with concurrent radiation therapy. Radiation was completed on [**2143-11-26**]. He was admitted from [**2143-11-26**] to the [**2143-12-3**] with febrile neutropenia and dehydration. He underwent an esophagectomy on [**2144-1-20**]. Pathology from this showed a metastatic adenocarcinoma with 4/6 perigastric lymph nodes positive, and a separate foci of tumor in the adjacent adipose tissue. He completed treatment in [**2144-1-4**]. He had liver lesions noted on a CT scan [**2145-1-16**]. He had these biopsied on [**2145-1-27**] and the pathology came back as consistent with metastasis from esophageal cancer. . PAST MEDICAL HISTORY: ==================== - Esophageal cancer- moderate to poorly differentiated adenocarcinoma; Rec'd 5-FU/cisplatin with concurrent XRT in [**10-11**], now s/p minimally invasive esophagectomy [**1-10**]. - h/o atrial fibrillation - h/o S. viridans bacteremia - Sinusitis, status post surgery - Hypertension - Vocal cord paralysis MEDICATION ON ADMISSION: Emend 125mg day 1, 80mg days [**3-9**] Xeloda 2g [**Hospital1 **] (days [**2-17**]) Dexamethasone 4mg (days [**3-10**]) Magic mouthwash tid prn Lorazepam 0.5-1mg q4-6h prn Megestrol 100mg/10ml susp daily Metoclopramide 5mg tid Metoprolol 100mg [**Hospital1 **] Ondansetron 8mg q8h prn (? GI upset) Gelclair tid Oxycodone 5-10mg q4-6h prn Prochlorperazine 10mg q6-8h prn Ranitidine 150mg [**Hospital1 **] Sucralfate 1g tid Zolpidem 10mg hs prn ALLERGIES: Penicillins PHYSICAL EXAM: Vitals - T: 98.1 BP: 104/74 HR: 67 RR: 16 02 sat: 100% on RA . GENERAL: NAD, very pelasant gentleman, hoarse, very french accent SKIN: warm and well perfused, no excoriations or lesions, no rashes HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva, patent nares, MMM, good dentition, nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, no mrg LUNG: CTAB ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly M/S: moving all extremities well, no cyanosis, clubbing or edema, no obvious deformities PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact, strenght [**6-8**] in upper and lower extremities, DTRs [**6-8**], [**Name2 (NI) 73082**] 27 FAMILY HISTORY: He has a father with pancreatic cancer who died at the age of 70. SOCIAL HISTORY: He originally moved from [**Country 6171**] 17 years ago. Married, 2 children. Teaches French and Spanish. He used to smoke a pack a day, but quit 15 years ago. He used to drink a couple of glasses of wine with dinner each night, but not since diagnosis. ### Response: {'Drug induced neutropenia,Pneumonia, organism unspecified,Malignant neoplasm of liver, secondary,Candidiasis of mouth,Acute kidney failure, unspecified,Malignant neoplasm of other specified part of esophagus,Bacteremia,Dehydration,Anemia, unspecified,Atrial fibrillation,Other stomatitis and mucositis (ulcerative),Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Diarrhea,Pneumococcus infection in conditions classified elsewhere and of unspecified site,Unilateral paralysis of vocal cords or larynx, partial,Unspecified essential hypertension,Other and unspecified noninfectious gastroenteritis and colitis'}

CHIEF COMPLAINT: PRESENT ILLNESS: Mr. [**Known firstname **] [**Known lastname 35516**] is a 51-year-old gentleman who was the unrestrained driver in a high speed motor vehicle collision. The patient reportedly went through the windshield where he sustained severe head and face trauma. The patient was initially evaluated and stabilized at [**Hospital6 3105**] and then he was transferred to the [**Hospital1 69**] via [**Location (un) **]. The patient was intubated at [**Hospital3 **] and intubation was complicated by the fact that he had severe facial trauma including facial fractures and nasal fractures and a partial avulsion of his nose. MEDICAL HISTORY: MEDICATION ON ADMISSION: ALLERGIES: PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with brief [less than one hour] loss of consciousness,Closed fracture of orbital floor (blow-out),Open wound of lip, without mention of complication,Staphylococcal septicemia, unspecified,Mechanical complication due to urethral (indwelling) catheter,Alcoholic fatty liver,Other motor vehicle nontraffic accident involving collision with stationary object injuring passenger in motor vehicle other than motorcycle

Cl skul base fx/brf coma,Fx orbital floor-closed,Open wound of lip,Staphylcocc septicem NOS,Malfunc urethral cath,Alcoholic fatty liver,Oth coll stndng obj-psgr

Admission Date: [**2167-8-10**] Discharge Date: [**2167-9-10**] Date of Birth: Sex: M Service: HISTORY OF PRESENT ILLNESS: Mr. [**Known firstname **] [**Known lastname 35516**] is a 51-year-old gentleman who was the unrestrained driver in a high speed motor vehicle collision. The patient reportedly went through the windshield where he sustained severe head and face trauma. The patient was initially evaluated and stabilized at [**Hospital6 3105**] and then he was transferred to the [**Hospital1 69**] via [**Location (un) **]. The patient was intubated at [**Hospital3 **] and intubation was complicated by the fact that he had severe facial trauma including facial fractures and nasal fractures and a partial avulsion of his nose. PHYSICAL EXAMINATION: The patient upon arrival to the [**Hospital1 1444**] was intubated, sedated and paralyzed. At that time blood pressure was 127/77, pulse 105 with respiratory rate of 16, he was 100% on the ventilator with a temperature of 98.6. HEENT: Patient had a left depressed skull fracture, he had bilateral periorbital edema and ecchymosis, he had a laceration of his lower lip with multiple broken teeth and avulsion of his nose which was actively bleeding from the nose and mouth. The maxilla was stable. The neck, the C collar was in place. Chest, he had no bony deformities. He had bilateral breath sounds that were equal and symmetrical. Cardiovascular, the patient had a normal S1 and S2, but was tachycardic. The abdomen was soft and there was no evidence of trauma to the abdomen. The patient had blood at the urethral meatus. There was a Foley in place at the time. The patient's pelvis was stable. On rectal exam, there was decreased rectal tone, normal prostate. Extremities were warm. The patient had strong distal pulses. There was no bony deformities. There were several superficial lacerations over his lower extremity. HOSPITAL COURSE: The patient was then taken to imaging where he underwent full trauma series. The patient also had CT scan of the head which was significant for left orbit fracture and lateral wall and nasal ridge fracture. The patient was taken to the surgical Intensive Care Unit where he remained intubated and stable. The patient's surgical Intensive Care Unit stay was complicated by failure to wean from the vent initially. The patient's prolonged SICU stay resulted in sepsis and later MRSA bacteremia. The source of his bacteremia was thought to be pneumonia. The infectious disease service followed along with the surgical Intensive Care Unit service and ultimately the patient received a full course of antibiotics and his symptoms resolved. This allowed him to be extubated. Of note, the patient did require a tracheostomy because of long term ventilation. The patient was continued on Vancomycin which he will be on until [**2167-9-30**] as per the infectious disease service at the [**Hospital1 1444**]. The patient also had persistent hematuria throughout his hospital stay. This was thought to be secondary to a false passageway. The genitourinary issues were managed by urology and he had an indwelling catheter in place until [**2167-9-9**]. The patient was transferred from the surgical Intensive Care Unit to the floor where he was stable. He was able to tolerate a pureed diet along with nectar thick liquids. His pain control was adequate. The patient underwent a CT scan of his orbit on [**2167-9-9**] to evaluate his need for surgery. He was offered surgery by the plastic surgical service. The patient continued to do well and was stable throughout his entire course on the surgical floor. He was discharged to rehabilitation on [**2167-9-10**] in stable condition. At that time his medications included Lopressor 25 mg po bid, Heparin 5000 units subcutaneously [**Hospital1 **], Detrol 1 mg po bid and Percocet 1-2 tablets po q 4-6 hours prn, Vancomycin 1.2 gm IV q 18. The Vancomycin will be continued through [**9-30**] at which time it should be discontinued. The patient will follow-up in the trauma clinic in two weeks. He will be seen by the urology clinic in two weeks and he will also follow-up with the plastic surgery clinic in two weeks. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3598**], MD [**MD Number(1) 3599**] Dictated By:[**Doctor First Name 31859**] MEDQUIST36 D: [**2167-9-10**] 10:59 T: [**2167-9-10**] 11:17 JOB#: [**Job Number 35517**] Name: [**Known lastname 6332**], [**Known firstname **] Unit No: [**Numeric Identifier 6333**] Admission Date: [**2167-8-10**] Discharge Date: [**2167-9-10**] Date of Birth: [**2115-12-8**] Sex: M Service: ADDENDUM: Mr. [**Known lastname **] was offered surgery for his facial fractures by the plastic surgery team. After considering this option with his family, the patient decided not to undergo surgery for his facial fractures, which would only have been for cosmetic enhancement. Also of note, the patient had his catheter removed and was passing blood and clots at the time of discharge. This is to be expected for the next several weeks, as he had an injury to his prostate. As long as the patient does not go into urinary retention, there is no need for concern. Of course, if the patient does go into urinary retention, he will need to have a catheter placed and be seen by the urology service. [**First Name4 (NamePattern1) 168**] [**Last Name (NamePattern1) 1030**], MD [**MD Number(1) 1031**] Dictated By:[**Name8 (MD) 6334**] MEDQUIST36 D: [**2167-9-10**] 11:17 T: [**2167-9-10**] 11:38 JOB#: [**Job Number 6335**]

801,802,873,038,996,571,E823

{'Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with brief [less than one hour] loss of consciousness,Closed fracture of orbital floor (blow-out),Open wound of lip, without mention of complication,Staphylococcal septicemia, unspecified,Mechanical complication due to urethral (indwelling) catheter,Alcoholic fatty liver,Other motor vehicle nontraffic accident involving collision with stationary object injuring passenger in motor vehicle other than motorcycle'}

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: Mr. [**Known firstname **] [**Known lastname 35516**] is a 51-year-old gentleman who was the unrestrained driver in a high speed motor vehicle collision. The patient reportedly went through the windshield where he sustained severe head and face trauma. The patient was initially evaluated and stabilized at [**Hospital6 3105**] and then he was transferred to the [**Hospital1 69**] via [**Location (un) **]. The patient was intubated at [**Hospital3 **] and intubation was complicated by the fact that he had severe facial trauma including facial fractures and nasal fractures and a partial avulsion of his nose. MEDICAL HISTORY: MEDICATION ON ADMISSION: ALLERGIES: PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: ### Response: {'Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with brief [less than one hour] loss of consciousness,Closed fracture of orbital floor (blow-out),Open wound of lip, without mention of complication,Staphylococcal septicemia, unspecified,Mechanical complication due to urethral (indwelling) catheter,Alcoholic fatty liver,Other motor vehicle nontraffic accident involving collision with stationary object injuring passenger in motor vehicle other than motorcycle'}

CHIEF COMPLAINT: BRBPR, anemia PRESENT ILLNESS: Mr. [**Known lastname **] is a 49-year-old male with history of anemia and GI bleeds who presents with bright red blood per rectum and hematemesis x1. He has had extensive workup done both here in [**Location (un) 86**] as well some [**State 2690**] including endoscopy, colonoscopy, capsule study, tagged red blood cell scan. On tagged red blood cell scan apparently there was an area that showed possible source of the patient's anemia however he does not have records and does not remember exactly. . The patient yesterday evening went to [**Hospital3 **] to be further eval for his palpitations and bloody stool. Currently he says he has not had a bloody bowel movement for the past 8-12 hours. Last episode was yesterday evening. Otherwise the patient denies any hematemesis or coffee-ground emesis. The patient denies any chest pain, shortness of breath, nausea, vomiting, and diarrhea. He does not have any fevers or chills currently. He also does not have any abdominal pain. . In the ED, initial VS: 97.5, 103, 114/70, 20, 99%. His initial hematocrit was 18.6, repeat the same. They attempted to contact the [**Hospital 2690**] hospital where tagged rbc scan was done however medical records was closed, number is ([**Telephone/Fax (1) 87738**]. He also recieved 1st unit PRBC, needs 2nd unit still. Pt asymptomatic currently, guiac neg. Guiaic trace positive without frank blood in vault. . On arrival to the MICU, he is feeling much better. His anemia symptoms (SOB, dizziness, weakness) have resolved with 1 U pRBCs. He also has not had anymore bleeding today. Has never had pain with his bloody bowel movements but does get nausea. Never had hematemesis. MEDICAL HISTORY: -Hx of GI bleeds x 2. Most recent bleed in [**10-1**], found to have duodenal ulcer at [**Hospital 87735**] Hospital, which was clipped vs cauterized -Hyperlipidemia -S/p motorcycle accident [**2162**], with bowel resection, ileostomy and reversal. MEDICATION ON ADMISSION: Simvastatin 40 mg qhs Protonix 40 mg b.i.d. iron 325 mg b.i.d. alendronate qweekly nortriptyline 50 mg qhs ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: On Admission: Vitals: T: 96.8, BP:137/65, P:101, R:18, O2: 100% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP 12-14 cm, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: mildly firm but non-tender, non-distended, bowel sounds present, no organomegaly, well healed midline scar GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, gait deferred FAMILY HISTORY: Mother: MI at age 70. Father: MI at age 64. Three children (two sons and one daughter) are healthy. No known GI disease in the family. SOCIAL HISTORY: Lives at home with wife and children. Remote smoker (quit >20 years ago). Denies illicits or etoh intake.

Other and unspecified noninfectious gastroenteritis and colitis,Acute posthemorrhagic anemia,Iron deficiency anemia secondary to blood loss (chronic),Other and unspecified hyperlipidemia,Depressive disorder, not elsewhere classified,Mononeuritis of lower limb, unspecified,Unspecified disorder of kidney and ureter,Personal history of other injury

Noninf gastroenterit NEC,Ac posthemorrhag anemia,Chr blood loss anemia,Hyperlipidemia NEC/NOS,Depressive disorder NEC,Mononeuritis leg NOS,Renal & ureteral dis NOS,Hx injury NEC

Admission Date: [**2169-1-7**] Discharge Date: [**2169-1-11**] Date of Birth: [**2119-2-7**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 30**] Chief Complaint: BRBPR, anemia Major Surgical or Invasive Procedure: Enteroscopy History of Present Illness: Mr. [**Known lastname **] is a 49-year-old male with history of anemia and GI bleeds who presents with bright red blood per rectum and hematemesis x1. He has had extensive workup done both here in [**Location (un) 86**] as well some [**State 2690**] including endoscopy, colonoscopy, capsule study, tagged red blood cell scan. On tagged red blood cell scan apparently there was an area that showed possible source of the patient's anemia however he does not have records and does not remember exactly. . The patient yesterday evening went to [**Hospital3 **] to be further eval for his palpitations and bloody stool. Currently he says he has not had a bloody bowel movement for the past 8-12 hours. Last episode was yesterday evening. Otherwise the patient denies any hematemesis or coffee-ground emesis. The patient denies any chest pain, shortness of breath, nausea, vomiting, and diarrhea. He does not have any fevers or chills currently. He also does not have any abdominal pain. . In the ED, initial VS: 97.5, 103, 114/70, 20, 99%. His initial hematocrit was 18.6, repeat the same. They attempted to contact the [**Hospital 2690**] hospital where tagged rbc scan was done however medical records was closed, number is ([**Telephone/Fax (1) 87738**]. He also recieved 1st unit PRBC, needs 2nd unit still. Pt asymptomatic currently, guiac neg. Guiaic trace positive without frank blood in vault. . On arrival to the MICU, he is feeling much better. His anemia symptoms (SOB, dizziness, weakness) have resolved with 1 U pRBCs. He also has not had anymore bleeding today. Has never had pain with his bloody bowel movements but does get nausea. Never had hematemesis. Past Medical History: -Hx of GI bleeds x 2. Most recent bleed in [**10-1**], found to have duodenal ulcer at [**Hospital 87735**] Hospital, which was clipped vs cauterized -Hyperlipidemia -S/p motorcycle accident [**2162**], with bowel resection, ileostomy and reversal. Social History: Lives at home with wife and children. Remote smoker (quit >20 years ago). Denies illicits or etoh intake. Family History: Mother: MI at age 70. Father: MI at age 64. Three children (two sons and one daughter) are healthy. No known GI disease in the family. Physical Exam: On Admission: Vitals: T: 96.8, BP:137/65, P:101, R:18, O2: 100% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP 12-14 cm, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: mildly firm but non-tender, non-distended, bowel sounds present, no organomegaly, well healed midline scar GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, gait deferred On Discharge: Vitals - 97.7 98/58 83 20 97%RA GA: AOx3, NAD HEENT: PERRLA. MMM. no lymphadenopathy. neck supple. Cards: RRR, S1/S2 heard. no murmurs/gallops/rubs. Pulm: CTAB no crackles or wheezes Abd: soft, NT ND, +BS. no organomegaly. Extremities: wwp, no edema. Skin: warm and dry Neuro/Psych: Awake, alert and oriented. Moving all extremities. Pertinent Results: Labs: On Admission - [**2169-1-8**] 05:28PM BLOOD Hct-25.5* [**2169-1-8**] 09:28AM BLOOD WBC-7.3 RBC-3.47*# Hgb-9.6*# Hct-28.8*# MCV-83 MCH-27.6 MCHC-33.4 RDW-16.0* Plt Ct-299 [**2169-1-7**] 08:48PM BLOOD Hct-20.5* [**2169-1-7**] 10:40AM BLOOD WBC-6.3 RBC-2.30*# Hgb-6.2*# Hct-18.6*# MCV-81* MCH-27.1 MCHC-33.5 RDW-16.5* Plt Ct-276 [**2169-1-8**] 09:28AM BLOOD PT-13.2* PTT-28.0 INR(PT)-1.2* [**2169-1-7**] 08:48PM BLOOD PT-13.3* PTT-30.4 INR(PT)-1.2* [**2169-1-7**] 10:40AM BLOOD PT-13.6* PTT-28.0 INR(PT)-1.3* [**2169-1-8**] 09:28AM BLOOD Glucose-89 UreaN-11 Creat-0.8 Na-138 K-4.4 Cl-104 HCO3-27 AnGap-11 [**2169-1-7**] 10:40AM BLOOD Glucose-110* UreaN-17 Creat-0.7 Na-136 K-4.2 Cl-104 HCO3-26 AnGap-10 [**2169-1-7**] 10:40AM BLOOD ALT-22 AST-20 AlkPhos-56 TotBili-1.3 [**2169-1-8**] 09:28AM BLOOD Calcium-8.1* Phos-3.3 Mg-2.4 [**2169-1-7**] 10:40AM BLOOD Albumin-3.3* Calcium-8.3* Phos-3.3 Mg-2.2 On Discharge - [**2169-1-11**] 06:15AM BLOOD WBC-5.9 RBC-3.89* Hgb-10.6* Hct-32.2* MCV-83 MCH-27.4 MCHC-33.0 RDW-16.9* Plt Ct-308 [**2169-1-11**] 06:15AM BLOOD Glucose-110* UreaN-11 Creat-0.9 Na-138 K-3.8 Cl-103 HCO3-27 AnGap-12 [**2169-1-11**] 06:15AM BLOOD Calcium-8.2* Phos-3.5 Mg-2.4 Studies: . CTA Pelvis - IMPRESSION: 1. No evidence of active gastrointestinal hemorrhage. There are some unusual varices about the proximal jejunum shortly beyond what appears to represent a duodenal jejunal anastomotic site although without suggestion of active bleeding. 2. Exophytic nodule (10 mm) along the lower pole of the left kidney, not significantly changed; it may represent an unusual lobulation but a small solid tumor such as renal cell carcinoma is a differential consideration. Follow-up MR evaluation is suggested when clinically appropriate to evaluate further. At that time, a probably hemorrhagic or proteinaceous cyst in the right upper pole could also be reassessed. 3. Stable benign bony findings. 4. Cholelithiasis. . US Gallbladder - IMPRESSION: Mildly echogenic liver, suggestive of hepatic steatosis. No focal liver lesions. No ultrasound evidence of portal hypertension. . Enteroscopy - Impression: Friability and erythema in the stomach antrum compatible with gastritis or GAVE Friability, erythema and erosions in the duodenal-jejunal anastamosis compatible with mild anastamotic enteritis Otherwise normal EGD to mid-jejunum Brief Hospital Course: Mr. [**Known lastname **] is a 49 year old male with history of GI bleed of unknown etiology even after extensive work-up who was transferred from an OSH due to GI bleed. . # GI bleed: Patient flew in from [**State 2690**] to [**Location (un) 86**] the day PTA. Felt unwell during flight. Had palpitations and noted pale skin. Given these Sx, he presented to OSH for eval of BRBPR and palpiations. Transferred to [**Hospital1 18**] at his request. In the ED, the patient was HD stable. Initial labs showed a crit of 18.6. Given 1 unit of PRBCs in the ED and transferred to the MICU. In the MICU the patient received 2 additional transfusions. Remained stable and transferred to the medical floor. On the floor, the patient received 1 additional unit of blood to maintain hct > 25. No further episodes of bleeding. Underwent push enteroscopy that showed friability and erythema in the stomach antrum compatible with gastritis or GAVE. Friability, erythema and erosions in the duodenal-jejunal anastamosis compatible with mild anastamotic enteritis. Records were obtained from patient's hospitalization in [**State **] and it was decided that no further GI interventions were necessary. Source of bleeding believed to be related to prior surgical anastamosis. Seen by surgery who agreed that no furhter inpatient work-up was ncessary. Will be followed by GI and surgery in clinic. . #. Chronic anemia: Baseline hematocrit is 28 but presented with a hematocrit of 18. Transfused 4 units over hospital course. Had a wide RDW. Most likely iron deficiency due to long history of melena and other forms of GIB. Continued on home iron supplementation. . #. Hyperlipidemia: Continued home statin. . #. Depression: Continued home nortriptyline. . #. Transitional issues: - Follow-up with GI and surgery for further evaluation of intermittent GI bleeding Medications on Admission: Simvastatin 40 mg qhs Protonix 40 mg b.i.d. iron 325 mg b.i.d. alendronate qweekly nortriptyline 50 mg qhs Discharge Medications: 1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 2. alendronate 70 mg Tablet Sig: One (1) Tablet PO QWEEK (). Disp:*4 Tablet(s)* Refills:*0* 3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. ferrous sulfate 324 mg (65 mg iron) Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Gastrointestinal Bleed; Source Unknown Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you at [**Hospital1 18**]! You were transferred here due to gastro-intestinal bleeding. In the hospital you were initially in the intensive care unit. You received 4 units of blood and were monitored closely. You underwent an enteroscopy that did not show any active bleeding. You were also seen by our surgeons who did not feel any immediate intervention was necessary. You will be discharged with plans for close follow-up with your primary care doctor, gastroenterology and surgery. See below for changes to your home medication regimen: 1) Please STOP Nortryptiline. This medication was on your medication list however it does not appear you were taking it. See below for instructions regarding follow-up care: Followup Instructions: Department: DIV. OF GASTROENTEROLOGY When: TUESDAY [**2169-1-24**] at 2:00 PM With: [**Name6 (MD) 11170**] [**Last Name (NamePattern4) 11171**], MD [**Telephone/Fax (1) 463**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage Name: [**Doctor Last Name **],DEVINA Location: [**Hospital **] [**Hospital **] HEALTH CENTER Address: [**Location (un) 10215**], [**Hospital1 **],[**Numeric Identifier 9647**] Phone: [**Telephone/Fax (1) 10216**] When: Wednesday, [**1-26**], 2:45 PM Department: GENERAL SURGERY/[**Hospital Unit Name 2193**] When: THURSDAY [**2169-2-2**] at 1:30 PM With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Completed by:[**2169-1-12**]

558,285,280,272,311,355,593,V155

{'Other and unspecified noninfectious gastroenteritis and colitis,Acute posthemorrhagic anemia,Iron deficiency anemia secondary to blood loss (chronic),Other and unspecified hyperlipidemia,Depressive disorder, not elsewhere classified,Mononeuritis of lower limb, unspecified,Unspecified disorder of kidney and ureter,Personal history of other injury'}

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: BRBPR, anemia PRESENT ILLNESS: Mr. [**Known lastname **] is a 49-year-old male with history of anemia and GI bleeds who presents with bright red blood per rectum and hematemesis x1. He has had extensive workup done both here in [**Location (un) 86**] as well some [**State 2690**] including endoscopy, colonoscopy, capsule study, tagged red blood cell scan. On tagged red blood cell scan apparently there was an area that showed possible source of the patient's anemia however he does not have records and does not remember exactly. . The patient yesterday evening went to [**Hospital3 **] to be further eval for his palpitations and bloody stool. Currently he says he has not had a bloody bowel movement for the past 8-12 hours. Last episode was yesterday evening. Otherwise the patient denies any hematemesis or coffee-ground emesis. The patient denies any chest pain, shortness of breath, nausea, vomiting, and diarrhea. He does not have any fevers or chills currently. He also does not have any abdominal pain. . In the ED, initial VS: 97.5, 103, 114/70, 20, 99%. His initial hematocrit was 18.6, repeat the same. They attempted to contact the [**Hospital 2690**] hospital where tagged rbc scan was done however medical records was closed, number is ([**Telephone/Fax (1) 87738**]. He also recieved 1st unit PRBC, needs 2nd unit still. Pt asymptomatic currently, guiac neg. Guiaic trace positive without frank blood in vault. . On arrival to the MICU, he is feeling much better. His anemia symptoms (SOB, dizziness, weakness) have resolved with 1 U pRBCs. He also has not had anymore bleeding today. Has never had pain with his bloody bowel movements but does get nausea. Never had hematemesis. MEDICAL HISTORY: -Hx of GI bleeds x 2. Most recent bleed in [**10-1**], found to have duodenal ulcer at [**Hospital 87735**] Hospital, which was clipped vs cauterized -Hyperlipidemia -S/p motorcycle accident [**2162**], with bowel resection, ileostomy and reversal. MEDICATION ON ADMISSION: Simvastatin 40 mg qhs Protonix 40 mg b.i.d. iron 325 mg b.i.d. alendronate qweekly nortriptyline 50 mg qhs ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: On Admission: Vitals: T: 96.8, BP:137/65, P:101, R:18, O2: 100% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP 12-14 cm, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: mildly firm but non-tender, non-distended, bowel sounds present, no organomegaly, well healed midline scar GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, gait deferred FAMILY HISTORY: Mother: MI at age 70. Father: MI at age 64. Three children (two sons and one daughter) are healthy. No known GI disease in the family. SOCIAL HISTORY: Lives at home with wife and children. Remote smoker (quit >20 years ago). Denies illicits or etoh intake. ### Response: {'Other and unspecified noninfectious gastroenteritis and colitis,Acute posthemorrhagic anemia,Iron deficiency anemia secondary to blood loss (chronic),Other and unspecified hyperlipidemia,Depressive disorder, not elsewhere classified,Mononeuritis of lower limb, unspecified,Unspecified disorder of kidney and ureter,Personal history of other injury'}

CHIEF COMPLAINT: Headache/collapse PRESENT ILLNESS: 65 yo M with no PMH who presents after onset of headache deteriorating to AMS with diffuse SAH. Per wife, patient woke up today in USOH. Around 1600 today he started to develop a headache that was abrupt in onset although at the time didn't seem to be a worst HA of life. Around [**2065**], wife noted that patient became abruptly worse with AMS and then became unresponsive. He was at the time moving all extremities but not coherent. Wife called 911 and patient was taken to an OSH. At the OSH, pt was MAE but not responding to commands and disoriented, was intubated and CT head showed large diffuse SAH.Pt tranferred to [**Hospital1 18**] for further management. On transport to [**Hospital1 **], pt became significantly tachycardic to the 170-180's without hemodynamic instability. He was given 10mg pancuronium 1.5hrs PTA at [**Hospital1 18**]. At [**Hospital1 18**], pt with initial tachycardia to 180's.Initial exam with possible paralysis on board. Repeat CT head was done emergently showing large diffuse SAH with IV extension.Consultation for SAH. MEDICAL HISTORY: None MEDICATION ON ADMISSION: None ALLERGIES: No Allergies/ADRs on File PHYSICAL EXAM: PHYSICAL EXAM: GCS E: 1 V: 1 Motor 1 O: T: 99 BP: 122/79 HR: 68 R vent 20 O2Sats 96% Gen: Intubated/sedated HEENT: Pupils: 6mm bilateral non reactive Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. No C/C/E. FAMILY HISTORY: No family history of SAH SOCIAL HISTORY: Wife denies that patient smokes, drinks, or uses recreational drugs.

Subarachnoid hemorrhage,Cerebral edema,Acute kidney failure, unspecified,Coma,Encounter for palliative care,Do not resuscitate status

Subarachnoid hemorrhage,Cerebral edema,Acute kidney failure NOS,Coma,Encountr palliative care,Do not resusctate status

Admission Date: [**2146-12-25**] Discharge Date: [**2146-12-27**] Date of Birth: [**2081-4-17**] Sex: M Service: NEUROSURGERY Allergies: No Allergies/ADRs on File Attending:[**First Name3 (LF) 2724**] Chief Complaint: Headache/collapse Major Surgical or Invasive Procedure: EVD placement History of Present Illness: 65 yo M with no PMH who presents after onset of headache deteriorating to AMS with diffuse SAH. Per wife, patient woke up today in USOH. Around 1600 today he started to develop a headache that was abrupt in onset although at the time didn't seem to be a worst HA of life. Around [**2065**], wife noted that patient became abruptly worse with AMS and then became unresponsive. He was at the time moving all extremities but not coherent. Wife called 911 and patient was taken to an OSH. At the OSH, pt was MAE but not responding to commands and disoriented, was intubated and CT head showed large diffuse SAH.Pt tranferred to [**Hospital1 18**] for further management. On transport to [**Hospital1 **], pt became significantly tachycardic to the 170-180's without hemodynamic instability. He was given 10mg pancuronium 1.5hrs PTA at [**Hospital1 18**]. At [**Hospital1 18**], pt with initial tachycardia to 180's.Initial exam with possible paralysis on board. Repeat CT head was done emergently showing large diffuse SAH with IV extension.Consultation for SAH. Past Medical History: None Social History: Wife denies that patient smokes, drinks, or uses recreational drugs. Family History: No family history of SAH Physical Exam: PHYSICAL EXAM: GCS E: 1 V: 1 Motor 1 O: T: 99 BP: 122/79 HR: 68 R vent 20 O2Sats 96% Gen: Intubated/sedated HEENT: Pupils: 6mm bilateral non reactive Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. No C/C/E. Neuro: Mental status: Intubated, GCS 3 Cranial Nerves: I: Not tested II: 6mm equal round and non reactive to light. III, IV, VI: Unable to assess V, VII: unable to assess VIII: Unable to assess IX, X: Unable to assess [**Doctor First Name 81**]: Unable to assess XII: Unable to assess. Motor: Normal bulk and tone bilaterally. No purposeful movement. BUE no response to painful stim. BLE withdraws to painful stimuli. Reflexes: No cough/gag. Toes downgoing bilaterally Exam upon discharge: expired per brain death criteria Pertinent Results: CT Head: extensive SAH & IVH involving both lateral, 3rd, & 4th ventricles; diffuse edema Brief Hospital Course: Pt presented to ED with fixed and dilated pupils and massive hemorrhage on CT. EVD placed emergently showing high ICPs. Pt was monitored closely in ICU with no improvement in exam. Family discussion was held to discuss grave prognosis. [**Location (un) 511**] Organ Bank also spoke with family and they stated he would want to donate his organs. He was met brain death criteria in the afternoon of [**2146-12-27**]. Medications on Admission: None Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Massive intracerbral hemorrhage Discharge Condition: expired Discharge Instructions: none Followup Instructions: none Completed by:[**2146-12-27**]

430,348,584,780,V667,V498

{'Subarachnoid hemorrhage,Cerebral edema,Acute kidney failure, unspecified,Coma,Encounter for palliative care,Do not resuscitate 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: Headache/collapse PRESENT ILLNESS: 65 yo M with no PMH who presents after onset of headache deteriorating to AMS with diffuse SAH. Per wife, patient woke up today in USOH. Around 1600 today he started to develop a headache that was abrupt in onset although at the time didn't seem to be a worst HA of life. Around [**2065**], wife noted that patient became abruptly worse with AMS and then became unresponsive. He was at the time moving all extremities but not coherent. Wife called 911 and patient was taken to an OSH. At the OSH, pt was MAE but not responding to commands and disoriented, was intubated and CT head showed large diffuse SAH.Pt tranferred to [**Hospital1 18**] for further management. On transport to [**Hospital1 **], pt became significantly tachycardic to the 170-180's without hemodynamic instability. He was given 10mg pancuronium 1.5hrs PTA at [**Hospital1 18**]. At [**Hospital1 18**], pt with initial tachycardia to 180's.Initial exam with possible paralysis on board. Repeat CT head was done emergently showing large diffuse SAH with IV extension.Consultation for SAH. MEDICAL HISTORY: None MEDICATION ON ADMISSION: None ALLERGIES: No Allergies/ADRs on File PHYSICAL EXAM: PHYSICAL EXAM: GCS E: 1 V: 1 Motor 1 O: T: 99 BP: 122/79 HR: 68 R vent 20 O2Sats 96% Gen: Intubated/sedated HEENT: Pupils: 6mm bilateral non reactive Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. No C/C/E. FAMILY HISTORY: No family history of SAH SOCIAL HISTORY: Wife denies that patient smokes, drinks, or uses recreational drugs. ### Response: {'Subarachnoid hemorrhage,Cerebral edema,Acute kidney failure, unspecified,Coma,Encounter for palliative care,Do not resuscitate status'}

CHIEF COMPLAINT: chest pain PRESENT ILLNESS: 63 yo male with pmhx of HTN initially presented to [**Hospital1 **] on [**2144-2-11**] at 2:45am with chest heaviness. Pt describes the heaviness as starting 2-3 days prior to admission, lasting 10-15 minutes, occurring 2-3x / day, and associated with symptoms of feeling exhausted and jaw discomfort. Of note, pain is not associated with exertion, nausea, diaphoresis, palpitations, or pleuritic characteristics. Then one night ago, patient had difficulty lying flat, felt increasing discomfort, and presented to OSH ED. At OSH ED, initial vital signs were BP 190/93, HR 77, RR 20, T 97.5, Sat 100 RA. He was given nitroglycerine paste, then switched to Nitro drip, receivd 5mg IV metoprolol x 3, and was then transferred to [**Hospital1 18**] for further evaluation. Initial ECG (2:55am on [**2-11**]) at OSH demonstrated HR 74, sinus rhythm, LVH, left anterior hemi fascicular block, st depression <1mm v4-v5-v6-I-AVL, no t wave inversion. Another ECG during transport at 7:51 am has new t wave inversions on III-AVF. Patient was then admitted to the CCU where he underwent aspirin desensitization due to an aspirin allergy and was then transferred to the floor. . At baseline, patient is very active in his work as a carpenter and he uses an exercise bike for 20 minutes several times a week. He can go up 3-4 flight of stairs or walk more than [**12-17**] blocks without discomfort. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . CARDIAC RISK FACTORS: Dyslipidemia, Hypertension MEDICAL HISTORY: Hypertension Hyperlipidemia Heart Murmur MEDICATION ON ADMISSION: Atenolol 25 mg PO daily Omega-3 100 mg COq10 60 mg Lecithin granules 1 tsp daily ? Prostate support ALLERGIES: Aspirin / Penicillins PHYSICAL EXAM: BP 154/50, HR 82 RR 16 Sats 99 % RA General: Patient well developed, well nourished, oriented x 3 HEENT: Pupils equal and reactive to light. dry oral mycose Neck: No JVD, no LAD. No thyromegaly appreciated. Neck supple. Lungs: Clear to ausculation bilaterally. Cardiac: Regular rate and rhythm, s1-s2 normal. Holosytolic murmur III/VI in the apex., No rubs, gallops appreciated. Abdomen: BS+, soft, non tender, non distended. NO hepatomegaly. FAMILY HISTORY: There is no family history of premature coronary artery disease or sudden death. Father [**Name (NI) **] cancer, Grand mother Stomach cancer, SOCIAL HISTORY: Social history is significant for the absence of current tobacco use. He gave up smoking about 25 years ago. Smoked pipe or chew tobacco for 10-15 years. There is no history of alcohol abuse. He works as a carpenter. He lives with his wife and 3 kids in [**Last Name (un) 21037**]. He rarely eat red meed and no dairy products.

Subendocardial infarction, initial episode of care,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia,Unspecified essential hypertension

Subendo infarct, initial,Crnry athrscl natve vssl,Hyperlipidemia NEC/NOS,Hypertension NOS

Admission Date: [**2144-2-11**] Discharge Date: [**2144-2-13**] Date of Birth: [**2080-6-21**] Sex: M Service: MEDICINE Allergies: Aspirin / Penicillins Attending:[**First Name3 (LF) 2698**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Cardiac Catherization History of Present Illness: 63 yo male with pmhx of HTN initially presented to [**Hospital1 **] on [**2144-2-11**] at 2:45am with chest heaviness. Pt describes the heaviness as starting 2-3 days prior to admission, lasting 10-15 minutes, occurring 2-3x / day, and associated with symptoms of feeling exhausted and jaw discomfort. Of note, pain is not associated with exertion, nausea, diaphoresis, palpitations, or pleuritic characteristics. Then one night ago, patient had difficulty lying flat, felt increasing discomfort, and presented to OSH ED. At OSH ED, initial vital signs were BP 190/93, HR 77, RR 20, T 97.5, Sat 100 RA. He was given nitroglycerine paste, then switched to Nitro drip, receivd 5mg IV metoprolol x 3, and was then transferred to [**Hospital1 18**] for further evaluation. Initial ECG (2:55am on [**2-11**]) at OSH demonstrated HR 74, sinus rhythm, LVH, left anterior hemi fascicular block, st depression <1mm v4-v5-v6-I-AVL, no t wave inversion. Another ECG during transport at 7:51 am has new t wave inversions on III-AVF. Patient was then admitted to the CCU where he underwent aspirin desensitization due to an aspirin allergy and was then transferred to the floor. . At baseline, patient is very active in his work as a carpenter and he uses an exercise bike for 20 minutes several times a week. He can go up 3-4 flight of stairs or walk more than [**12-17**] blocks without discomfort. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . CARDIAC RISK FACTORS: Dyslipidemia, Hypertension Past Medical History: Hypertension Hyperlipidemia Heart Murmur Social History: Social history is significant for the absence of current tobacco use. He gave up smoking about 25 years ago. Smoked pipe or chew tobacco for 10-15 years. There is no history of alcohol abuse. He works as a carpenter. He lives with his wife and 3 kids in [**Last Name (un) 21037**]. He rarely eat red meed and no dairy products. Family History: There is no family history of premature coronary artery disease or sudden death. Father [**Name (NI) **] cancer, Grand mother Stomach cancer, Physical Exam: BP 154/50, HR 82 RR 16 Sats 99 % RA General: Patient well developed, well nourished, oriented x 3 HEENT: Pupils equal and reactive to light. dry oral mycose Neck: No JVD, no LAD. No thyromegaly appreciated. Neck supple. Lungs: Clear to ausculation bilaterally. Cardiac: Regular rate and rhythm, s1-s2 normal. Holosytolic murmur III/VI in the apex., No rubs, gallops appreciated. Abdomen: BS+, soft, non tender, non distended. NO hepatomegaly. Extremities: No edema, pallor or cyanosis. Right groin: No bruit, no hematoma Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: [**2144-2-11**] 09:32AM BLOOD WBC-6.6 RBC-4.55* Hgb-13.7* Hct-39.1* MCV-86 MCH-30.1 MCHC-35.0 RDW-13.1 Plt Ct-344 [**2144-2-13**] 06:05AM BLOOD WBC-8.6 RBC-4.61 Hgb-13.9* Hct-39.8* MCV-86 MCH-30.1 MCHC-34.9 RDW-13.2 Plt Ct-293 [**2144-2-13**] 06:05AM BLOOD PT-12.4 PTT-22.6 INR(PT)-1.1 [**2144-2-11**] 09:32AM BLOOD Glucose-133* UreaN-11 Creat-0.8 Na-140 K-4.1 Cl-105 HCO3-27 AnGap-12 [**2144-2-13**] 06:05AM BLOOD Glucose-94 Creat-0.7 Na-140 K-3.8 Cl-105 HCO3-26 AnGap-13 [**2144-2-11**] 09:32AM BLOOD CK(CPK)-165 [**2144-2-11**] 07:30PM BLOOD CK(CPK)-147 [**2144-2-12**] 05:30AM BLOOD CK(CPK)-136 [**2144-2-11**] 09:32AM BLOOD CK-MB-8 cTropnT-0.11* [**2144-2-11**] 07:30PM BLOOD CK-MB-6 cTropnT-0.19* [**2144-2-12**] 05:30AM BLOOD CK-MB-5 cTropnT-0.18* [**2144-2-11**] 09:32AM BLOOD Triglyc-104 HDL-52 CHOL/HD-5.7 LDLcalc-224* LDLmeas-232* [**2144-2-11**] 09:32AM BLOOD Calcium-9.2 Phos-3.4 Mg-2.3 Cholest-297* PTCA COMMENTS: Initial angiography revealed a 100% thrombotic occlusion of proximal RCA with collaterals from left system. We planned to treat this stenosis with PTCA/stenting. We commenced heparin and Integrilin prophylactically. A 6F AR-2 guide enagaged the RCA providing adequate support. A whisper wire crossed proximal RCA occlusion without complication and the lesion was then predilated with a 2.5x9mm balloon. There was no flow after the predilatation. We then used a Quickcat thrombectomy catheter resulting in removal of thrombus but no antegrade flow. We then further predilated with a 3.5x15mm balloon with restoration of normal flow. We then stented the lesion with a 3.5x18mm Vision stent deployed to 14atms. Excellent result with normal antegrade flow and no residual stenosis. Patient remained painfree throughout procedure. COMMENTS: 1. Selective coronary angiography of this right dominant system revealed two vessel disease. The LMCA and LCX had no angiographically-apparent disease. The LAD had a mild, tapering 50% lesion in the proximal vessel. The RCA was occluded proximally with visible thrombus. 2. Left ventriculography revealed a normal ejection fraction with no mitral regurgitation or wall motion abnormalities. 3. LVEDP was mildly elevated at 18mmHg. 4. Successful PCI/stent to proximal RCA thrombotic occlusion with a 3.5x15mm Vision bare metal stent. Excellent result with normal antegrade flow and no residual stenosis. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Normal ventricular function. 3. Successful PCI/stent to proximal RCA. . CT abd/pelvis [**2-12**]: 1. Large amount of fat stranding within the right inguinal region extending along the right anterior medial thigh consistent with _____ blood products, but no focal fluid collections suggestive of an organizing hematoma are present. 2. No retroperitoneal hematoma identified. 3. Enlarged prostate with peripheral calcification suggestive of chronic prostatitis. . Echocardiogram [**2144-2-13**]: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 70%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (area 1.2-1.9cm2). The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion Brief Hospital Course: 63 y/o M with h/o HTN who presents with two days of chest discomfort who was found to have mild, tapering 50% lesion in the proximal LAD and proximal RCA occluded with visible thrombus. # ACS: Transfered from OSH for ASA desensitization and cardiac catherization. On arrival Pt chest pain free. Pt loaded with [**Month/Day/Year **], Heparin and Integrillin started. Pt tolerated ASA desensitization without difficulty. Remained chest pain free until cath which showed mild, tapering 50% lesion in the proximal LAD and proximal RCA occluded with visible thrombus for which he underwent PTCA with placement of BMS. After procedure, during sheath pull, patient became hypotensive briefly, likely [**1-17**] vago-vagal response. He was given fluids and atropine and BP normalized. He was also noted to have a significant drop in Hct, and received 2 units PRBCs. CT abd/pelvis was negative for RP bleed. Repeat Hct after only 1 unit was back to baseline, indicating some degree of lab error. Hct was checked q6H and remained stable. He received aspirin, [**Month/Day (2) 4532**], BB, statin, and ACEi. Repeat echocardiogram without evidence of thrombus or depressed EF. The patient was discharged to home with post-MI instructions in addition to follow with PCP and new cardiologist. . # Hyperlipidemia: The patient was continued on Zetia and started on Statin. . # HTN: Metoprolol and low dose lisinopril. . # FEN: Cardiac/heart healthy diet . # Ppx: He was on heparin drip, and then was ambulatory. . FULL CODE Medications on Admission: Atenolol 25 mg PO daily Omega-3 100 mg COq10 60 mg Lecithin granules 1 tsp daily ? Prostate support Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: NSTEMI Discharge Condition: Afebrile, vital signs stable. Discharge Instructions: You were admitted with a heart attack and had a stent placed. It is very important that you take all your medications as directed, especially [**Last Name (LF) 4532**], [**First Name3 (LF) **] your cardiologist. . Call your PCP or return to the closest Emergency Department if you have: chest pain, shortness of breath, fainting spell, recurrent fevers, inability to keep down food or drink, or any other concerning symptoms. Followup Instructions: Please call your PCP and make an appointment to be seen in 1 week. You need to start seeing a cardiologist. If you would like to be seen close to home ask your PCP for [**Name Initial (PRE) **] referral. Otherwise please call the [**Hospital1 18**] Cardiology department at ([**Telephone/Fax (1) 2037**] and make an appointment to be seen in 1 month by Dr [**Last Name (STitle) **] along with Dr [**Last Name (STitle) 4019**] or Dr. [**Last Name (STitle) **]. Completed by:[**2144-2-17**]

410,414,272,401

{'Subendocardial infarction, initial episode of care,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia,Unspecified essential hypertension'}

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: chest pain PRESENT ILLNESS: 63 yo male with pmhx of HTN initially presented to [**Hospital1 **] on [**2144-2-11**] at 2:45am with chest heaviness. Pt describes the heaviness as starting 2-3 days prior to admission, lasting 10-15 minutes, occurring 2-3x / day, and associated with symptoms of feeling exhausted and jaw discomfort. Of note, pain is not associated with exertion, nausea, diaphoresis, palpitations, or pleuritic characteristics. Then one night ago, patient had difficulty lying flat, felt increasing discomfort, and presented to OSH ED. At OSH ED, initial vital signs were BP 190/93, HR 77, RR 20, T 97.5, Sat 100 RA. He was given nitroglycerine paste, then switched to Nitro drip, receivd 5mg IV metoprolol x 3, and was then transferred to [**Hospital1 18**] for further evaluation. Initial ECG (2:55am on [**2-11**]) at OSH demonstrated HR 74, sinus rhythm, LVH, left anterior hemi fascicular block, st depression <1mm v4-v5-v6-I-AVL, no t wave inversion. Another ECG during transport at 7:51 am has new t wave inversions on III-AVF. Patient was then admitted to the CCU where he underwent aspirin desensitization due to an aspirin allergy and was then transferred to the floor. . At baseline, patient is very active in his work as a carpenter and he uses an exercise bike for 20 minutes several times a week. He can go up 3-4 flight of stairs or walk more than [**12-17**] blocks without discomfort. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . CARDIAC RISK FACTORS: Dyslipidemia, Hypertension MEDICAL HISTORY: Hypertension Hyperlipidemia Heart Murmur MEDICATION ON ADMISSION: Atenolol 25 mg PO daily Omega-3 100 mg COq10 60 mg Lecithin granules 1 tsp daily ? Prostate support ALLERGIES: Aspirin / Penicillins PHYSICAL EXAM: BP 154/50, HR 82 RR 16 Sats 99 % RA General: Patient well developed, well nourished, oriented x 3 HEENT: Pupils equal and reactive to light. dry oral mycose Neck: No JVD, no LAD. No thyromegaly appreciated. Neck supple. Lungs: Clear to ausculation bilaterally. Cardiac: Regular rate and rhythm, s1-s2 normal. Holosytolic murmur III/VI in the apex., No rubs, gallops appreciated. Abdomen: BS+, soft, non tender, non distended. NO hepatomegaly. FAMILY HISTORY: There is no family history of premature coronary artery disease or sudden death. Father [**Name (NI) **] cancer, Grand mother Stomach cancer, SOCIAL HISTORY: Social history is significant for the absence of current tobacco use. He gave up smoking about 25 years ago. Smoked pipe or chew tobacco for 10-15 years. There is no history of alcohol abuse. He works as a carpenter. He lives with his wife and 3 kids in [**Last Name (un) 21037**]. He rarely eat red meed and no dairy products. ### Response: {'Subendocardial infarction, initial episode of care,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia,Unspecified essential hypertension'}

CHIEF COMPLAINT: Increased chest pain and shortness of breath. PRESENT ILLNESS: The patient is a 68-year-old gentleman with a known history of coronary artery disease and recent onset of atrial fibrillation. The patient complained of increased symptoms of dyspnea and angina. He underwent cardiac catheterization, which revealed three-vessel disease. He is now admitted for coronary artery bypass graft. MEDICAL HISTORY: 1. Coronary artery disease status post myocardial infarction 2. Recent onset atrial fibrillation in the past eight weeks. 3. Tuberculosis. The patient was hospitalized for two months in the [**2095**]. 4. Hypertension. 5. Noninsulin dependent diabetes mellitus. 6. Gastroesophageal reflux disease. 7. Prostate carcinoma status post XRT and brachytherapy. 8. CVA times three in [**2098**], [**2108**], and [**2111**]. 9. Hypercholesterolemia. MEDICATION ON ADMISSION: 1. Plavix discontinued [**4-11**]. 2. Detrol 2 mg b.i.d. 3. Atenolol 75 mg in the AM; 50 mg q.PM. 4. Glyburide 3 mg b.i.d. 5. Lipitor 10 mg h.s. 6. Amitriptyline 10 mg q.d. 7. Zestril 30 mg q.a.m. and 10 mg q.p.m. ALLERGIES: The patient is allergic to ASPIRIN, WHICH CAUSES INCREASED FACIAL SWELLING AND INCREASED SHORTNESS OF BREATH. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

Coronary atherosclerosis of native coronary artery,Other and unspecified angina pectoris,Atrial fibrillation,Mitral valve disorders,Syncope and collapse,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Esophageal reflux

Crnry athrscl natve vssl,Angina pectoris NEC/NOS,Atrial fibrillation,Mitral valve disorder,Syncope and collapse,DMII wo cmp nt st uncntr,Hypertension NOS,Esophageal reflux

Admission Date: [**2118-4-19**] Discharge Date: [**2118-4-28**] Date of Birth: [**2049-7-21**] Sex: M Service: CARDIAC S. DATE OF DISCHARGE: Pending awaiting rehabilitation bed. CHIEF COMPLAINT: Increased chest pain and shortness of breath. HISTORY OF THE PRESENT ILLNESS: The patient is a 68-year-old gentleman with a known history of coronary artery disease and recent onset of atrial fibrillation. The patient complained of increased symptoms of dyspnea and angina. He underwent cardiac catheterization, which revealed three-vessel disease. He is now admitted for coronary artery bypass graft. PAST MEDICAL HISTORY: 1. Coronary artery disease status post myocardial infarction 2. Recent onset atrial fibrillation in the past eight weeks. 3. Tuberculosis. The patient was hospitalized for two months in the [**2095**]. 4. Hypertension. 5. Noninsulin dependent diabetes mellitus. 6. Gastroesophageal reflux disease. 7. Prostate carcinoma status post XRT and brachytherapy. 8. CVA times three in [**2098**], [**2108**], and [**2111**]. 9. Hypercholesterolemia. PAST SURGICAL HISTORY: 1. Right carotid endarterectomy in [**2109**]. 2. Stomach repair status post multiple stab wounds in the [**2075**]. 3. Benign tumor left axillary area, probably [**2075**]. 4. Back surgery in [**2089**]. MEDICATIONS ON ADMISSION: 1. Plavix discontinued [**4-11**]. 2. Detrol 2 mg b.i.d. 3. Atenolol 75 mg in the AM; 50 mg q.PM. 4. Glyburide 3 mg b.i.d. 5. Lipitor 10 mg h.s. 6. Amitriptyline 10 mg q.d. 7. Zestril 30 mg q.a.m. and 10 mg q.p.m. ALLERGIES: The patient is allergic to ASPIRIN, WHICH CAUSES INCREASED FACIAL SWELLING AND INCREASED SHORTNESS OF BREATH. HOSPITAL COURSE: The patient underwent coronary artery bypass graft times on [**2118-4-19**]. The patient was taken to the CSRU intubated and on Milrinone and nitroglycerin drips. The patient was extubated on postoperative day #1. He was started on Amiodarone for atrial fibrillation. On postoperative day #2, the patient was slightly agitated and required Haldol. The blood pressure was labile and he needed antihypertensive medication. The patient continued to be in atrial fibrillation. He made slow progress over the next couple of days. He had some episodes of wheezing, which improved with treatment with nebulizers. The patient progressively improved in his mental status and he was more oriented in the next couple of days. On [**2118-4-24**], while on the bedside commode, the patient had a brief period of unresponsiveness for about 30 seconds. The heart rate and blood pressure were stable at this point. The patient was transferred to the regular floor in stable condition on postoperative day #6. While on the floor, the mental status again improved significantly. He was left confused and more oriented. He was started on heparin drip for atrial fibrillation and on Coumadin. The pacing wires were discontinued on postoperative day #7. He stayed in house until he became therapeutic on his Coumadin. He was ready for discharge to rehabilitation on postoperative day #9. MEDICATIONS ON DISCHARGE: 1. Lopressor 75 mg b.i.d. 2. Lasix 20 mg q.d. times one week. 3. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq q.d. times one week. 4. Colace 100 mg b.i.d. 5. Zantac 150 mg b.i.d. 6. Amiodarone 400 mg q.d. times one month. 7. Atrovent and Albuterol nebulizers q.4h.p.r.n. 8. Lisinopril 30 mg q.a.m., 10 mg q.p.m. 9. Coumadin 3 mg q.d. with goal INR 1.8 to 2.5. The primary care physician is to follow the INR after discharge from rehabilitation. 10. Glyburide 3 mg b.i.d. 11. Lipitor 10 mg h.s. 12. Tylenol with codeine one to two tablets q.4h. to 6h.p.r.n. CONDITION ON DISCHARGE: Stable. The patient is being discharged to a rehabilitation facility. FO[**Last Name (STitle) **]P CARE: The patient is to followup with Dr. [**First Name (STitle) **], primary care physician in two weeks and Dr. [**Last Name (Prefixes) **] in four weeks. INR has to be checked twice q.week at rehabilitation and will be followed by the primary care physician post discharge. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern1) 2209**] MEDQUIST36 D: [**2118-4-28**] 11:43 T: [**2118-4-28**] 14:15 JOB#: [**Job Number 2674**]

414,413,427,424,780,250,401,530

{'Coronary atherosclerosis of native coronary artery,Other and unspecified angina pectoris,Atrial fibrillation,Mitral valve disorders,Syncope and collapse,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Esophageal reflux'}

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: Increased chest pain and shortness of breath. PRESENT ILLNESS: The patient is a 68-year-old gentleman with a known history of coronary artery disease and recent onset of atrial fibrillation. The patient complained of increased symptoms of dyspnea and angina. He underwent cardiac catheterization, which revealed three-vessel disease. He is now admitted for coronary artery bypass graft. MEDICAL HISTORY: 1. Coronary artery disease status post myocardial infarction 2. Recent onset atrial fibrillation in the past eight weeks. 3. Tuberculosis. The patient was hospitalized for two months in the [**2095**]. 4. Hypertension. 5. Noninsulin dependent diabetes mellitus. 6. Gastroesophageal reflux disease. 7. Prostate carcinoma status post XRT and brachytherapy. 8. CVA times three in [**2098**], [**2108**], and [**2111**]. 9. Hypercholesterolemia. MEDICATION ON ADMISSION: 1. Plavix discontinued [**4-11**]. 2. Detrol 2 mg b.i.d. 3. Atenolol 75 mg in the AM; 50 mg q.PM. 4. Glyburide 3 mg b.i.d. 5. Lipitor 10 mg h.s. 6. Amitriptyline 10 mg q.d. 7. Zestril 30 mg q.a.m. and 10 mg q.p.m. ALLERGIES: The patient is allergic to ASPIRIN, WHICH CAUSES INCREASED FACIAL SWELLING AND INCREASED SHORTNESS OF BREATH. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: ### Response: {'Coronary atherosclerosis of native coronary artery,Other and unspecified angina pectoris,Atrial fibrillation,Mitral valve disorders,Syncope and collapse,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Esophageal reflux'}

CHIEF COMPLAINT: Ankle swelling, feeling weak. PRESENT ILLNESS: Mr. [**Known lastname 7086**] is a 64-year-old Guatemalan man with a history of hypertension, diabetes, and smoking who was recently treated for bronchitis with Azithromycin. He presented to his primary care doctor on the day of admission for followup. He was noted to have bilateral edema which developed over the past four days and a heart rate greater than 150. He was sent to the Emergency Room at [**Hospital1 **]-Nishoba. There his EKG and echocardiogram were hemodynamically stable and he was transferred to [**Hospital6 1760**] for further care. He reports recent cough productive of sputum. There was no fever or chills. He also complained of throat pain and soreness. He described orthopnea but no paroxysmal nocturnal dyspnea. He denied chest pain, shortness of breath, diaphoresis, nausea, vomiting, abdominal pain, diarrhea, constipation, recent weight loss, or chills. He has never had a history of cardiac disease. MEDICAL HISTORY: The patient has a past medical history of hypertension, cerebrovascular accident 15 years ago, diabetes mellitus times six years, right eye injury, right leg break, and PPD negative recently at his primary care doctor's office. MEDICATION ON ADMISSION: ALLERGIES: Not known. PHYSICAL EXAM: FAMILY HISTORY: The family history is notable for liver cancer. SOCIAL HISTORY: The patient is married with four children and was recently in [**Location (un) 86**] from [**Country 7192**]. He was a teacher.

Congestive heart failure, unspecified,Atrial fibrillation,Swelling, mass, or lump in chest,Obstructive chronic bronchitis with (acute) exacerbation,Endocarditis, valve unspecified, unspecified cause,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension

CHF NOS,Atrial fibrillation,Chest swelling/mass/lump,Obs chr bronc w(ac) exac,Endocarditis NOS,DMII wo cmp nt st uncntr,Hypertension NOS

Admission Date: [**2119-1-24**] Discharge Date: Date of Birth: [**2054-9-28**] Sex: M Service: CHIEF COMPLAINT: Ankle swelling, feeling weak. SOURCE OF HISTORY: The history is obtained from Dr. [**First Name (STitle) **]. HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 7086**] is a 64-year-old Guatemalan man with a history of hypertension, diabetes, and smoking who was recently treated for bronchitis with Azithromycin. He presented to his primary care doctor on the day of admission for followup. He was noted to have bilateral edema which developed over the past four days and a heart rate greater than 150. He was sent to the Emergency Room at [**Hospital1 **]-Nishoba. There his EKG and echocardiogram were hemodynamically stable and he was transferred to [**Hospital6 1760**] for further care. He reports recent cough productive of sputum. There was no fever or chills. He also complained of throat pain and soreness. He described orthopnea but no paroxysmal nocturnal dyspnea. He denied chest pain, shortness of breath, diaphoresis, nausea, vomiting, abdominal pain, diarrhea, constipation, recent weight loss, or chills. He has never had a history of cardiac disease. PAST MEDICAL HISTORY: The patient has a past medical history of hypertension, cerebrovascular accident 15 years ago, diabetes mellitus times six years, right eye injury, right leg break, and PPD negative recently at his primary care doctor's office. MEDICATIONS: Amaryl 2.5 mg p.o. q.d., Accupril, Azithromycin, Glucotrol, and Hydrochlorothiazide. ALLERGIES: Not known. SOCIAL HISTORY: The patient is married with four children and was recently in [**Location (un) 86**] from [**Country 7192**]. He was a teacher. FAMILY HISTORY: The family history is notable for liver cancer. PHYSICAL EXAMINATION: Temperature was 99.6, blood pressure 100/70, heart rate 170 and irregularly irregular, and respiratory rate 17. The patient was saturating at 100% on 4 liters of oxygen. In general, he appeared alert, awake, and oriented times three lying comfortably. He had a small right pupil and the eye had a corneal scar. The left pupil was round and reactive. Extraocular movements were normal. Jugular venous pressure was elevated at 5 cm according to Dr.[**Name (NI) 34140**] note and 16 cm according to Dr. [**Last Name (STitle) **]. There were no carotid bruits. The thyroid was palpable. There was no lymphadenopathy. The chest revealed a few bibasilar crackles with good air movement bilaterally. There was no dullness. On cardiac examination, he had hyperdynamic precordium. There was a systolic ejection murmur across the precordium as well. The abdomen was soft and nontender with normal bowel sounds. No spleen was palpable. Guaiac was negative. The liver was palpable 3.4 cm below the costal margin. The extremities showed good distal pulses. Neurologically, cranial nerves II-XII were intact. He had 5/5 strength throughout. There was a constant grimace and he had normal speech. LABORATORY INVESTIGATIONS: Sodium was 129, potassium 3.9, chloride 90, bicarbonate 26, BUN 17, creatinine 0.5, glucose 308, white blood cell count 13.3, hematocrit 40.7, platelets 395,000. Coagulation parameters were normal. Magnesium was 1.8, albumin 2.6, calcium 8.5, CK 36. At the outside hospital he was noted to have elevated liver function tests and alkaline phosphatase. Troponin was less than 0.2. An electrocardiogram revealed a rate of 170 in atrial flutter. There was normal axis and normal intervals with left ventricular hypertrophy and J point elevation. An echocardiogram obtained from [**Hospital1 **]-Nishoba Emergency Room showed an ejection fraction of approximately 10%. The left ventricle was normal in size. There was severe global hypokinesis. There was moderate to severe tricuspid regurgitation. The right ventricle showed severe global hypokinesis. A chest x-ray on [**2119-1-16**] showed a large heart silhouette and right lower lobe mass. On [**2119-1-24**], he had a question of congestion and persistent right lower lobe mass. AST was 35, ALT 50, alkaline phosphatase 284, total bilirubin 0.4, TSH 1.2, free T4 1.2, serum iron level 30, TIBC 300, TRF 154. HOSPITAL COURSE: In summary, Mr. [**Known lastname 7086**] is a 64-year-old man with new onset atrial flutter and severely depressed cardiac function with evidence of congestive heart failure. His hospital course can be summarized as follows. Rhythm: Initially Mr. [**Known lastname 7086**] was in atrial flutter with 2:1 block at a rate of 133. He was asymptomatic from this point of view and hemodynamically stable. He did not appear volume overloaded initially. A transesophageal echocardiogram was obtained to assess for the possibility of clots. This showed no mass nor thrombus in the left atrium nor the right atrium. There was evidence of mild aortic stenosis and diffuse atheromatous aorta. Therefore, Mr. [**Known lastname 7086**] was cardioverted and in less than one hour he reverted spontaneously to atrial fibrillation post procedure. To manage this, Amiodarone was initially considered but because of concerns of liver and pulmonary toxicity, was not pursued. Therefore Procainamide intravenously was used and he converted to sinus rhythm; however when the Procainamide was transitioned to an oral regimen, he reverted to atrial fibrillation and intravenous Procainamide was therefore re-initiated. Mr. [**Known lastname 7086**] [**Last Name (Titles) **] converted to sinus rhythm again after 12 hours. A Procainamide level check was 16 which was elevated. When he was once again changed to oral Procainamide, he reverted to atrial fibrillation. Therefore Amiodarone was started on [**2119-1-29**] after which he developed intermittent paroxysmal atrial fibrillation. A repeat transesophageal echocardiogram on [**2119-2-1**] showed a thrombus in the left atrial appendage and he converted to normal sinus rhythm spontaneously. In terms of his anticoagulation, this had initially been considered when he was in atrial fibrillation but because of intermittent symptoms of hemoptysis, this was not pursued. On bronchoscopy, when no endobronchial lesion was found, Mr. [**Known lastname 7086**] was therefore heparinized. Congestive heart failure: Mr. [**Known lastname 7086**] was in florid congestive heart failure as evidenced by a JVP of 16 cm along with scrotal and pedal edema. His ejection fraction of less than 10% combining with severe global left ventricular hypokinesis and moderate aortic stenosis was likely a contributor to his congestive heart failure. Our choice of therapy was limited by his blood pressure. His ACE inhibitor starting with Captopril 6.25 mg p.o. t.i.d. was poorly tolerated because of his hypotension. We therefore continued him on low dose ACE inhibitor and held this with the parameter of systolic pressure of 80. The goal would be to help in ventricular remodeling and to enhance forward flow. As well, Mr. [**Known lastname 7086**] was also started on Lasix 20 mg p.o. q.d. initially and had a poor response but then diuresed well over the ensuing days. In the hospital, Mr. [**Known lastname 7086**] complained of chest pressure/pain intermittently. Electrocardiograms obtained repeatedly showed atrial fibrillation but no new EKG changes. His CKs were cycled along with his symptoms and have remained negative to date. A catheterization was also considered but withheld because of Mr. [**Known lastname 7086**]' questionable lung mass. At the time of dictation, it is unlikely that we will pursue catheterization because it is unclear that this would change his prognosis. Pulmonary: Mr. [**Known lastname 7086**]' right lower lobe mass was concerning for tumor. A bronchoscopy was delayed until [**2119-2-2**] because of his atrial fibrillation. This revealed no endobronchial lesions. Sputum washings were obtained all of which have been negative for malignant cells. A thoracentesis was also performed for a right pleural effusion. This procedure was difficult and required multiple attempts under ultrasound guidance. Eventually 150 cc of fluid was sent and the pathology revealed no malignant cells. He had no pneumothorax post procedure. Mr. [**Known lastname 7086**] complained of shortness of breath intermittently. Because of a concern for possible chronic obstructive pulmonary disease, he was begun on Atrovent and Levaquin on [**2119-2-5**] with symptomatic improvement. At the time of dictation, a VAT versus transbronchial lung biopsy were under consideration by Dr. [**First Name (STitle) **] [**Name (STitle) **] given the non-diagnostic sputum/bronchial washings/pleural fluid. Gastrointestinal: Mr. [**Known lastname 7086**]' elevated liver function tests were consistent with an obstructive picture. On hospital day #4, he developed some nausea which was felt to be secondary to either his elevated liver function tests/Procainamide toxicity/diabetic gastroparesis/constipation. However, this resolved the next day with Reglan 10 mg intravenously t.i.d. Endocrine: Amaryl was increased to 4 mg p.o. q.d. for his diabetes. A TSH was also obtained for underlying reasons for his atrial fibrillation and pre-Amiodarone TFT monitoring. The TSH remained at 1.2 which was normal. Prophylaxis: Mr. [**Known lastname 7086**] was on subcutaneous Heparin initially but this was discontinued eventually. He was also on Zantac. Code status: Full. Social: Mr. [**Known lastname 7086**] had excellent support from his daughter throughout the hospitalization course. Unfortunately the absence of his insurance coverage could not allow for him to be covered in an acute rehabilitation setting as suggested by physiotherapy. We have therefore pursued a walker to help his mobility. A physical therapy consult felt that Mr. [**Known lastname 7086**] had impaired strength, impaired mobility, and decreased functional ability. They were going to follow Mr. [**Known lastname 7086**] throughout his hospitalization in place of acute rehabilitation. DISCHARGE DIAGNOSES: New onset atrial fibrillation, status post DC cardioversion, Procainamide trial, and currently on Amiodarone; left atrial appendage thrombus, on anticoagulation with Warfarin; congestive heart failure secondary to global cardiomyopathy likely of ischemic origin; right lower lung mass, not yet determined, status post non-diagnostic bronchoscopy. DISCHARGE MEDICATIONS: ECASA 325 mg p.o. q.d., Amiodarone 400 mg p.o. b.i.d., Amaryl 4 mg p.o. q.d., Lasix 20 mg p.o. q.o.d., Lisinopril 10 mg p.o. q.d. hold for blood pressure less than 80, Levaquin 500 mg p.o. q.d. to end on [**2119-2-15**], Atrovent 2 puffs q.i.d. p.r.n., Dulcolax 10 mg p.o. b.i.d. p.r.n., Cepacol lozenges p.r.n., Coumadin with the dose to be reconfirmed. DISPOSITION: Regrettably because Mr. [**Known lastname 7086**]' insurance could not cover acute rehabilitation, the best we could offer is to go home with VNA. DISCHARGE FOLLOWUP: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 34141**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**] Dictated By:[**Last Name (NamePattern1) 19923**] MEDQUIST36 D: [**2119-2-8**] 15:08 T: [**2119-2-8**] 17:33 JOB#: [**Job Number **] Admission Date: [**2119-1-24**] Discharge Date: Date of Birth: [**2054-9-28**] Sex: M Service: CCU CHIEF COMPLAINT: Ankle swelling and feeling weak. HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 7086**] is a 64-year-old gentleman with a history of type II diabetes, hypertension and smoking who is recently being treated for bronchitis with for follow-up with complaints of bilateral lower extremity edema times four days. He was found to have a heart rate greater than 150 and he was sent to the Emergency Room at [**Hospital3 3834**]. There he had an EKG and echocardiogram which were felt to be hemodynamically stable and he was transferred to [**Hospital1 69**] for further care. He reports a recent cough productive of brown He describes orthopnea but no PND. Denies chest pain, shortness of breath, diaphoresis, nausea, vomiting, abdominal pain, diarrhea, constipation, recent weight loss or chills. He has never had a history of cardiac disease. He reports baseline being able to walk around his house with the assistance of a cane. PAST MEDICAL HISTORY: Hypertension, CVA (15 years ago), type II diabetes times 6 years, right eye injury, right leg break, PPD negative, recently tested by primary care doctor. ALLERGIES: No known drug allergies. MEDICATIONS: Amaryl 2.5 mg po q d, Accupril dose unknown, Azithromycin finished [**1-23**], Glucotrol dose unknown, Hydrochlorothiazide 25 mg po q day. SOCIAL HISTORY: Married with four children, lives in [**Country 7192**], here visiting daughter. Former teacher. Positive tobacco history of three packs per day times 23 years, quit 27 years ago. FAMILY HISTORY: Liver cancer. PHYSICAL EXAMINATION: At time of admission temperature 99.6, blood pressure in the 100's/70's, heart rate in the 170's, respiratory rate 17, FAO2 100% on four liters nasal cannula. General, alert, awake, oriented times three, lying comfortably in bed. HEENT: Normocephalic, atraumatic, right pupil small with cornea scar, left pupil round, reactive, extraocular movements intact. Facial grimace present. Neck, JVP 5 cm, no carotid bruits, palpable thyroid gland, no lymphadenopathy. Chest, few bibasilar crackles, good air movement bilaterally, no dullness, no E to A changes. Heart tachy, hyperdynamic, systolic ejection murmur audible throughout the precordium. Abdomen, liver palpable 3-4 cm below costal margin, nontender, normal bowel sounds. No palpable splenomegaly. Guaiac negative. Extremities, good DP pulses, bilateral edema. Neuro, cranial nerves II through XII intact, 5 strength throughout, constant grimace, normal speech. LABORATORY DATA: White blood cell count 13.3, hematocrit 40.7, platelet count 395,000, PT 13, INR 1.1, PTT 22.9, sodium 129, potassium 3.9, chloride 90, CO2 26, BUN 17, creatinine 0.5, glucose 308, magnesium 1.8, albumin 2.6, calcium 8.5, CPK 36, LFT's reported to be elevated including alkaline phosphatase elevation at outside hospital. Troponin less than .2. EKG showed atrial flutter at a rate of 170, normal axis, normal interval, positive LVH, J point elevation. Echo at [**First Name (Titles) 27946**] [**Last Name (Titles) **] showed an LVEF of 10%, normal LV size, severe global hypokinesis, moderate to severe tricuspid regurgitation, severe global hypokinesis at the right ventricle. Chest x-ray on [**1-21**] showed large heart silhouette and right lower lobe mass. Chest x-ray on [**1-24**] showed question of congestion, persistent right lower lobe mass. HOSPITAL COURSE: 1. Cardiovascular: A) Atrial fibrillation/flutter. The patient presented with newly diagnosed atrial flutter of unknown duration. He was initially rate controlled with Diltiazem and loaded on Digoxin while awaiting TEE for rule out of atrial clot and anticipation of DC cardioversion. TSH and T4 levels were checked and within normal limits. Because of patient's apparent volume overload on exam was given Lasix in the interim. On [**1-25**] a TEE was done which showed enlarged left atrium with spontaneous contrast, no LA, no left atrial appendage, no right atrial appendage thrombi were seen. Procedure was tolerated without difficulty and on the afternoon of [**1-25**] discontinuation of cardioversion was done with one 360 joule shock resulting in transient normal sinus rhythm and another 360 joule shock reverting to normal sinus rhythm but within less than one hour reverting back to atrial fibrillation. There were initial thoughts of starting the patient on Amiodarone to assist in maintaining him in normal sinus rhythm but these were deferred as it was questionable what patient's follow-up would be concerns over long-term need for monitoring of Amiodarone secondary to potential toxicity. On the evening of [**1-25**], following failure to maintain normal sinus rhythm after discontinuation of cardioversion, the patient was reloaded on IV Procainamide and started on a Procainamide drip to attempt chemical cardioversion. On [**1-26**] the patient chemically cardioverted to normal sinus rhythm, however, when switched to po Procainamide he reverted back into atrial fibrillation on the morning of [**1-27**]. The patient was then restarted on IV Procainamide drip and by [**1-28**] he had returned to [**Location 213**] sinus rhythm with no elevated Procainamide levels. He was then restarted on oral Procainamide on [**1-28**] but then reverted back into atrial fibrillation that evening. Throughout this time he maintained a heart rate in the 120's, 130's, at times as high as 140's, was able to maintain adequate blood pressure which for patient was systolics of 90-110. Following discussion about patient's failure to remain in sinus rhythm following discontinuation of cardioversion and chemical cardioversion with Procainamide, it was decided that patient would benefit from a trial of Amiodarone loading followed by cardioversion. The patient was started on Amiodarone on [**1-29**] and on [**2-1**] after it was felt to be an adequate Amiodarone load (initially IV and po at 400 mg po qid) the patient returned for TEE in anticipation of repeat discontinuation of cardioversion. However, TEE on [**2-1**] revealed thrombus in the left atrial appendage and discontinuation of cardioversion was cancelled for concerns that cardioversion may increase risk of CVA. However, patient converted spontaneously to normal sinus rhythm on [**2-1**] in the afternoon and continued on Amiodarone now in normal sinus rhythm. From [**2-1**] through [**2-7**] the patient was slowly titrated downward on Amiodarone dose from 400 mg po qid to 400 mg po tid and then with concerns over low blood pressure to 400 mg po bid. On [**2-5**] the patient now on 400 mg po bid dose, converted back into atrial fibrillation and then subsequently between [**2-5**] and [**2-7**] periodically converted between normal sinus rhythm and atrial fibrillation, occasionally accompanied by symptoms of chest pain or shortness of breath at the time of conversion. B) Congestive heart failure - the patient was noted to have an ejection fraction of 10% with normal LV size, severe global hypokinesis, moderate to severe tricuspid regurgitation, severe global hypokinesis of the right ventricle. Echocardiogram done at [**Hospital3 27946**] Emergency Room, the cause of patient's cardiomyopathy is not known. The patient did receive various doses of IV and po Lasix for diuresis for symptoms of congestive heart failure between time of admission and [**2-7**]. He also started various medical therapies including ACE inhibitor to decrease afterload, however, the dosing of medications had become variable as patient continued to have hypotension, systolic blood pressures often in the 70's to 90 range limiting ability to give medications that could further lower blood pressure. Discussions about possibility of coronary artery disease were held with patient and patient's daughters. The patient was given an Aspirin daily and may be considered for cardiac catheterization at a later date to evaluate coronary artery disease. 2. Pulmonary: The patient has a right lower lobe mass on chest x-ray confirmed by chest CT and found to be 3.6 by 4.8 cm in size. He was seen by pulmonary consult service and was recommended for bronchoscopy and thoracentesis for diagnosis purposes. He received both of those procedures on [**2-2**] under fluoroscopic guidance. Results of these procedures including chemistries, microbiology and cytology and pathology have been largely non diagnostic to date. Further work-up of right lower lobe mass is currently being contemplated. 3. The patient continued to have hemoptysis mostly mild with sputum production, intermittent shortness of breath and was felt to be possibly demonstrating signs of COPD exacerbation. He was started on Atrovent MDI and Levaquin on [**2-4**]. 4. Chest Pain: The patient periodically reported left sided chest pain/pressure, at times accompanied by shortness of breath. He did not have any EKG changes consistently with his chest pain and did not have any changes in his CPK enzyme on serial examination. The rest of the episodes were self limited, spontaneously resolved. Others seem to resolve with assistance of 0.5 mg IV Ativan. Cause of this chest pain is not known. 5. Infectious Disease: Question of dysuria during [**Hospital 228**] hospital stay. Urinalysis and urine culture were sent and revealed coag negative staph, may represent skin contamination. Follow-up urine cultures are pending at this time. 6. Heme: The patient was initially started on Heparin drip for anticoagulation as per first TEE. However, because patient had significant hemoptysis (reported to be approximately 200 cc) without a significant fall in hematocrit, Heparin was withheld. Because of presence of clot in atrial appendage on follow-up TEE, the need for anticoagulation was reassessed later in [**Hospital 228**] hospital course. Bronchoscopy did not demonstrate any endobronchial lesions and it was felt that patient was safe to restart anticoagulation and was restarted on Heparin while being loaded on Coumadin. He subsequently became supratherapeutic on his INR and Heparin and Coumadin were held and are currently on hold while patient's INR returns to therapeutic range of [**1-28**]. 7. Increased LFT's: The patient has mild transaminitis most notably elevated alkaline phosphatase. The exact significance of this finding is not known. The patient is asymptomatic at this time. Abdominal CT did reveal some heterogenicity of the liver of questionable significance. Liver function tests are currently being monitored. Further work-up may be done at a later date. 8. Type II Diabetes: The patient was initially put on regular insulin sliding scale secondary to variable po intake. Was later restarted on Amaryl 2 mg po q d with continued elevated serum glucose requiring sliding scale insulin coverage. He has now been increased to Amaryl 4 mg po q d. 9. Fluids, Electrolytes & Nutrition: The patient has hyponatremia likely secondary to CHF. He has been free water restricted with variable results and needs further monitoring. 10. Prophylaxis: The patient received Zantac and anticoagulation as described above for prophylaxis. 11. Code: Full code. 12. Disposition: The patient is to be evaluated by physical therapy and is being seen by social work case management for discussion of disposition possibilities. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**] Dictated By:[**Last Name (NamePattern1) 6614**] MEDQUIST36 D: [**2119-2-7**] 14:31 T: [**2119-2-7**] 20:07 JOB#: [**Job Number 34139**] Name: [**Known lastname 1810**], [**Known firstname 5993**] Unit No: [**Numeric Identifier 5994**] Admission Date: Discharge Date: Date of Birth: Sex: Service: ADDENDUM: Pulmonary: In time, Mr. [**Known lastname **] initial results from the transbronchial biopsy and right lower lobe thoracentesis returned. Both were unremarkable for malignancy. Therefore, the decision was to proceed to CT scan guided biopsy of the right lower lobe lung mass and drainage of the right pleural effusion. Radiology was contact[**Name (NI) **] and they requested a two week follow-up CT scan of the chest to assess for progression of the right lower lobe lung mass, which was concerning for possible pneumonia / atelectasis / malignancy. The follow-up CT scan of the chest showed no change in the size of the right lower lobe lung mass. The left effusion was increased and loculated. There was a ground glass nodule in the left lung apex which was concerning for bronchoalveolar carcinoma. An enhancement of the pleura suggested possible exudate. In view of these findings, the Medical team requested Radiology to proceed with biopsy of the right lower lobe lung mass and to drain the fluid on the right side for evaluation of cytology. Radiology initially agreed to do both and we continued Mr. [**Known lastname **] on heparin and discontinued his Coumadin. To achieve a target INR of 1.3 or less, Mr. [**Known lastname **] received fresh frozen plasma four units and vitamin K 5.0 mg subcutaneous times one. Despite these interventions, INR hovered in the 1.5 range. The procedure was delayed because of change over of radiology attendings on the weekend. On [**2-13**], Mr. [**Known lastname **] received his CT scan guided right pleural effusion drainage. 10 cc were withdrawn and revealed serosanguinous fluid. The fluid was negative for malignant cells. Dr. [**Last Name (STitle) 5995**] was reluctant to biopsy Mr. [**Known lastname **]' right lower lobe lung because it appeared atelectatic and there was no obvious mass to biopsy. Therefore, the recommendation was to proceed to an FDG nuclear scan of the chest to assess for viability of the right lower lobe lung mass. If the CT scan would be positive, then consideration for re-biopsy might be pursued. If the scan was negative, then it was likely that the right lower lobe lung tissue was atelectasis. In time the pigtail catheter drained no further fluid and was discontinued 48 hours following insertion. Mr. [**Known lastname **] had some residual peri-wound discomfort post discontinuation of the pigtail. He denied shortness of breath however. Cardiac: Mr. [**Known lastname **] [**Last Name (Titles) 5996**] to sinus rhythm with occasional ectopy. Amiodarone was decreased to 400 mg po q day times one week, then 200 mg po q day upon discharge. Heparin was continued for anticoagulation against the left atrial clot. Coumadin was also loaded with two 10 mg dosages; however, when his INR was found to be 3.3 following the second dose, Coumadin was withheld. The INR upon discharge was 4.4 and Mr. [**Known lastname **] was instructed to hold Coumadin until [**2119-2-19**]. He would have follow-up with the [**Hospital3 1946**] on [**2119-2-20**], where an INR would be checked and his dosage would be adjusted accordingly. In terms of Mr. [**Known lastname **]' congestive heart failure, Captopril was continued despite his low blood pressure which hovered in the range of 78 systolic to 92. He received Lasix 20 mg po qod and diuresed well on these afterload measures. However, Mr. [**Known lastname **] continued to complain of recurrent chest pressure intermittently. Electrocardiograms obtained repeatedly showed no changes and his pressure was relieved by Ativan. Endocrine: We continued Mr. [**Known lastname **] on Amaril 4.0 mg po q AM. A trial of 2.0 mg po q day for better control of evening and morning sugars was ineffective as eventually his glucose returned in a normal range during these time frames. Therefore the decision is to send Mr. [**Known lastname **] on 4.0 mg po q AM. Podiatry: Physiotherapy was consulted to help Mr. [**Known lastname **]' ambulation. They found that he had a discrepancy in his leg length due to a remote hip fracture sustained in Guatamala which was never repaired. Podiatry was requested to help with proper shoe fitting for his right foot. They referred us to a number of [**Location (un) **] Prosthetics. DIAGNOSES: 1. Atrial fibrillation. 2. Left atrial appendage clot. 3. Right lower lobe lung mass, not yet diagnosed - atelectasis versus cancer. DISCHARGE MEDICATIONS: Amiodarone 200 mg po q day, Lisinopril 10 mg po q day, Lasix 20 mg po qod, Coumadin 2.0 mg po q HS to begin on [**2119-2-19**], with a 1.0 mg dosage. Last INR was 4.4 on [**2-17**]. Amaril 4.0 mg po q AM, enteric coated A.S.A. 325 mg po q day, Atrovent two puffs [**Hospital1 **] prn, home O2 as needed, Compazine 10 mg po bid prn. FOLLOW-UP: 1. With [**Hospital3 1946**] on [**2119-2-20**], at 11:00 AM on the sixth floor, South Suite, [**Apartment Address(1) 5997**]. 2. Follow-up with Dr. [**First Name (STitle) **] in one week. His number is [**Telephone/Fax (1) **]. The daughter has been asked to book an appointment for the Wednesday following Mr. [**Known lastname **]' departure. 3. Follow-up on [**3-1**], for FDG nuclear study on [**Hospital Ward Name **], fourth floor at 10:30 AM. 4. Follow-up on [**3-1**], with Dr. [**Last Name (STitle) 86**] in Electrophysiology Clinic at 03:30 PM on [**Hospital Ward Name **], seventh floor. 5. Follow-up on [**3-8**], with Dr. [**Last Name (STitle) **] at 11:00 AM. DISPOSITION: Home with [**Hospital6 1346**] and Physical Therapy. Home with O2 as needed. DISCHARGE INSTRUCTIONS: Mr. [**Known lastname **] was instructed to hold his Coumadin doses until [**2119-2-19**], where he would take 1.0 mg. His next Coumadin dose would be readjusted by the [**Hospital3 1946**] on [**2119-2-20**]. Through his daughter he was also instructed on the risks of potential bleed being on Coumadin and with an elevated INR. The family was asked to assist Mr. [**Known lastname **] upon ambulation and prevent him from falling. Mr. [**Known lastname **] was asked to return to the hospital should he have any further concerns. Dictated By:[**Last Name (NamePattern1) 5998**] MEDQUIST36 D: [**2119-2-17**] 10:58 T: [**2119-2-20**] 08:13 JOB#: [**Job Number 5999**]

428,427,786,491,424,250,401

{'Congestive heart failure, unspecified,Atrial fibrillation,Swelling, mass, or lump in chest,Obstructive chronic bronchitis with (acute) exacerbation,Endocarditis, valve unspecified, unspecified cause,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension'}

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: Ankle swelling, feeling weak. PRESENT ILLNESS: Mr. [**Known lastname 7086**] is a 64-year-old Guatemalan man with a history of hypertension, diabetes, and smoking who was recently treated for bronchitis with Azithromycin. He presented to his primary care doctor on the day of admission for followup. He was noted to have bilateral edema which developed over the past four days and a heart rate greater than 150. He was sent to the Emergency Room at [**Hospital1 **]-Nishoba. There his EKG and echocardiogram were hemodynamically stable and he was transferred to [**Hospital6 1760**] for further care. He reports recent cough productive of sputum. There was no fever or chills. He also complained of throat pain and soreness. He described orthopnea but no paroxysmal nocturnal dyspnea. He denied chest pain, shortness of breath, diaphoresis, nausea, vomiting, abdominal pain, diarrhea, constipation, recent weight loss, or chills. He has never had a history of cardiac disease. MEDICAL HISTORY: The patient has a past medical history of hypertension, cerebrovascular accident 15 years ago, diabetes mellitus times six years, right eye injury, right leg break, and PPD negative recently at his primary care doctor's office. MEDICATION ON ADMISSION: ALLERGIES: Not known. PHYSICAL EXAM: FAMILY HISTORY: The family history is notable for liver cancer. SOCIAL HISTORY: The patient is married with four children and was recently in [**Location (un) 86**] from [**Country 7192**]. He was a teacher. ### Response: {'Congestive heart failure, unspecified,Atrial fibrillation,Swelling, mass, or lump in chest,Obstructive chronic bronchitis with (acute) exacerbation,Endocarditis, valve unspecified, unspecified cause,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension'}

CHIEF COMPLAINT: tearing midchest and back pain PRESENT ILLNESS: Mr. [**Known lastname 805**] is a 77 yo s/p repair of ascending aortic aneurysm vs type A [**Known lastname **] [**2115**]. He has a known type B thoracic aortic [**Year (4 digits) **] which has been followed with serial exams/studies. Over the last 2 months Mr. [**Known lastname 805**] has been experiencing worsening shortness of breath and not feeling well. He was admitted for several days one month ago for blood pressure control, and discharged on [**6-3**]. He reports that he has been compliant with his medications since then, though his blood pressures have been running in the 130s-140s when he checks them at home. He went to his PCP [**5-29**] where he had a CXR which showed ?increase in aneurysm size and he was sent to [**Hospital1 18**] ED for eval. A CTA in the ED showed a large 7cm descending aortic aneurysm w/acute on chronic [**Hospital1 **], starting just distal to prior graft anastomosis and extending to just above the celiac axis. He saw both Dr. [**Last Name (STitle) 914**] and Dr. [**Last Name (STitle) **] as an outpatient and had completed some preoperative studies including an echo and pMIBI. He presents to the ED today after waking with a tearing mid chest/back pain. CT scan reveals acute intramural hematoma superimposed on a chronic Type B [**Last Name (STitle) **]. He is hemodynamically stable. He reports that the pain persists, and that morphine only takes the edge off for a short while. He also attests to shortness of breath that is brought on by the pain and improves with morphine. He denies any fevers/chills, and reports that his appetite has been good at home. MEDICAL HISTORY: type A aortic [**Last Name (STitle) **], s/p repair chronic type b aortic [**Last Name (STitle) **] 7cm descending aortic aneurysm hypercholesterolemia hypertension obesity coronary artery disease paraesophageal hernia sleep apnea renal insufficiency diverticulosis chronic back pain hematuria benign prostatic hypertrophy vertigo MEDICATION ON ADMISSION: MEDICATIONS: Albuterol PRN ASA 81' Zolpidem 5' Pravastatin 40' Meclizine 12.5'''P Nifedipine CR 60' Lisinopril 40' Toprol 100' Nexium 40' ALLERGIES: Nitroglycerin PHYSICAL EXAM: At time of initial vascular consult: Vital Signs: Temp: 96.8 RR: 18 Pulse: 63 BP: 161/93 Neuro/Psych: Oriented x3, Affect Normal, NAD. Neck: No masses, Trachea midline, Thyroid normal size, non-tender, no masses or nodules, No right carotid bruit, No left carotid bruit. Nodes: No clavicular/cervical adenopathy, No inguinal adenopathy. FAMILY HISTORY: - No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. - Mother: died when he was 13-14 unclear cause - Father: unknown SOCIAL HISTORY: Retired constructon worker, Bus Driver. Married with 6 children.

Dissection of aorta, thoracoabdominal,Hematemesis,Other shock without mention of trauma,Other esophagitis,Diaphragmatic hernia without mention of obstruction or gangrene,Obesity, unspecified,Obstructive sleep apnea (adult)(pediatric),Coronary atherosclerosis of native coronary artery,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Pure hypercholesterolemia,Chronic kidney disease, unspecified,Anxiety state, unspecified,Personal history of tobacco use

Dsct of thoracoabd aorta,Hematemesis,Shock w/o trauma NEC,Other esophagitis,Diaphragmatic hernia,Obesity NOS,Obstructive sleep apnea,Crnry athrscl natve vssl,Hy kid NOS w cr kid I-IV,Pure hypercholesterolem,Chronic kidney dis NOS,Anxiety state NOS,History of tobacco use

Admission Date: [**2132-7-2**] Discharge Date: [**2132-7-3**] Date of Birth: [**2055-3-15**] Sex: M Service: SURGERY Allergies: Nitroglycerin Attending:[**First Name3 (LF) 6088**] Chief Complaint: tearing midchest and back pain Major Surgical or Invasive Procedure: Portion of EGD at the bedside in the ICU History of Present Illness: Mr. [**Known lastname 805**] is a 77 yo s/p repair of ascending aortic aneurysm vs type A [**Known lastname **] [**2115**]. He has a known type B thoracic aortic [**Year (4 digits) **] which has been followed with serial exams/studies. Over the last 2 months Mr. [**Known lastname 805**] has been experiencing worsening shortness of breath and not feeling well. He was admitted for several days one month ago for blood pressure control, and discharged on [**6-3**]. He reports that he has been compliant with his medications since then, though his blood pressures have been running in the 130s-140s when he checks them at home. He went to his PCP [**5-29**] where he had a CXR which showed ?increase in aneurysm size and he was sent to [**Hospital1 18**] ED for eval. A CTA in the ED showed a large 7cm descending aortic aneurysm w/acute on chronic [**Hospital1 **], starting just distal to prior graft anastomosis and extending to just above the celiac axis. He saw both Dr. [**Last Name (STitle) 914**] and Dr. [**Last Name (STitle) **] as an outpatient and had completed some preoperative studies including an echo and pMIBI. He presents to the ED today after waking with a tearing mid chest/back pain. CT scan reveals acute intramural hematoma superimposed on a chronic Type B [**Last Name (STitle) **]. He is hemodynamically stable. He reports that the pain persists, and that morphine only takes the edge off for a short while. He also attests to shortness of breath that is brought on by the pain and improves with morphine. He denies any fevers/chills, and reports that his appetite has been good at home. Past Medical History: type A aortic [**Last Name (STitle) **], s/p repair chronic type b aortic [**Last Name (STitle) **] 7cm descending aortic aneurysm hypercholesterolemia hypertension obesity coronary artery disease paraesophageal hernia sleep apnea renal insufficiency diverticulosis chronic back pain hematuria benign prostatic hypertrophy vertigo Echo [**2132-5-9**]: EF 60%, nml LV, Grade I diastolic dysfunction, trivial AI, trace MR Social History: Retired constructon worker, Bus Driver. Married with 6 children. - Tobacco history: None - ETOH: None - Illicit drugs: None Family History: - No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. - Mother: died when he was 13-14 unclear cause - Father: unknown Physical Exam: At time of initial vascular consult: Vital Signs: Temp: 96.8 RR: 18 Pulse: 63 BP: 161/93 Neuro/Psych: Oriented x3, Affect Normal, NAD. Neck: No masses, Trachea midline, Thyroid normal size, non-tender, no masses or nodules, No right carotid bruit, No left carotid bruit. Nodes: No clavicular/cervical adenopathy, No inguinal adenopathy. Skin: No atypical lesions. Heart: Regular rate and rhythm. Lungs: Clear, Normal respiratory effort. Gastrointestinal: Non distended, No masses, Guarding or rebound, No hepatosplenomegally, No hernia, No AAA. Rectal: Not Examined. Extremities: No popiteal aneurysm, No femoral bruit/thrill, No RLE edema, No LLE Edema, No varicosities, No skin changes. Pulse Exam (P=Palpation, D=Dopplerable, N=None) RUE Radial: P. LUE Radial: P. RLE Femoral: P. Popiteal: P. DP: P. PT: P. LLE Femoral: P. Popiteal: P. DP: P. PT: P. Pertinent Results: [**2132-7-2**] 11:40AM BLOOD WBC-6.7 RBC-4.11* Hgb-13.0* Hct-36.7* MCV-89 MCH-31.7 MCHC-35.4* RDW-14.3 Plt Ct-192 [**2132-7-2**] 05:16PM BLOOD WBC-9.3 RBC-3.94* Hgb-12.5* Hct-36.1* MCV-92 MCH-31.6 MCHC-34.5 RDW-14.3 Plt Ct-197 [**2132-7-3**] 01:43AM BLOOD WBC-9.6 RBC-3.89* Hgb-12.2* Hct-35.8* MCV-92 MCH-31.3 MCHC-34.1 RDW-14.5 Plt Ct-192 [**2132-7-3**] 05:06AM BLOOD Hct-34.3* [**2132-7-3**] 02:31PM BLOOD WBC-8.0 RBC-3.04* Hgb-9.5* Hct-28.7* MCV-95 MCH-31.1 MCHC-33.0 RDW-14.3 Plt Ct-137* [**2132-7-2**] 11:40AM BLOOD PT-12.8 PTT-24.3 INR(PT)-1.1 [**2132-7-3**] 01:43AM BLOOD PT-13.4 PTT-26.5 INR(PT)-1.1 [**2132-7-3**] 02:31PM BLOOD PT-16.1* PTT-34.7 INR(PT)-1.4* [**2132-7-2**] 11:40AM BLOOD Glucose-133* UreaN-19 Creat-1.5* Na-142 K-4.8 Cl-108 HCO3-25 AnGap-14 [**2132-7-2**] 05:16PM BLOOD Glucose-114* UreaN-17 Creat-1.5* Na-142 K-3.4 Cl-109* HCO3-24 AnGap-12 [**2132-7-3**] 01:43AM BLOOD Glucose-132* UreaN-22* Creat-1.8* Na-142 K-3.6 Cl-108 HCO3-23 AnGap-15 [**2132-7-2**] 11:40AM BLOOD cTropnT-<0.01 [**2132-7-3**] 01:43AM BLOOD CK-MB-1 cTropnT-<0.01 [**2132-7-2**] 05:16PM BLOOD Calcium-8.8 Phos-3.4 Mg-2.1 [**2132-7-3**] 01:43AM BLOOD Albumin-4.1 Calcium-8.8 Phos-3.6 Mg-2.1 [**2132-7-3**] 01:43AM BLOOD ALT-13 AST-18 LD(LDH)-175 AlkPhos-59 Amylase-99 TotBili-0.4 Wet Read: MDAg WED [**2132-7-2**] 12:40 PM new acute intramural hematoma in the descending thoracic aorta (type B) superimposed on stable type B [**Year (4 digits) **]. No further inferior extension of [**Year (4 digits) **] into abdomen. d/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1785**] [**Last Name (NamePattern1) **] (Cardiac surgery, PA) in person 12:37pm [**2132-7-2**]. Wet Read Audit # 1 Final Report INDICATION: Severe chest pain, evaluate for worsening [**Year (4 digits) **]. COMPARISON: [**2132-5-29**]. TECHNIQUE: Volumetric multidetector CT of the chest was performed after administration of 100 mL of Visipaque intravenous contrast. Coronal, sagittal, and oblique reformats were obtained for evaluation. CT CHEST WITH INTRAVENOUS CONTRAST: The patient is status post prior repair of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 11916**] type A aortic [**Last Name (NamePattern4) **]. Again seen is the [**Location (un) 11916**] type B [**Location (un) **] originating at the surgical site in the aortic arch, just distal to the origin of the left subclavian artery and terminating at superior margin of the ostium for the celiac axis. False lumen thrombosis is stable. New from the prior study is an acute intramural hematoma extending from the aortic arch superiorly to just proximal to the termination of the [**Location (un) **] inferiorly (2:82). The intramural hematoma spans the intimal flap, indicating it is not increased thrombosis of the false lumen, and is well seen on 2:64 with mass effect on the true and false lumens. The overall aortic diameter at that level, essentially unchanged, measuring 5.8 cm, previously 5.6 cm. Pulmonary arterial vasculature is well visualized to the subsegmental level without filling defect to suggest pulmonary embolism. No pathologically enlarged mediastinal, axillary or hilar lymph nodes are present. The heart and pericardium are within normal limits. There is no pleural or pericardial effusion. A moderate hiatal hernia is slightly increased in size since [**2132-5-29**]. Lung window images demonstrate bibasilar atelectasis. There is no worrisome nodule, mass, or consolidation. The study is not tailored for subdiaphragmatic evaluation. The intimal flap terminates at superior margin of the ostium for the celiac axis (301b:33) so all mesenteric vessels originate from the true lumen. Scattered diverticula are seen throughout the colon without inflammatory changes. The visualized portions of the appendix are normal. IMPRESSION: 1. New acute type B intramural hematoma superimposed on stable type B aortic [**Year (4 digits) **]. Unchanged thrombosis of the false lumen and stable aortic size. 2. Moderate hiatal hernia is increased from [**2132-5-29**]. 3. Diverticulosis without diverticulitis. Findings discussed with [**First Name8 (NamePattern2) 1785**] [**Last Name (NamePattern1) **] (CT surgery PA) in person, 12:37 p.m. [**2132-7-2**]. Discussed with Dr. [**Last Name (STitle) 914**] (CT surgery attending) in person, 1 p.m. [**2132-7-2**] Discussed with Dr. [**First Name4 (NamePattern1) 1692**] [**Last Name (NamePattern1) **] (vascular surgery resident) by phone 1:15 p.m. [**2132-7-2**]. The study and the report were reviewed by the staff radiologist. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7411**] Approved: WED [**2132-7-2**] 5:34 PM Imaging Lab Brief Hospital Course: Mr. [**Known lastname 805**] is a 77 y/o gentleman who has had an ascending aortic aneurysm repair in the past and has a known type B thoracic aortic [**Known lastname **]. He was admitted for several days one month ago for blood pressure control, and discharged on [**6-3**]. He reports that he has been compliant with his medications since then, though his blood pressures have been running in the 130s-140s when he checks them at home. He saw both Dr. [**Last Name (STitle) 914**] and Dr. [**Last Name (STitle) **] as an outpatient and had completed some preoperative studies including an echo and pMIBI. On [**2132-7-2**], he experienced acute tearing chest pain at his left upper chest radiating to the back and was told to come to the ER emergently. He was admitted to the ICU for BP control and an expedited workup to plan for open TAA repair. He was started on a nicardipine drip. He was on dilaudid PCA for chest pain management. Pain was resolved with BP control. Vascular and cardiac surgery consultation and operative planning continued. Cardiology saw the patient and in assessing his overall status and reviewing his outpatient testing felt as if there was no contraindication to moving forward with aortic surgery to repair his [**Date Range **]. Overnight on his first hospital night the patient had three episodes of coffee ground emesis, but no hemodynamic compromise. GI was consulted. He reported episodic usage of naproxen around once a week and daily use of aspirin. Otherwise he denies any hx of peptic ulcer disease or prior GI bleeding. He reported a history of GERD and daily PPI usage. An aortic-esophageal fistula seemed extremely unlikely in this case and GI felt as if gastritis or gastric erosions were more likely the source of bleeding. Nevertheless we felt it was important to identify and characterize the nature of the UGIB before proceding with operative TAA repair and the incipient heparinization, cardiac bypass etc. Bedside EGD was planned for [**7-3**] with MAC anesthesia in order to evaluate for potential causes of bleeding prior to aortic surgery. If no bleeding source visualized, lumbar drains were to be placed that day as well in preparation for surgery the following AM. A protonix drip was started. The patient did not tolerate MAC anesthesia and was choking and gagging throughout the initial portion of the procedure and he was deemed to be at a high risk for aspiration. The EGD was aborted and discussion was had with the patient and his family about repeating the EGD in the afternoon with elective intubation. Consent was obtained, he was intubated by the ICU staff, and preparations were being made to begin the EGD. He had been vomiting prior to intubation. The mouthpiece was placed to prepare for the EGD and the patient was being turned slightly into the right lateral decubitus position and his tele alarmed showing no pulse or blood pressure, pulse check found there to be no pulse and a code was called, compressions were initiated, the patient went into PEA. Multiple rounds of chest compressions, epi, bicarb, atropine were given. Echo showed empty RV/LV with no ventricular activity and the code was called at 2:54 pm An autopsy was performed identifying the ascending aorta graft anastamoses to be intact. A Type B [**Month/Year (2) **] arising distal to the left subclavian artery, with reentry at the celiac trunk was seen. Rupture of adventitia in the left anterior mediastinum with abundant hematoma dissecting through the mediastinal soft tissue and 3 liters of blood filling the chest cavity causing atelectasis of the left lung. No GI bleeding source was identified. Medications on Admission: MEDICATIONS: Albuterol PRN ASA 81' Zolpidem 5' Pravastatin 40' Meclizine 12.5'''P Nifedipine CR 60' Lisinopril 40' Toprol 100' Nexium 40' Discharge Disposition: Expired Discharge Diagnosis: PEA arrest secondary to aortic rupture and subsequent hypovolemic shock Discharge Condition: deceased Discharge Instructions: deceased Followup Instructions: deceased Completed by:[**2132-8-4**]

441,578,785,530,553,278,327,414,403,272,585,300,V158

{'Dissection of aorta, thoracoabdominal,Hematemesis,Other shock without mention of trauma,Other esophagitis,Diaphragmatic hernia without mention of obstruction or gangrene,Obesity, unspecified,Obstructive sleep apnea (adult)(pediatric),Coronary atherosclerosis of native coronary artery,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Pure hypercholesterolemia,Chronic kidney disease, unspecified,Anxiety state, unspecified,Personal history of tobacco use'}

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: tearing midchest and back pain PRESENT ILLNESS: Mr. [**Known lastname 805**] is a 77 yo s/p repair of ascending aortic aneurysm vs type A [**Known lastname **] [**2115**]. He has a known type B thoracic aortic [**Year (4 digits) **] which has been followed with serial exams/studies. Over the last 2 months Mr. [**Known lastname 805**] has been experiencing worsening shortness of breath and not feeling well. He was admitted for several days one month ago for blood pressure control, and discharged on [**6-3**]. He reports that he has been compliant with his medications since then, though his blood pressures have been running in the 130s-140s when he checks them at home. He went to his PCP [**5-29**] where he had a CXR which showed ?increase in aneurysm size and he was sent to [**Hospital1 18**] ED for eval. A CTA in the ED showed a large 7cm descending aortic aneurysm w/acute on chronic [**Hospital1 **], starting just distal to prior graft anastomosis and extending to just above the celiac axis. He saw both Dr. [**Last Name (STitle) 914**] and Dr. [**Last Name (STitle) **] as an outpatient and had completed some preoperative studies including an echo and pMIBI. He presents to the ED today after waking with a tearing mid chest/back pain. CT scan reveals acute intramural hematoma superimposed on a chronic Type B [**Last Name (STitle) **]. He is hemodynamically stable. He reports that the pain persists, and that morphine only takes the edge off for a short while. He also attests to shortness of breath that is brought on by the pain and improves with morphine. He denies any fevers/chills, and reports that his appetite has been good at home. MEDICAL HISTORY: type A aortic [**Last Name (STitle) **], s/p repair chronic type b aortic [**Last Name (STitle) **] 7cm descending aortic aneurysm hypercholesterolemia hypertension obesity coronary artery disease paraesophageal hernia sleep apnea renal insufficiency diverticulosis chronic back pain hematuria benign prostatic hypertrophy vertigo MEDICATION ON ADMISSION: MEDICATIONS: Albuterol PRN ASA 81' Zolpidem 5' Pravastatin 40' Meclizine 12.5'''P Nifedipine CR 60' Lisinopril 40' Toprol 100' Nexium 40' ALLERGIES: Nitroglycerin PHYSICAL EXAM: At time of initial vascular consult: Vital Signs: Temp: 96.8 RR: 18 Pulse: 63 BP: 161/93 Neuro/Psych: Oriented x3, Affect Normal, NAD. Neck: No masses, Trachea midline, Thyroid normal size, non-tender, no masses or nodules, No right carotid bruit, No left carotid bruit. Nodes: No clavicular/cervical adenopathy, No inguinal adenopathy. FAMILY HISTORY: - No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. - Mother: died when he was 13-14 unclear cause - Father: unknown SOCIAL HISTORY: Retired constructon worker, Bus Driver. Married with 6 children. ### Response: {'Dissection of aorta, thoracoabdominal,Hematemesis,Other shock without mention of trauma,Other esophagitis,Diaphragmatic hernia without mention of obstruction or gangrene,Obesity, unspecified,Obstructive sleep apnea (adult)(pediatric),Coronary atherosclerosis of native coronary artery,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Pure hypercholesterolemia,Chronic kidney disease, unspecified,Anxiety state, unspecified,Personal history of tobacco use'}

CHIEF COMPLAINT: Chest pain PRESENT ILLNESS: 70 year old female who presented to [**Hospital6 3105**] on [**2154-10-2**] with chest pain, dyspnea and palpitations. Enzymes were negative. A cardiac catheterization was performed which revealed severe three vessel disease. She was transferred to the [**Hospital1 18**] for surgical revascularization. MEDICAL HISTORY: Hyperlipidemia HTN COPD Asthma Dilated cardiomyopathy Hypothyroid Past tubal ligation, ceserean section and ventral hernia repair. MEDICATION ON ADMISSION: prazosin 5mg twice daily Lipitor 20 mg daily Synthroid 100mcg once daily Aspirin 81mg once daily Calcium Lisinopril 20mg once daily ALLERGIES: Penicillins PHYSICAL EXAM: BP: 145/72 98.7 Pulse 82 NEURO: No gross deficits, no carotid bruits, normal strength and gait PULM: Bilateral exp wheezes HEART: RRR, no murmur ABD: Obese, soft, nontender EXT: Warm, no edema. FAMILY HISTORY: SOCIAL HISTORY: Does not drink alcohol. Quit smoking 30 years ago. Lives in [**Male First Name (un) 1056**] and is in [**Location (un) 86**] visiting her family. Lives with daughter.

Coronary atherosclerosis of native coronary artery,Other primary cardiomyopathies,Pneumonia due to Pseudomonas,Urinary tract infection, site not specified,Atrial fibrillation,Bronchiectasis without acute exacerbation,Unspecified essential hypertension,Unspecified acquired hypothyroidism

Crnry athrscl natve vssl,Prim cardiomyopathy NEC,Pseudomonal pneumonia,Urin tract infection NOS,Atrial fibrillation,Bronchiectas w/o ac exac,Hypertension NOS,Hypothyroidism NOS

Admission Date: [**2154-10-5**] Discharge Date: [**2154-10-14**] Date of Birth: [**2084-5-26**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2154-9-11**] CABGx3 History of Present Illness: 70 year old female who presented to [**Hospital6 3105**] on [**2154-10-2**] with chest pain, dyspnea and palpitations. Enzymes were negative. A cardiac catheterization was performed which revealed severe three vessel disease. She was transferred to the [**Hospital1 18**] for surgical revascularization. Past Medical History: Hyperlipidemia HTN COPD Asthma Dilated cardiomyopathy Hypothyroid Past tubal ligation, ceserean section and ventral hernia repair. Social History: Does not drink alcohol. Quit smoking 30 years ago. Lives in [**Male First Name (un) 1056**] and is in [**Location (un) 86**] visiting her family. Lives with daughter. Physical Exam: BP: 145/72 98.7 Pulse 82 NEURO: No gross deficits, no carotid bruits, normal strength and gait PULM: Bilateral exp wheezes HEART: RRR, no murmur ABD: Obese, soft, nontender EXT: Warm, no edema. Pertinent Results: [**2154-10-5**] 09:12PM GLUCOSE-103 UREA N-16 CREAT-1.0 SODIUM-142 POTASSIUM-3.2* CHLORIDE-101 TOTAL CO2-33* ANION GAP-11 [**2154-10-5**] 09:12PM ALT(SGPT)-14 AST(SGOT)-15 LD(LDH)-167 ALK PHOS-73 TOT BILI-0.4 [**2154-10-5**] 09:12PM ALBUMIN-4.0 [**2154-10-5**] 09:12PM %HbA1c-5.2 [Hgb]-DONE [A1c]-DONE [**2154-10-5**] 09:12PM WBC-6.8 RBC-3.66* HGB-11.4* HCT-35.1* MCV-96 MCH-31.2 MCHC-32.5 RDW-13.2 [**2154-10-5**] 09:12PM PLT COUNT-193 [**2154-10-5**] 09:12PM PT-12.6 PTT-28.2 INR(PT)-1.1 [**2154-10-12**] 05:40AM BLOOD WBC-11.3* RBC-2.88* Hgb-8.6* Hct-27.1* MCV-94 MCH-29.9 MCHC-31.9 RDW-14.5 Plt Ct-132* [**2154-10-12**] 05:40AM BLOOD Plt Ct-132* [**2154-10-12**] 05:40AM BLOOD Glucose-101 UreaN-17 Creat-0.8 Na-142 K-4.8 Cl-106 HCO3-30 AnGap-11 [**2154-10-4**] CXR Well defined nodule projecting over 9th left posterior rib. Diffuse interstitial markings [**2154-10-11**] CXR Small left pleural effusion. No pneumothorax. [**2154-10-7**] CT Chest 1. A 19-mm nodular lesion in the lingula showing eccentric calcifications, is concerning for a scar carcinoma or other lung cancer. PET/CT would be helpful for further evaluation. 2. Peribronchial thickening and mild bronchiectasis in the left lower lobe and right middle lobe, likely due to endobronchial infection. 3. Mild mediastinal lymphadenopathy. 4. Multiple noncalcified less than 5-mm pulmonary nodules; followup for these is recommended in three to six months. 5. Coronary artery calcifications. 6. Pulmonary arterial hypertension. 7. Hypodense 10 mm lesion in the liver,likely a cyst 8. Gall stones. [**2154-10-8**] Carotid Ultrasound No appreciable plaque or wall thickening involving either carotid system. Antegrade flow in both vertebral arteries. [**2154-10-9**] EKG Sinus rhythm Ventricular premature complexes Consider left atrial abnormality Right bundle branch block Consider prior inferior myocardial infarction ST-T wave abnormalities are diffuse - cannot exclude in part ischemia - clinical correlation is suggested Since previous tracing of [**2154-10-6**], ventricular ectopy, right bundle branch block, and further ST-T wave changes present. Brief Hospital Course: Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2154-10-5**] for surgical management of her coronary artery disease. She was worked-up by the cardiac surgical service in the usual preoperative manner including a carotid duplex ultrasound which showed no flow limiting stenosis. A chest x-ray revealed a nodule which was further worked-up by a chest CT scan. This revealed a 19 x 13 mm nodular lesion in the lingula with some eccentric calcifications. Noncalcified nodules, smaller than 5mm, were seen in the posterior segment of the right upper lobe, lingula, and left lower lobe. Mild bronchiectasis and peribronchial thickening is noted in the left lower lobe and right middle lobe with thickening along the right major fissure. The airways are patent up to the subsegmental bronchi. There are no pleural of pericardial effusions. An 11-mm internal mammary and 15-mm precarinal enlarged lymph nodes were also noted. Follow-up CT scan and or PET scan were recommended in the future to assess the stability of these lesions. Levofloxacin was started for a urinary tract infection. On [**2154-10-9**], Ms. [**Known lastname **] was taken to the operating room where she underwent coronary artery bypass grafting to three vessels. Postoperatively she was taken to the cardiac surgical intensive care unit for monitoring. On postoperative day one, Ms. [**Known lastname **] [**Last Name (Titles) 5058**] neurologically intact and was extubated. She grew pseudomonas in her sputum for which she was switched to clindamycin. The pulmonology service was consulted for bronchiectasis who recommended good pulmonary toilet and incentive spirometry. Later on postoperative day one, she was transferred to the cardiac surgical step down unit for further recovery. Ms. [**Known lastname **] was gently diuresed toward her preoperative weight. She developed atrial fibrillation which converted to normal sinus rhythm with amiodarone. Her drains and pacing wires were removed per protocol. The physical therapy service worked with Ms. [**Known lastname **] to help with her postoperative strength and mobility. She continued to make steady progress and was discharged home on postoperative day five. She will follow-up with Dr. [**Last Name (STitle) **], her cardiologist and her primary care physician as an outpatient. Medications on Admission: prazosin 5mg twice daily Lipitor 20 mg daily Synthroid 100mcg once daily Aspirin 81mg once daily Calcium Lisinopril 20mg once daily Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*2* 2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours). Disp:*120 Capsule, Sustained Release(s)* Refills:*2* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*60 Capsule(s)* Refills:*2* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 30 doses. Disp:*30 Tablet(s)* Refills:*0* 5. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) for 2 weeks. Disp:*112 Capsule(s)* Refills:*0* 7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 8. Metoprolol Tartrate 25 mg Tablet Sig: Four (4) Tablet PO BID (2 times a day): Take in place of Toprol XL. Disp:*240 Tablet(s)* Refills:*2* 9. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Coronary artery disease Dilated cardiomyopathy Asthma/COPD/chronic bronchitis Hypertension Hypercholesterolemia Hypothyroid Discharge Condition: Stable Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Shower daily, wash incision with mild soap and water and pat dry. No lotions, creams, powders, or baths. No lifting more than 10 pounds or driving until folloup with surgeon. Call with temperature more than 101.4, redness or drainage from incision, or weight gain more than 2 pounds in one day or five in one week. Followup Instructions: Dr. [**Last Name (STitle) **] 4 weeks Dr. [**Last Name (STitle) 62800**] 1-2 weeks Completed by:[**2154-10-15**]

414,425,482,599,427,494,401,244

{'Coronary atherosclerosis of native coronary artery,Other primary cardiomyopathies,Pneumonia due to Pseudomonas,Urinary tract infection, site not specified,Atrial fibrillation,Bronchiectasis without acute exacerbation,Unspecified essential hypertension,Unspecified acquired hypothyroidism'}

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: Chest pain PRESENT ILLNESS: 70 year old female who presented to [**Hospital6 3105**] on [**2154-10-2**] with chest pain, dyspnea and palpitations. Enzymes were negative. A cardiac catheterization was performed which revealed severe three vessel disease. She was transferred to the [**Hospital1 18**] for surgical revascularization. MEDICAL HISTORY: Hyperlipidemia HTN COPD Asthma Dilated cardiomyopathy Hypothyroid Past tubal ligation, ceserean section and ventral hernia repair. MEDICATION ON ADMISSION: prazosin 5mg twice daily Lipitor 20 mg daily Synthroid 100mcg once daily Aspirin 81mg once daily Calcium Lisinopril 20mg once daily ALLERGIES: Penicillins PHYSICAL EXAM: BP: 145/72 98.7 Pulse 82 NEURO: No gross deficits, no carotid bruits, normal strength and gait PULM: Bilateral exp wheezes HEART: RRR, no murmur ABD: Obese, soft, nontender EXT: Warm, no edema. FAMILY HISTORY: SOCIAL HISTORY: Does not drink alcohol. Quit smoking 30 years ago. Lives in [**Male First Name (un) 1056**] and is in [**Location (un) 86**] visiting her family. Lives with daughter. ### Response: {'Coronary atherosclerosis of native coronary artery,Other primary cardiomyopathies,Pneumonia due to Pseudomonas,Urinary tract infection, site not specified,Atrial fibrillation,Bronchiectasis without acute exacerbation,Unspecified essential hypertension,Unspecified acquired hypothyroidism'}

CHIEF COMPLAINT: Weakness on left, disorientation PRESENT ILLNESS: [**Known firstname **] [**Known lastname 50417**] is a 35yo M with a history of IHSS, chronic post nasal drip and GERD who is a chief surgical resident at the [**Hospital1 18**]. While performing his daily clinical duties on the [**Hospital Ward Name **], he noticed the acute onset of fall with inability to use his left hand. At that time he appeared confused. In discussion with his collegues, it appears that the patient had complained of a headache one day prior , however was acting normally on the day of presenation. Today, he describes a sensation of confusion and dysarthria at the time. A code stroke was called at 1340, and he was seen by the stroke fellow, on whose exam, he was found to be disoriented, not following commands, with a left sided neglect, significant left sided weakness and sensory loss and rightward gaze preference. MEDICAL HISTORY: Postnasal drip IHSS (history of being on toprol x 10 years, recently weaned off) GERD MEDICATION ON ADMISSION: None ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: ADMISSION PHYSICAL EXAM: VS T:afebrile HR:54 BP: 158/98 RR: 16 SaO2: 100% RA General: Awake, agitated. Head: NC/AT, no conjunctival icterus, no oropharyngeal lesions Neck: Supple, no nuchal rigidity, no bruits Cardiovascular: RRR, no M/R/G Pulmonary: Equal air entry bilaterally, no crackles or wheezes Abdomen: Soft, NT, ND, +BS, no guarding Extremities: Warm, no edema, palpable radial/dorsalis pedis pulses Skin: No rashes or lesions Psychiatric: Appears agitated. FAMILY HISTORY: NC SOCIAL HISTORY: The patient is a surgical resident. He lives at home with his wife.

Cerebral embolism with cerebral infarction,Pneumonitis due to inhalation of food or vomitus,Paroxysmal ventricular tachycardia,Other primary cardiomyopathies,Esophageal reflux

Crbl emblsm w infrct,Food/vomit pneumonitis,Parox ventric tachycard,Prim cardiomyopathy NEC,Esophageal reflux

Admission Date: [**2153-8-16**] Discharge Date: [**2153-8-21**] Date of Birth: [**2118-3-6**] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern1) 11784**] Chief Complaint: Weakness on left, disorientation Major Surgical or Invasive Procedure: Angiographically guided cerebral arterial clot retrieval History of Present Illness: [**Known firstname **] [**Known lastname 50417**] is a 35yo M with a history of IHSS, chronic post nasal drip and GERD who is a chief surgical resident at the [**Hospital1 18**]. While performing his daily clinical duties on the [**Hospital Ward Name **], he noticed the acute onset of fall with inability to use his left hand. At that time he appeared confused. In discussion with his collegues, it appears that the patient had complained of a headache one day prior , however was acting normally on the day of presenation. Today, he describes a sensation of confusion and dysarthria at the time. A code stroke was called at 1340, and he was seen by the stroke fellow, on whose exam, he was found to be disoriented, not following commands, with a left sided neglect, significant left sided weakness and sensory loss and rightward gaze preference. Past Medical History: Postnasal drip IHSS (history of being on toprol x 10 years, recently weaned off) GERD Social History: The patient is a surgical resident. He lives at home with his wife. Family History: NC Physical Exam: ADMISSION PHYSICAL EXAM: VS T:afebrile HR:54 BP: 158/98 RR: 16 SaO2: 100% RA General: Awake, agitated. Head: NC/AT, no conjunctival icterus, no oropharyngeal lesions Neck: Supple, no nuchal rigidity, no bruits Cardiovascular: RRR, no M/R/G Pulmonary: Equal air entry bilaterally, no crackles or wheezes Abdomen: Soft, NT, ND, +BS, no guarding Extremities: Warm, no edema, palpable radial/dorsalis pedis pulses Skin: No rashes or lesions Psychiatric: Appears agitated. Neurologic Examination: - Mental Status - Awake, alert, agitated, not following commands. Cannot provide history. Follows one-step commands inconsistently. Spontaneous language fluent. No dysarthria. Left neglect to all modalities. - Cranial Nerves [II] PERRL 3->2 brisk. Left hemianopsia. [III, IV, VI] EOMI, no nystagmus. Right gaze preference, not overcome by OCR. [V] V1-V3 with decreased PP on left [VII] Left UMN-type facial palsy. [VIII] Orients to voice. [IX, X] Palate elevation symmetric. [[**Doctor First Name 81**]] SCM/Trapezius strength 5/5 bilaterally. [XII] Tongue midline. - Motor - Normal bulk and tone. Minimal movement in LUE > LLE extremities to pain only. Right at least 4/5 strength throughout with spontaneous movement. No tremor or asterixis. - Sensory - Significantly decreased to pain on left, grossly intact on right. Plantar response extensor on left and plantor on right. . DISCHARGE PHYSICAL EXAM: Vitals: Tm 99.1/Tc 98.4, BP 122/64, HR 67, RR 20, 98%RA HEENT: OP clear CV: RRR (confirmed on tele) PULM: mild pain on deep inspiration ABD: NT, ND EXT: no peripheral edema . Neurological Exam: MS - AAOx3, speech fluent, no difficulty naming CN - PERRL, EOMI, face symmetrical, tongue midline MOTOR - 5/5 strength throughout, normal tone, normal bulk REFLEXES - 2 and symmetric throughout COORDINATION - able to point bilaterally GAIT - narrow bases, good initiation Pertinent Results: Labs on Admission: [**2153-8-16**] 01:45PM BLOOD PT-12.4 PTT-22.8 INR(PT)-1.0 [**2153-8-16**] 04:27PM BLOOD Glucose-114* UreaN-19 Creat-1.0 Na-139 K-4.3 Cl-105 HCO3-25 AnGap-13 [**2153-8-16**] 04:27PM BLOOD ALT-21 AST-29 CK(CPK)-827* AlkPhos-52 [**2153-8-17**] 12:50AM BLOOD CK(CPK)-1765* [**2153-8-17**] 09:28AM BLOOD CK(CPK)-1864* [**2153-8-16**] 04:27PM BLOOD Calcium-8.5 Phos-3.5 Mg-1.8 Cholest-165 [**2153-8-16**] 04:27PM BLOOD %HbA1c-5.7 eAG-117 [**2153-8-16**] 04:27PM BLOOD Triglyc-110 HDL-42 CHOL/HD-3.9 LDLcalc-101 [**2153-8-17**] 09:28AM BLOOD CRP-9.3* [**2153-8-16**] 04:27PM BLOOD TSH-2.9 Labs on Discharge: [**2153-8-21**] 04:15AM BLOOD WBC-6.3 RBC-4.95 Hgb-13.2* Hct-37.9* MCV-77* MCH-26.7* MCHC-34.8 RDW-12.9 Plt Ct-196 [**2153-8-21**] 04:15AM BLOOD PT-18.7* INR(PT)-1.7* [**2153-8-21**] 04:15AM BLOOD Glucose-97 UreaN-14 Creat-1.1 Na-142 K-4.0 Cl-105 HCO3-30 AnGap-11 [**2153-8-20**] 06:50AM BLOOD CK(CPK)-282 [**2153-8-21**] 04:15AM BLOOD Calcium-8.8 Phos-4.9* Mg-2.3 MRI Head s/p tPA: A few small foci of decreased diffusion in the right parietal lobe in the MCA territory and in the left frontal lobe adjacent to the operculum representing acute infarcts, likely embolic. However, no significant mass effect noted. Mild edema/ cortical swelling noted in this location. Patent major intra- and extra-cranial arteries, without focal flow-limiting stenosis, occlusion or obvious aneurysm more than 3 mm within the resolution of MR angiogram. Previously noted slightly dense focus in the right parietal lobe is not identifiable on the present study. The nature of the finding on the CT head is not clear. Consider followup with non-contrast CT head study to assess for interval change. CT Head (Code stroke): Dense appearance of the right internal carotid artery termination and the middle cerebral artery concerning for thrombus. Subtle equivocal focal hypodense appearance of the right insular cortex. No acute hemorrhage or mass effect. A large area of perfusion abnormality in the right MCA territory, representing ischemia. Small areas of acute infarction within cannot be completely excluded based on the present study and correlation with MRI can be considered if not contraindicated. Post TPA CT Scan: 1. Interval development of a tiny dense focus in the right parietal lobe of uncertain etiology- ? procedure related/ thrombus. Consider a close followup and correlation with the procedure performed. Assessment for subtle hemorrhage is limited given the presence of intravenous contrast and intra-arterial contrast. Within this limitation, no large area of hemorrhage or mass effect is noted. Subtle hypodense appearance of the right insular cortex, attention on close followup. ECHO [**2153-8-16**]: IMPRESSION: There is moderate hypertrophy of the mid and apical left ventricular walls. The apical segments and apex appear near-akinetic. No thrombus is seen. There is a mid-cavitary gradient of approximately 56 mm Hg. Findings are consistent with "burnt out" apical LVH. No cardiac source of embolus is seen. ECHO [**2153-8-20**]: Conclusions There is marked mid-cavitary hypertrophy with normal cavity size. The apex is mildly aneurysmal and dyskinetic. No intraventricular thrombus is seen. The remaining segments contract well. There is no pericardial effusion. MICROBIOLOGY: [**2153-8-18**] 9:13 am URINE Source: CVS. URINE CULTURE (Preliminary): PRESUMPTIVE STREPTOCOCCUS BOVIS. >100,000 ORGANISMS/ML.. STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000 ORGANISMS/ML.. Brief Hospital Course: [**Known firstname **] [**Known lastname 50417**] is a 35yo M surgical resident at the [**Hospital1 18**] with a history of hypertrophic cardiomyopathy who collapsed on [**8-17**] during rounds, code stroke called, on evaluation found to have a dense right hemispheric syndrome with an NIHSS of 18, now s/p IV TPA and MERCI retrieval, doing well neurologically with course c/b aspiration PNA. . # NEURO: This is a peculiar presentation of a R MCA stroke of a likely cardioembolic source in the setting of mild apical hypokinesis as seen on echo with deffinity contrast. Patient made a full neurological recovery and was able to complete fine finger movements with his L hand, had no evidence of apraxia or neglect on the L side and no focal weakness. Pt will be bridged on full dose ASA to coumadin. He has a hypercoagulability panel pending, but the most likely source of his stroke was a clot forming in his hypokinetic apical aneurysm. On repeat echo, there was no additional clot in the apical aneurysm, and for this reason, as well as some mild blush of tPA seen on CT scan on initial post-tPA eval, he was not put on a heparin bridge. # CARDS: We started patient on Toprol XL, (which he had been on 1 year ago as an outpatient, but has stopped because of side effects), because patient had occasional runs of NSVT on tele while an inpatient. We started him on lipitor 20mg once a day for modifiable risk factor management. He received an echo that showed a small apical aneurysm that was likely the source of his stroke (see above). He will follow-up with Dr. [**Last Name (STitle) 171**] for cardiology in the future and will have his PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**], follow his INRs to ensure that he remains therapeutic. # ID: Patient spiked a fever to 103.2 with chills on [**8-18**]. He had a witnessed aspiration event on his way to the CT scanner at the time of his stroke. Therefore, it was assumed that his fever was secondary to aspiration PNA, which was confirmed with verbal report frmo radiology. He was started on vancomycin and zosyn on [**8-18**] and was planned to receive an 8 day course (to finish [**8-25**]). In order to make patient's dosing regimen easier, he was sent home on vancomycin and ertapenem. A PICC line was placed so that pt could go home with his IV antibiotics. Of note, patient had a UCx result that showed gram positive bacteria, but the accompanying U/A was unremarkable. We felt that this was likely a contaminant, but we repeated the U/A (again unremarkable) and the UCx (stil pending). These will need to be followed up on at pt's PCP [**Name9 (PRE) 702**] appointment. # PULM: Extubated to room air within 1 day of stroke without complication, but then developed aspiration PNA (see above) so we continued vanc and zosyn with transition to ertapenem prior to dispo. # MSK: CK elevated to 1800's at peak, then trended down throughout the admission. Unclear source. Chart reviewed to ensure no chest compressions were given when pt collapsed, which they were not. No reports of pt fighting the vent, and cardiac enzymes were negative except for CK. We therefore do not have a very good explanation of the elevated CK. Patient was kept on IVF to protect his kidneys and told to remain hydrated when he went home. # RENAL: Cr mildly elevated on [**8-20**], likely [**1-3**] volume depletion because of poor PO intake and diarrhea from ABx. We put patient on IVF and his Cr quickly improved back to baseline. We told patient to avoid dehydration in the future. # HEMATOLOGY: pt with microcytic anemia. This will need further outpatient workup, but was not addressed in the setting of patient's acute issues. # ENDO: no hx of DM2, but FSs were mildly elevated initially after stroke. He was put on an insulin sliding scale, but his FSs improved without any other intervention and he was sent home off of any medications to control his blood sugars. # GI/NUTRITION: we started pt on omperazole 20mg QD given hx of gastritis and recent GERD sx, as well as imodium PRN diarrhea because he was having GI upset from his ABx. # CODE: Full Code PENDING LABS: UCx final sensitivities [**8-18**] BCx x2 [**2153-8-18**] UCx [**8-20**] Hypercoagulability Panel [**8-17**] TRANSITIONAL CARE ISSUES: Patient will need his INR followed to ensure that he remains therapeutic. His UCx data will need to be followed to determine if his previously positive UCx was the result of a contaminant or a true UTI. He will need his PNA followed up on to ensure that pt fully recovers on his current ABx regimen. Medications on Admission: None Discharge Medications: 1. vancomycin in D5W 1 gram/200 mL Piggyback Sig: 1,000 mg Intravenous Q 12H (Every 12 Hours): Last dose = [**8-25**]. Disp:*11 doses* Refills:*0* 2. ertapenem 1 gram Recon Soln Sig: One (1) gram Intravenous every twenty-four(24) hours: Last dose = [**8-25**]. Disp:*5 doses* Refills:*0* 3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Please stop this 24 hours after your INR becomes therapetic. Disp:*30 Tablet(s)* Refills:*0* 4. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: Your PCP will adjust your dose to keep your INR between [**1-4**]. Disp:*30 Tablet(s)* Refills:*2* 5. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 6. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2* 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 8. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp:*10 Tablet(s)* Refills:*0* 9. Zofran 4 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. Disp:*20 Tablet(s)* Refills:*0* 10. Imodium A-D 2 mg Tablet Sig: One (1) Tablet PO four times a day as needed for diarrhea. Disp:*20 Tablet(s)* Refills:*0* 11. Outpatient Lab Work Please check INR on [**8-22**]. Please fax the results in to patient's PCP [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**]: Office Fax:([**Telephone/Fax (1) 27997**] If there are any issues, please call pt's PCP [**Last Name (NamePattern4) **]: Office Phone:([**Telephone/Fax (1) 21461**] 12. Outpatient Lab Work Please check patient's INR on [**8-24**]. Please fax the results to patient's PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**] on: Office Fax:([**Telephone/Fax (1) 27997**] If there are any issues, please call his PCP [**Last Name (NamePattern4) **]: ([**Telephone/Fax (1) 21461**] 13. Outpatient Lab Work Please check patient's INR on [**8-27**]. Please fax the results to patient's PCP Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**] on: [**Telephone/Fax (1) 21460**] If there are any issues, please call pt's PCP [**Last Name (NamePattern4) **]: ([**Telephone/Fax (1) 21461**] 14. Outpatient Lab Work Please check patient's INR on [**8-29**]. Please fax the results to patient's PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**] on: ([**Telephone/Fax (1) 27997**]. If there are any issues, please call patient's PCP [**Last Name (NamePattern4) **]: ([**Telephone/Fax (1) 21461**] 15. Outpatient Lab Work Please check patient's INR on [**8-31**]. Please fax the results to patient's PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**] on: ([**Telephone/Fax (1) 27997**]. If there are any issues, please call patient's PCP [**Last Name (NamePattern4) **]: ([**Telephone/Fax (1) 21461**] 16. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for itching. Disp:*20 Tablet(s)* Refills:*0* 17. Ativan 1 mg Tablet Sig: One (1) Tablet PO four times a day as needed for anxiety for 5 days. Disp:*20 Tablet(s)* Refills:*0* 18. Outpatient Lab Work Vancomycin trough on morning of [**8-22**] as well as INR to be drawn by IV team/VNA. Please give results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**] on: Phone: [**Telephone/Fax (1) 10492**] Fax: [**Telephone/Fax (1) 21460**] Discharge Disposition: Home With Service Facility: [**Last Name (un) 6438**] Discharge Diagnosis: Primary: R MCA stroke Secondary: Hypertrophic Cardiomyopathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. NEURO EXAM: Non-focal Discharge Instructions: Dear Dr. [**Known lastname 50417**], You were seen in the hospital for a right sided middle cerbral artery stroke. You were given intravenous tPA and were then taken to the angio suite where a MERCI device was used to remove any remaining clot. You were kept in the hospital where you made a full neurological recovery. However, while here, you developed a pneumonia, likely the results of aspiration when the stroke occurred. You were started on antibiotics which improved the pneumonia, and you will go home on these to complete an 8 day course. You will go home on warfarin. Your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1007**], will manage your dosing. You were sent home with prescriptions for outpatient lab work to be done every other day until your INR is between [**1-4**]. You can use as many of the prescriptions for labwork you need until you are therapeutic on your INR. Once your INR is therapeutic, Dr. [**Last Name (STitle) 1007**] will decide how often you need your INR checked and will arrange for these tests. We made the following changes to your medications: 1) We STARTED you on WARFARIN at 5mg once a day. You will have your INR monitored by your PCP. 2) We STARTED you on TOPROL XL 25mg once a day. 3) We STARTED you on OMEPRAZOLE 20mg once a day. You may stop taking this when your antibiotics course is completed if you are no longer experiencing GERD. 4) We STARTED you on ASPIRIN 325mg once a day. You can stop taking this once your INR is between [**1-4**]. 5) We STARTED you on SIMVASTATIN 20mg once a day. 6) We STARTED you on OXYCODONE 5mg every 6 hours as needed for pain for the next 5 days. 7) We STARTED you on ZOFRAN 4mg every 6 hours as needed for nausea for the next 5 days. 8) We STARTED you on IMODIUM every 6 hours as needed for diarrhea while taking your antibiotics. 9) We STARTED you on ERTAPENEM 1 gram every 24 hours until [**8-25**] to complete an 8 day course for aspiration PNA. 10) We STARTED you on VANCOMYCIN 1 gram every 12 hours unil [**8-25**] to complete an 8 day course for aspiration PNA. 11) We STARTED you on HYDROXYZINE 25mg every 6 hours as needed for itching for the next 5 days. 12) We STARTED you on ATIVAN 1mg four times a day as needed for anciety for the next 5 days. If you experience any of the below listed Danger Signs, please contact your doctor or go to the nearest Emergency Room. It was a pleasure taking care of you on this hospitalization. Followup Instructions: Department: INTERNAL MEDICINE When: FRIDAY [**2153-8-24**] at 10:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**], MD [**Telephone/Fax (1) 10492**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 24**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: CARDIAC SERVICES When: WEDNESDAY [**2153-9-19**] at 12:40 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: NEUROLOGY When: FRIDAY [**2153-9-21**] at 12:00 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD [**Telephone/Fax (1) 2574**] Building: [**Hospital6 29**] [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

434,507,427,425,530

{'Cerebral embolism with cerebral infarction,Pneumonitis due to inhalation of food or vomitus,Paroxysmal ventricular tachycardia,Other primary cardiomyopathies,Esophageal reflux'}

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: Weakness on left, disorientation PRESENT ILLNESS: [**Known firstname **] [**Known lastname 50417**] is a 35yo M with a history of IHSS, chronic post nasal drip and GERD who is a chief surgical resident at the [**Hospital1 18**]. While performing his daily clinical duties on the [**Hospital Ward Name **], he noticed the acute onset of fall with inability to use his left hand. At that time he appeared confused. In discussion with his collegues, it appears that the patient had complained of a headache one day prior , however was acting normally on the day of presenation. Today, he describes a sensation of confusion and dysarthria at the time. A code stroke was called at 1340, and he was seen by the stroke fellow, on whose exam, he was found to be disoriented, not following commands, with a left sided neglect, significant left sided weakness and sensory loss and rightward gaze preference. MEDICAL HISTORY: Postnasal drip IHSS (history of being on toprol x 10 years, recently weaned off) GERD MEDICATION ON ADMISSION: None ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: ADMISSION PHYSICAL EXAM: VS T:afebrile HR:54 BP: 158/98 RR: 16 SaO2: 100% RA General: Awake, agitated. Head: NC/AT, no conjunctival icterus, no oropharyngeal lesions Neck: Supple, no nuchal rigidity, no bruits Cardiovascular: RRR, no M/R/G Pulmonary: Equal air entry bilaterally, no crackles or wheezes Abdomen: Soft, NT, ND, +BS, no guarding Extremities: Warm, no edema, palpable radial/dorsalis pedis pulses Skin: No rashes or lesions Psychiatric: Appears agitated. FAMILY HISTORY: NC SOCIAL HISTORY: The patient is a surgical resident. He lives at home with his wife. ### Response: {'Cerebral embolism with cerebral infarction,Pneumonitis due to inhalation of food or vomitus,Paroxysmal ventricular tachycardia,Other primary cardiomyopathies,Esophageal reflux'}

CHIEF COMPLAINT: Cardiac arrest s/p suspected heroin overdose PRESENT ILLNESS: Mr. [**Name14 (STitle) 80449**] is a 30 yo male with past medical history of hemochromatosis and hepatitis C found down after reported heroin use, found to be in cardiac arrest in the field. Per report EMS was called by a friend who reported the patient became unresponsive after heroin and alcohol use. Down time prior to EMS arrival was approximately 10 minutes per report. He was intubated in the field, and received 30 minutes of CPR with initial rhythm of asystole followed by PEA. He received epi X2, atropine X2, HCO3 X2 and narcan 6 mg. Pt initially taken to [**Hospital 8125**] Hospital where intial BP 58/22. Pt treated with IV fluid bolus with improvement in his BP and 2amp of bicarb. Pupils were fixed and dilated. Initial EtOH level was 265. Initial ABG 6.94/77/66/16. CT Head negative for acute bleed. He was transferred to [**Hospital1 18**] for ongoing care. MEDICAL HISTORY: Psoriasis MEDICATION ON ADMISSION: Seroquel Librium ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: PE on admission: Gen: intubated and sedated HEENT - Pupils 4mm - L pupil surgical, R pupil non-reactive CV: RRR, no MRG Resp: CTAB ABd: soft, NT/ND, NABS Ext: no edema Skin: diffuse psoriatic lesions over elbows, abd, kness and entire bilateral lower extremities Neuro: pt on propofol - no gag, no corneal reflexes, no response to threat, no withdrawal of extremities to pain/pressure FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Hx of heroin and ethanol abuse. Mother, father, and sister live in the area and were at patient's bedside.

Poisoning by heroin,Acute respiratory failure,Anoxic brain damage,Coma,Pneumonia, organism unspecified,Cardiac arrest,Toxic effect of ethyl alcohol,Opioid abuse, continuous,Unspecified viral hepatitis C without hepatic coma,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Other psoriasis,Encounter for palliative care,Poisoning by other and unspecified solid and liquid substances, undetermined whether accidentally or purposely inflicted

Poisoning-heroin,Acute respiratry failure,Anoxic brain damage,Coma,Pneumonia, organism NOS,Cardiac arrest,Toxic eff ethyl alcohol,Opioid abuse-continuous,Hpt C w/o hepat coma NOS,Klebsiella pneumoniae,Other psoriasis,Encountr palliative care,Undeter pois-sol/liq NEC

Admission Date: [**2145-10-3**] Discharge Date: [**2145-10-14**] Date of Birth: [**2115-7-13**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3984**] Chief Complaint: Cardiac arrest s/p suspected heroin overdose Major Surgical or Invasive Procedure: Intracranial bolt placed for ICP monitoring [**2145-10-7**] Bronchoscopy [**2145-10-10**] History of Present Illness: Mr. [**Name14 (STitle) 80449**] is a 30 yo male with past medical history of hemochromatosis and hepatitis C found down after reported heroin use, found to be in cardiac arrest in the field. Per report EMS was called by a friend who reported the patient became unresponsive after heroin and alcohol use. Down time prior to EMS arrival was approximately 10 minutes per report. He was intubated in the field, and received 30 minutes of CPR with initial rhythm of asystole followed by PEA. He received epi X2, atropine X2, HCO3 X2 and narcan 6 mg. Pt initially taken to [**Hospital 8125**] Hospital where intial BP 58/22. Pt treated with IV fluid bolus with improvement in his BP and 2amp of bicarb. Pupils were fixed and dilated. Initial EtOH level was 265. Initial ABG 6.94/77/66/16. CT Head negative for acute bleed. He was transferred to [**Hospital1 18**] for ongoing care. On arrival to the [**Hospital1 18**] ED, vitals: HR 130, 150/100. Neurologic exam on arrival included pupils fixed and non-reactive at 6mm. No withdrawal of extremities to pain. CXR showed ET in place. He was started on the Artic Sun post-arrest hypothermia protocol. 2 PIVs were placed and he was started on propofol for sedation. ABG on arrival: 7.41/24/172/16. Labs showed serum EtOH of 198. Serum benzo screen positive. Past Medical History: Psoriasis Hemochromatosis Hepatitis C Hx substance abuse, EtOH/IVDU (Heroin) Social History: Hx of heroin and ethanol abuse. Mother, father, and sister live in the area and were at patient's bedside. Family History: Noncontributory. Physical Exam: PE on admission: Gen: intubated and sedated HEENT - Pupils 4mm - L pupil surgical, R pupil non-reactive CV: RRR, no MRG Resp: CTAB ABd: soft, NT/ND, NABS Ext: no edema Skin: diffuse psoriatic lesions over elbows, abd, kness and entire bilateral lower extremities Neuro: pt on propofol - no gag, no corneal reflexes, no response to threat, no withdrawal of extremities to pain/pressure Pertinent Results: [**2145-10-3**] 06:50PM BLOOD WBC-4.9 RBC-3.95* Hgb-13.5* Hct-38.4* MCV-97 MCH-34.2* MCHC-35.3* RDW-14.9 Plt Ct-165 [**2145-10-3**] 06:50PM BLOOD PT-12.2 PTT-23.1 INR(PT)-1.0 [**2145-10-3**] 10:06PM BLOOD Glucose-194* UreaN-8 Creat-1.1 Na-145 K-3.4 Cl-107 HCO3-19* AnGap-22* [**2145-10-3**] 10:06PM BLOOD ALT-184* AST-317* CK(CPK)-2060* AlkPhos-141* Amylase-55 [**2145-10-3**] 10:06PM BLOOD CK-MB-7 cTropnT-<0.01 [**2145-10-3**] 06:50PM BLOOD ASA-NEG Ethanol-198* Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG [**2145-10-5**] 10:18AM URINE bnzodzp-POS barbitr-NEG opiates-POS cocaine-NEG amphetm-NEG mthdone-NEG Brief Hospital Course: Pt is a 30 yo male s/p cardiac arrest in the setting of suspected heroin overdose. Reported downtime of ~10min in the field f/b 30min of CPR before restoration of vital signs. Admitted to the Medical ICU for Artic Sun post-arrest induced mild hypothermia protocol. #Anoxic brain injury - Minimal neurologic response prior to initiation of cooling protocol. 24hr protocol completed and rewarming initiated. During rewarming, he developed profound rigors and subsequently became febrile to 104. The rigors were not responsive to increasing sedation or demerol, thus he was re-paralyzed. The following morning, the paralytic was discontinued, and he developed movements more consistent with seizure activity most prominent in the R arm and R leg. He was loaded with phenytoin with some improvement in seizure activity and neurology was consulted. He developed persistent breakthrough seizure-like movements requiring boluses of phenytoin and initiation of Keppra. A video EEG was performed and results showed diffuse encephalopathic changes without evidence of electrographic seizures. An MRI was performed on [**2145-10-6**] which revealed findings c/w global infaraction, anoxic brain injury, and diffuse cerebal edema. On the morning of [**2145-10-7**], pt was noted to have a change in his pupillary exam and papilledema. A STAT head CT revealed complete loss of grey-white matter differentiation c/w diffuse cerebral edema. Pt was started on mannitol infusion, HOB to 30 degrees, and hyperventilated to a PCO2 of 28. Neurosurgery was consulted, placed a bolt, found the initial ICP to be 24. Pt was continued on mannitol q6h, Keppra, and continous ICP monitoring (ICPs ranged from 20s-60s). Neurologic exams off-sedation revealed absent corneal reflexes, absent cold calorics, and no response to painful stimuli. Apnea tests x 2 ([**10-11**], [**10-13**]) revealed that patient continued to demonstrate respiratory effort, and thus did not meet criteria for brain death. After ongoing discussions with the family regarding his poor prognosis, and based on previously expressed wishes of the patient, the family decided to shift goals of care to CMO on the morning of [**2145-10-14**]. He was extubated, made comfortable with morphine, and declared dead at 1:39pm on [**2145-10-14**]. NEOB had been contact[**Name (NI) **] and pt was ruled out for donation after cardiac death. # S/p Cardiopulmonary Arrest: Pt received the 24hr post-arrest hypothermia protocol. Cardiac enzymes were cycled and were negative for any significant ischemia. A transthoracic ECHO done on [**2145-10-5**] revelead normal structure and function. Pt remained hemodynamically stable without need for vasopressor support. #Fever: Pt became febrile in the midst of diffuse rigors. Blood, urine, and sputum cultures were sent. A CXR on [**2145-10-6**] revealed a new LLL opacity, consistent with atelectasis vs. infiltrate. He was started on Levofloxacin and Flagyl to cover for possible aspiration. He was switched to Ceftriaxone and Flagyl the following morning (concern for lowering the seizure threshold on flouroquinolones). Blood and urine cultures were negative but sputum cultures were positive for Klebsiella, Enterobacter, and Staph Aureus. Bronchoscopy on [**2145-10-20**] revealed copious purulent secretions. Pt was treated with appropriate IV antibiotics until the decision made made to focus on CMO. The family was provided with support from social work and the hospital priest & chaplaincy services. They were at the bedside when he expired. Medications on Admission: Seroquel Librium Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Death due to severe anoxic brain injury s/p cardio-respiratory arrest due to suspected heroin and alcohol overdose Discharge Condition: Deceased [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]

965,518,348,780,486,427,980,305,070,041,696,V667,E980

{"Poisoning by heroin,Acute respiratory failure,Anoxic brain damage,Coma,Pneumonia, organism unspecified,Cardiac arrest,Toxic effect of ethyl alcohol,Opioid abuse, continuous,Unspecified viral hepatitis C without hepatic coma,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Other psoriasis,Encounter for palliative care,Poisoning by other and unspecified solid and liquid substances, undetermined whether accidentally or purposely inflicted"}

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: Cardiac arrest s/p suspected heroin overdose PRESENT ILLNESS: Mr. [**Name14 (STitle) 80449**] is a 30 yo male with past medical history of hemochromatosis and hepatitis C found down after reported heroin use, found to be in cardiac arrest in the field. Per report EMS was called by a friend who reported the patient became unresponsive after heroin and alcohol use. Down time prior to EMS arrival was approximately 10 minutes per report. He was intubated in the field, and received 30 minutes of CPR with initial rhythm of asystole followed by PEA. He received epi X2, atropine X2, HCO3 X2 and narcan 6 mg. Pt initially taken to [**Hospital 8125**] Hospital where intial BP 58/22. Pt treated with IV fluid bolus with improvement in his BP and 2amp of bicarb. Pupils were fixed and dilated. Initial EtOH level was 265. Initial ABG 6.94/77/66/16. CT Head negative for acute bleed. He was transferred to [**Hospital1 18**] for ongoing care. MEDICAL HISTORY: Psoriasis MEDICATION ON ADMISSION: Seroquel Librium ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: PE on admission: Gen: intubated and sedated HEENT - Pupils 4mm - L pupil surgical, R pupil non-reactive CV: RRR, no MRG Resp: CTAB ABd: soft, NT/ND, NABS Ext: no edema Skin: diffuse psoriatic lesions over elbows, abd, kness and entire bilateral lower extremities Neuro: pt on propofol - no gag, no corneal reflexes, no response to threat, no withdrawal of extremities to pain/pressure FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Hx of heroin and ethanol abuse. Mother, father, and sister live in the area and were at patient's bedside. ### Response: {"Poisoning by heroin,Acute respiratory failure,Anoxic brain damage,Coma,Pneumonia, organism unspecified,Cardiac arrest,Toxic effect of ethyl alcohol,Opioid abuse, continuous,Unspecified viral hepatitis C without hepatic coma,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Other psoriasis,Encounter for palliative care,Poisoning by other and unspecified solid and liquid substances, undetermined whether accidentally or purposely inflicted"}

CHIEF COMPLAINT: ABD PAIN PRESENT ILLNESS: Patient is intubated and is therefore unable to communicate verbally. History is based on medical records provided by [**Hospital1 **] and Dr.[**Name (NI) 74774**] exploratory laparoscopy notes. This 63 yo female had a laparoscopic cholecystectomy on [**2111-9-14**] and was discharged home on the same day symptomatic (symptoms not mentioned). On the morning of [**2111-9-16**], the patient began to experience severe abdominal pain, which became worse and she was seen at [**Hospital3 **]/[**Hospital1 74775**] in [**Hospital1 1806**], MA where a CT scan showed an ileus with no evidence of any other abnormality and a small amount of fluid in the gallbladder fossa, consistent with the previous surgery. MEDICAL HISTORY: PMH: PVD, L subclavian stenosis s/p bypass, HTN, ^chol, COPD, s/p appy, s/p tonsillectomy, seizure d/o, CVA '[**08**], bilateral CEA MEDICATION ON ADMISSION: [**Last Name (un) 1724**]: dilantin, aggrenox, lorazepam, albuterol,, advair, lovastatin ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: fragile female a/o nad cta rrr abd j / g tube sites inact, clean Pulses: Fem DP PT Rt 2+ mono mono Lt 2+ mono mono FAMILY HISTORY: n/c SOCIAL HISTORY: Married female living with husband. Unknown occupation status. Smokes cigarettes: unknown amount, denies alcohol/illicit drug use

Acute vascular insufficiency of intestine,Peritoneal abscess,Other and unspecified postsurgical nonabsorption,Chronic airway obstruction, not elsewhere classified,Other convulsions,Thrombocytopenia, unspecified,Other ascites,Other postoperative infection,Other chronic postoperative pain,Unspecified essential hypertension,Pure hypercholesterolemia,Anemia, unspecified,Surgical operation with formation of external stoma causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation

Ac vasc insuff intestine,Peritoneal abscess,Intest postop nonabsorb,Chr airway obstruct NEC,Convulsions NEC,Thrombocytopenia NOS,Ascites NEC,Other postop infection,Chronic postop pain NEC,Hypertension NOS,Pure hypercholesterolem,Anemia NOS,Abn react-external stoma

Admission Date: [**2111-9-17**] Discharge Date: [**2111-10-28**] Date of Birth: [**2048-2-16**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2534**] Chief Complaint: ABD PAIN Major Surgical or Invasive Procedure: [**9-17**] Selective celiac arteriogram, celiac stenting, abdominal and pelvic arteriogram (CPT codes [**Numeric Identifier 7534**], [**Numeric Identifier 7535**], [**Numeric Identifier 25533**] and [**Numeric Identifier 24945**]). Failed attempt to cross SMA occlusion [**9-17**] Exploratory laparotomy. [**9-20**] PROCEDURE: 1. Exploratory laparotomy. 2. Small bowel resection. 3. Small bowel anastomosis x2. 4. Ileocolic anastomosis. 5. [**Last Name (un) **] gastrostomy. 6. [**State 19827**] patch abdominal closure. [**9-25**] PROCEDURE: 1. Reopening of abdomen. 2. Resection of small bowel anastomoses x3. [**9-28**] PROCEDURE: 1. Exploratory laparotomy. 2. Small bowel resection. 3. Tube jejunostomy. 4. Abdominal closure. [**10-16**] PROCEDURE: Hickman catheter insertion. History of Present Illness: Patient is intubated and is therefore unable to communicate verbally. History is based on medical records provided by [**Hospital1 **] and Dr.[**Name (NI) 74774**] exploratory laparoscopy notes. This 63 yo female had a laparoscopic cholecystectomy on [**2111-9-14**] and was discharged home on the same day symptomatic (symptoms not mentioned). On the morning of [**2111-9-16**], the patient began to experience severe abdominal pain, which became worse and she was seen at [**Hospital3 **]/[**Hospital1 74775**] in [**Hospital1 1806**], MA where a CT scan showed an ileus with no evidence of any other abnormality and a small amount of fluid in the gallbladder fossa, consistent with the previous surgery. She has a past medical history of vascular disease with a carotid artery stenosis and coronary artery disease. She had an ERCP because of stones in the bile duct and had been referred for a semi-urgent cholecystectomy and had undergone an uneventful laparoscopic cholecystectomy. The findings at surgery upon opening the patient's abdomen, the small bowel in the superior mesenteric distribution was considered "dusky", although completely and not frankly gangrenous. The operative site appeared with no evidence of any bile leak and all staples in place. There was no free fluid in the peritoneal cavity. It was elected to close the patient, start the patient on heparin, and refer her to vascular service. The superior mesenteric artery has a non-dopplerable pulse, but there is a palpable pulse in the splenic and the common hepatic artery. The aorta is considered markedly stenosed Past Medical History: PMH: PVD, L subclavian stenosis s/p bypass, HTN, ^chol, COPD, s/p appy, s/p tonsillectomy, seizure d/o, CVA '[**08**], bilateral CEA Social History: Married female living with husband. Unknown occupation status. Smokes cigarettes: unknown amount, denies alcohol/illicit drug use Family History: n/c Physical Exam: fragile female a/o nad cta rrr abd j / g tube sites inact, clean Pulses: Fem DP PT Rt 2+ mono mono Lt 2+ mono mono Pertinent Results: [**2111-10-16**] 09:52PM BLOOD WBC-10.7 RBC-3.57* Hgb-10.8* Hct-32.9* MCV-92 MCH-30.3 MCHC-32.9 RDW-15.0 Plt Ct-341 [**2111-10-13**] 03:06AM BLOOD PT-16.2* PTT-45.8* INR(PT)-1.5* [**2111-10-20**] 05:45AM BLOOD Glucose-82 UreaN-23* Creat-0.6 Na-133 K-4.4 Cl-105 HCO3-23 AnGap-9 [**2111-10-18**] 06:01AM BLOOD ALT-7 AST-10 AlkPhos-105 TotBili-0.5 [**2111-10-20**] 05:45AM BLOOD Calcium-8.6 Phos-4.3 Mg-2.0 [**2111-10-7**] 09:40AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.011 URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG URINE RBC-[**3-2**]* WBC-0-2 Bacteri-0 Yeast-NONE Epi-0 [**2111-10-9**] 11:52 am STOOL Site: STOOL CONSISTENCY: LOOSE CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2111-10-10**]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. [**2111-10-16**] 9:17 PM CHEST (SINGLE VIEW); CHEST FLUORO WITHOUT RADIOLOGI Reason: INSERTION HICKMAN LINE UNDER FLUORO FINDINGS: Two fluoroscopic spot films are obtained in the OR during placement of a central venous line. These limited films reveal right subclavian and right internal jugular venous catheters extending to the cavoatrial junction. No pneumothorax is visualized. [**2111-10-7**] 3:26 PM BILAT UP EXT VEINS US Reason: Please do a formal study of bilat. UE - look for DVT UPPER EXTREMITY ULTRASOUND: Grayscale and color Doppler ultrasound examinations of bilateral internal jugular, subclavian, axillary, brachial, basilic, and cephalic veins was performed. There is an occlusive thrombus of the right cephalic, which extends into the right subclavian although this vessel is not occluded. The extension of the subclavian exhibits echogenicity suggestive of organization. Remaining veins demonstrate normal wall-to-wall color flow, compressibility, and waveforms. IMPRESSION: Occlusive thrombus in the right cephalic vein which extends into the right subclavian vein without causing occlusion. Brief Hospital Course: [**9-17**]: PT ADMITTED TAKEN STAT TO THE OR: Selective celiac arteriogram, celiac stenting, abdominal and pelvic arteriogram (CPT codes [**Numeric Identifier 7534**], [**Numeric Identifier 7535**], [**Numeric Identifier 25533**] and [**Numeric Identifier 24945**]). Failed attempt to cross SMA occlusion. [**9-17**] Selective celiac arteriogram, celiac stenting, abdominal and pelvic arteriogram (CPT codes [**Numeric Identifier 7534**], [**Numeric Identifier 7535**], [**Numeric Identifier 25533**] and [**Numeric Identifier 24945**]). Failed attempt to cross SMA occlusion Exploratory laparotomy. There was no evidence of soilage of bowel contents in the abdomen. [**9-20**] - the patient was taken for a planned second look operation by Dr. [**Last Name (STitle) **], She had been hemodynamically stable during the interim period. There were several areas of small bowel requiring resection PROCEDURE: 1. Exploratory laparotomy. 2. Small bowel resection. 3. Small bowel anastomosis x2. 4. Ileocolic anastomosis. 5. [**Last Name (un) **] gastrostomy. 6. [**State 19827**] patch abdominal closure. Transfered back to the CVICU - intubated / pt required resusitation by meds and fluid [**9-25**] - patient did begin spiking fevers, reexploration, washout and closure were indicated. Bilious ascites with some fecalized material was encountered. Inspection revealed that the two small bowel anastomoses had broken down with the beginning of leakage of intestinal contents. Vascular surgery was notified intraoperatively and did come into the OR. All potentially viable lengths of small bowel were preserved. PROCEDURE: 1. Reopening of abdomen. 2. Resection of small bowel anastomoses x3. [**9-28**] - pt spiked fevers again, Upon entering the abdomen, there was a sulcus free within the intestinal cavity from a perforation of 1 of the closed loops of small bowel. Anadditional 18 cm of small bowel was identified and found to be nonviable. PROCEDURE: 1. Exploratory laparotomy. 2. Small bowel resection. 3. Tube jejunostomy. 4. Abdominal closure. Since that time, the patient has been stable. [**Hospital 74776**] transfered to the VICU, then the floor. Pt required Pain consult to wean of PCA. PCA was removed and pain control was maintained using a fentanyl patch with percocet elixir for breakthrough. The patient has had copious output from her Gtube and Jtube, managed with a variety of colostomy-style appliances. [**10-16**] - She requires agressive fluid and electrolyte repletion, It was decided to put a permanent line in PROCEDURE: Hickman catheter insertion. Pt had multiple cx's taken during this hospital sty. Her AB were broad coverage. Prior to discharge her Antibiotics were stopped. The morning after she spiked a temperature. No obvious sources of infection. CT abdomen done which showed small collection in the abdomen, decreased in size from previously. However, no ring enhancing with air. Patient was transferred to the General Surgery team for continued management of this problem. [**2111-10-4**] PERITONEAL FLUID {neg} [**2111-10-9**] ESCHERICHIA COLI, CIPROFLOXACIN - <=0.25 S [**2111-10-9**] ANAEROBIC CULTURE: NO ANAEROBES ISOLATED. [**2111-10-14**] [**Female First Name (un) **] ALBICANS, Fluconazole SENSITIVE. During her last week in the hospital she was afebrile and without complaint. Her TPN and fluids were titrated with her urine output and her G and J tube output to maintain her net fluid balence as neutral. Medications on Admission: [**Last Name (un) 1724**]: dilantin, aggrenox, lorazepam, albuterol,, advair, lovastatin Discharge Medications: 1. Acetaminophen 650 mg Suppository [**Last Name (un) **]: One (1) Suppository Rectal Q6H (every 6 hours) as needed. 2. Cyclobenzaprine 10 mg Tablet [**Last Name (un) **]: One (1) Tablet PO TID (3 times a day) as needed. 3. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Last Name (un) **]: 5-10 MLs PO Q4H (every 4 hours) as needed. 4. Fentanyl 100 mcg/hr Patch 72 hr [**Last Name (un) **]: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 5. Clopidogrel 75 mg Tablet [**Last Name (un) **]: One (1) Tablet PO DAILY (Daily). 6. Nystatin 100,000 unit/mL Suspension [**Last Name (un) **]: Five (5) ML PO QID (4 times a day): THRUSH / DC when THRUSH IS GONE. 7. Miconazole Nitrate 2 % Powder [**Last Name (un) **]: One (1) Appl Topical PRN (as needed). 8. Prochlorperazine Edisylate 5 mg/mL Solution [**Last Name (un) **]: One (1) Injection Q6H (every 6 hours) as needed. 9. HICKMAN CATHETER Heparin Flush Hickman (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 11. Enoxaparin 80 mg/0.8 mL Syringe [**Last Name (STitle) **]: One (1) Subcutaneous Q 24H (Every 24 Hours). 12. Levetiracetam 500 mg/5 mL Solution [**Last Name (STitle) **]: One (1) Intravenous Q12H (every 12 hours). 13. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) Inhalation Q6H (every 6 hours) as needed for SOB, wheeze. 14. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Last Name (STitle) **]: One (1) Inhalation Q6H (every 6 hours) as needed for SOB, wheeze. 15. Lorazepam 2 mg/mL Syringe [**Last Name (STitle) **]: 0.5 mg 0.5 mg Injection Q4H (every 4 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 1110**] Discharge Diagnosis: Small Bowel ischemia Discharge Condition: Good Discharge Instructions: CALL OR GO TO THE ER IF Signs and symptoms Although there are different types of intestinal ischemia, signs and symptoms are most often perceived as having a sudden (acute) or gradual (chronic) onset. Signs and symptoms of acute intestinal ischemia typically include: Sudden abdominal pain that may range from mild to severe An urgent need to move your bowels Frequent, forceful bowel movements Abdominal tenderness or distention Blood in your stool Nausea, vomiting Fever Chronic intestinal ischemia, in which blood flow to the intestines is reduced over time, is characterized by: Abdominal cramps or fullness, beginning within 30 minutes after eating and lasting for one to three hours Abdominal pain that gets progressively worse over weeks or months Fear of eating because of subsequent pain Unintended weight loss Diarrhea Nausea, vomiting Bloating CALL OR COME TO THE ER IF: WOUND CARE: PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS: Redness in or drainage from your wound(s). New pain, numbness or discoloration of your lower or upper extremities (notably on the side of the incision). Watch for signs and symptoms of infection. These are: a fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site. If you experience any of these or bleeding at the incision site, CALL THE DOCTOR. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2111-11-24**] 10:45 Follow-up with Dr. [**Last Name (STitle) **] [**2111-10-29**] @ 2pm telephone # [**Telephone/Fax (1) 600**]

557,567,579,496,780,287,789,998,338,401,272,285,E878

{'Acute vascular insufficiency of intestine,Peritoneal abscess,Other and unspecified postsurgical nonabsorption,Chronic airway obstruction, not elsewhere classified,Other convulsions,Thrombocytopenia, unspecified,Other ascites,Other postoperative infection,Other chronic postoperative pain,Unspecified essential hypertension,Pure hypercholesterolemia,Anemia, unspecified,Surgical operation with formation of external stoma causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation'}

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: ABD PAIN PRESENT ILLNESS: Patient is intubated and is therefore unable to communicate verbally. History is based on medical records provided by [**Hospital1 **] and Dr.[**Name (NI) 74774**] exploratory laparoscopy notes. This 63 yo female had a laparoscopic cholecystectomy on [**2111-9-14**] and was discharged home on the same day symptomatic (symptoms not mentioned). On the morning of [**2111-9-16**], the patient began to experience severe abdominal pain, which became worse and she was seen at [**Hospital3 **]/[**Hospital1 74775**] in [**Hospital1 1806**], MA where a CT scan showed an ileus with no evidence of any other abnormality and a small amount of fluid in the gallbladder fossa, consistent with the previous surgery. MEDICAL HISTORY: PMH: PVD, L subclavian stenosis s/p bypass, HTN, ^chol, COPD, s/p appy, s/p tonsillectomy, seizure d/o, CVA '[**08**], bilateral CEA MEDICATION ON ADMISSION: [**Last Name (un) 1724**]: dilantin, aggrenox, lorazepam, albuterol,, advair, lovastatin ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: fragile female a/o nad cta rrr abd j / g tube sites inact, clean Pulses: Fem DP PT Rt 2+ mono mono Lt 2+ mono mono FAMILY HISTORY: n/c SOCIAL HISTORY: Married female living with husband. Unknown occupation status. Smokes cigarettes: unknown amount, denies alcohol/illicit drug use ### Response: {'Acute vascular insufficiency of intestine,Peritoneal abscess,Other and unspecified postsurgical nonabsorption,Chronic airway obstruction, not elsewhere classified,Other convulsions,Thrombocytopenia, unspecified,Other ascites,Other postoperative infection,Other chronic postoperative pain,Unspecified essential hypertension,Pure hypercholesterolemia,Anemia, unspecified,Surgical operation with formation of external stoma causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation'}

CHIEF COMPLAINT: dyspnea, acute renal failure PRESENT ILLNESS: 70yoF with h/o DM2, HTN, L iliac artery stenosis s/p stent who presented with DOE and exertional chest tightness x1 wk. . She saw her PCP today where she c/o new onset exertional chest tightness [**7-19**] associated with neck pain. Also complaining of DOE which was also new and has been progressively worsening as well. She denied diaphoresis, nausea/vomiting, arm / jaw pain. Her vitals were significant for BP 179/88, p105, 100% RA NC. There was concern for new TWI's laterally, and sent to ED. . In the ED: 99.2 98 170/88 18 100% on RA. She denied chest pain, nausea, vomiting, diarrhea, black or bloody stools. She was initially well appearing and exam was reportedly non-focal initially, with clear lungs, RRR, no edema. Labs showed Trop 0.03, ARF with BUN/Cr 64/7.2 (up from Cr 1.4-1.7 baseline), HCO3 20, and K 5.7. EKG concerning for lateral strain pattern STD's with concomitant R precordial J point elevation. Renal consulted; CCU fellow and Atrius Cards notified. . In the ED, she became acutely dyspneic, tachypneic to 30-40's, and satting mid 80% on RA. Exam showed diffuse crackles and increased WOB; she was placed on NRB and given a trial of albuterol inhaler without much effect. Her BP was noted to be 200/100 and there was concern for flash pulmonary edema vs PE vs COPD/asthma. An EJ PIV was placed. CXR showed pulmonary edema. She was given SL NTG then started on Nitro gtt, and given 40 mg IV Lasix x1. BP's improved, then hypoTN to 70/40's and gtt stopped, then restarted when BP's went up to 180/100's; goal SBP 120's. Unable to place arterial line. She was also given 325 ASA. . Vitals before transfer: 97.4 p100 150/87 100% on 4L NC. Currently on Nitro 0.5 mcg/kg/min, and looking much better. . Review of Atrius records shows that she is followed by Atrius Oncologist [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 349**]. Per his most recent notes, she was seen in [**6-/2152**] and per his note: "anemia, small IgG lambda monoclonal protein, elevated light chains, elevated Beta 2 Microglobulin, transient mild hypercalcemia suggest either an MGUS, an early MM, or a low-grade lymphoma. Bone marrow biopsy was non-diagnostic." However, there was question whether these were due to the venous obstruction in her iliacs or an evolving lymphoproliferative disorder. Her kidney function was deteriorating as early as [**4-/2152**]; per Atrius records: Cr [**11/2151**]: 0.83 [**12/2151**]: 0.95 [**4-/2152**]: 1.67 [**4-/2152**]: 1.44 [**6-/2152**]: 1.72 . On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. MEDICAL HISTORY: # Diabetes Mellitus type II on insulin with renal complications (last A1c 7.5 [**6-/2152**]) # HTN # [**Month (only) 116**]-[**Last Name (un) 87639**] Syndrome: an inherited thrombophilic syndrome; compression of the L common iliac vein between overlying right common iliac artery and overlying vertebral body; associated with unprovoked L iliofemoral DVT and chronic venous insufficiency # L common and external iliac veins angioplasty and stenting on [**2152-3-29**], discharged on Coumadin # Asthma "anemia, small IgG lambda monoclonal protein, elevated light chains, elevated B2M, transient mild hypercalcemia suggest either an MGUS, an early MM, or a low-grade lymphoma. Bone marrow biopsy was non-diagnostic." # Lymphadenopathy: multiple enlarged L inguinal LN's noted on pelvic MRV in [**7-/2151**] -> s/p LN biopsy showing reactive LN # SPONDYLOLISTHESIS, ACQUIRED # SCIATICA # RHINITIS, ALLERGIC MEDICATION ON ADMISSION: - Chlorthalidone 25 daily - Colace [**Hospital1 **] prn - Lantus 20 SQ hs - Metformin 1000 daily - Oxycodone 5mg q4 prn - Percocet 5/325 [**12-12**] q4-6 prn - B12 - Benadryl 25 mg prn allergies - Ibuprofen 200 2-4 tabs prn Atrius records: - Losartan 100 mg Oral Tablet Take 1 tablet daily - Chlorthalidone 25 mg daily - Warfarin 1 mg Oral Tablet take 8 tablets daily or as directed ALLERGIES: Lisinopril PHYSICAL EXAM: VS: BP= 178/94 HR= 98 RR=16 O2 sat= 99% 3 L GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: Sclera anicteric. PERRL, EOMI. no pallor or cyanosis of the oral mucosa. No NECK: Supple no tracheal deviation CARDIAC: PMI located in 5th intercostal space, midclavicular line. RRR, normal S1, S2. No m/r/g. No thrills, lifts. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. crakles at bases ABDOMEN: Soft, NTND. No tenderness. BS+ EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 2+ Left: Carotid 2+ DP 2+ FAMILY HISTORY: FAMILY HISTORY: Brother Deceased at 69 Diabetes - Type II Father Deceased train accident Mother Deceased at 72 of MI Son Type 2 diabetes SOCIAL HISTORY: SOCIAL HISTORY From [**Country 3594**] - Tobacco history: quit 30yrs ago, claims to only smoke [**12-12**] cig/day - ETOH: denies - Illicit drugs: denies

Other ureteric obstruction,Acute diastolic heart failure,Acute kidney failure, unspecified,Pulmonary congestion and hypostasis,Hydronephrosis,Monoclonal paraproteinemia,Pure hypercholesterolemia,Hyperpotassemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Diabetes with unspecified complication, type II or unspecified type, uncontrolled,Iron deficiency anemia secondary to blood loss (chronic),Hematuria, unspecified

Ureteric obstruction NEC,Ac diastolic hrt failure,Acute kidney failure NOS,Pulm congest/hypostasis,Hydronephrosis,Monoclon paraproteinemia,Pure hypercholesterolem,Hyperpotassemia,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,DMII unspf uncntrld,Chr blood loss anemia,Hematuria NOS

Name: [**Known lastname **],[**Known firstname 3650**] Unit No: [**Numeric Identifier 17835**] Admission Date: [**2152-8-22**] Discharge Date: [**2152-9-9**] Date of Birth: [**2081-12-8**] Sex: F Service: MEDICINE Allergies: Lisinopril Attending:[**First Name3 (LF) 1472**] Addendum: Discharge paperwork stated that patient was on metformin at home prior to admission. She was instructed to continue this medication after discharge, but it was later confirmed that she does not take this. A prescription was not provided. In addition, her current renal function precludes her from taking this medication. Patient was called and this information was communicated and it was assured that she is not taking metformin and will not in the future. She is taking insulin. Discharge Disposition: Home With Service Facility: [**Location (un) 42**] VNA [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1473**] Completed by:[**2152-9-10**] Admission Date: [**2152-8-22**] Discharge Date: [**2152-9-9**] Date of Birth: [**2081-12-8**] Sex: F Service: MEDICINE Allergies: Lisinopril Attending:[**First Name3 (LF) 613**] Chief Complaint: dyspnea, acute renal failure Major Surgical or Invasive Procedure: bilateral percutaneous nephrostomy tubes with repositioning History of Present Illness: 70yoF with h/o DM2, HTN, L iliac artery stenosis s/p stent who presented with DOE and exertional chest tightness x1 wk. . She saw her PCP today where she c/o new onset exertional chest tightness [**7-19**] associated with neck pain. Also complaining of DOE which was also new and has been progressively worsening as well. She denied diaphoresis, nausea/vomiting, arm / jaw pain. Her vitals were significant for BP 179/88, p105, 100% RA NC. There was concern for new TWI's laterally, and sent to ED. . In the ED: 99.2 98 170/88 18 100% on RA. She denied chest pain, nausea, vomiting, diarrhea, black or bloody stools. She was initially well appearing and exam was reportedly non-focal initially, with clear lungs, RRR, no edema. Labs showed Trop 0.03, ARF with BUN/Cr 64/7.2 (up from Cr 1.4-1.7 baseline), HCO3 20, and K 5.7. EKG concerning for lateral strain pattern STD's with concomitant R precordial J point elevation. Renal consulted; CCU fellow and Atrius Cards notified. . In the ED, she became acutely dyspneic, tachypneic to 30-40's, and satting mid 80% on RA. Exam showed diffuse crackles and increased WOB; she was placed on NRB and given a trial of albuterol inhaler without much effect. Her BP was noted to be 200/100 and there was concern for flash pulmonary edema vs PE vs COPD/asthma. An EJ PIV was placed. CXR showed pulmonary edema. She was given SL NTG then started on Nitro gtt, and given 40 mg IV Lasix x1. BP's improved, then hypoTN to 70/40's and gtt stopped, then restarted when BP's went up to 180/100's; goal SBP 120's. Unable to place arterial line. She was also given 325 ASA. . Vitals before transfer: 97.4 p100 150/87 100% on 4L NC. Currently on Nitro 0.5 mcg/kg/min, and looking much better. . Review of Atrius records shows that she is followed by Atrius Oncologist [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 349**]. Per his most recent notes, she was seen in [**6-/2152**] and per his note: "anemia, small IgG lambda monoclonal protein, elevated light chains, elevated Beta 2 Microglobulin, transient mild hypercalcemia suggest either an MGUS, an early MM, or a low-grade lymphoma. Bone marrow biopsy was non-diagnostic." However, there was question whether these were due to the venous obstruction in her iliacs or an evolving lymphoproliferative disorder. Her kidney function was deteriorating as early as [**4-/2152**]; per Atrius records: Cr [**11/2151**]: 0.83 [**12/2151**]: 0.95 [**4-/2152**]: 1.67 [**4-/2152**]: 1.44 [**6-/2152**]: 1.72 . On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: # Diabetes Mellitus type II on insulin with renal complications (last A1c 7.5 [**6-/2152**]) # HTN # [**Month (only) 116**]-[**Last Name (un) 87639**] Syndrome: an inherited thrombophilic syndrome; compression of the L common iliac vein between overlying right common iliac artery and overlying vertebral body; associated with unprovoked L iliofemoral DVT and chronic venous insufficiency # L common and external iliac veins angioplasty and stenting on [**2152-3-29**], discharged on Coumadin # Asthma "anemia, small IgG lambda monoclonal protein, elevated light chains, elevated B2M, transient mild hypercalcemia suggest either an MGUS, an early MM, or a low-grade lymphoma. Bone marrow biopsy was non-diagnostic." # Lymphadenopathy: multiple enlarged L inguinal LN's noted on pelvic MRV in [**7-/2151**] -> s/p LN biopsy showing reactive LN # SPONDYLOLISTHESIS, ACQUIRED # SCIATICA # RHINITIS, ALLERGIC Social History: SOCIAL HISTORY From [**Country 3594**] - Tobacco history: quit 30yrs ago, claims to only smoke [**12-12**] cig/day - ETOH: denies - Illicit drugs: denies Family History: FAMILY HISTORY: Brother Deceased at 69 Diabetes - Type II Father Deceased train accident Mother Deceased at 72 of MI Son Type 2 diabetes Physical Exam: VS: BP= 178/94 HR= 98 RR=16 O2 sat= 99% 3 L GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: Sclera anicteric. PERRL, EOMI. no pallor or cyanosis of the oral mucosa. No NECK: Supple no tracheal deviation CARDIAC: PMI located in 5th intercostal space, midclavicular line. RRR, normal S1, S2. No m/r/g. No thrills, lifts. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. crakles at bases ABDOMEN: Soft, NTND. No tenderness. BS+ EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 2+ Left: Carotid 2+ DP 2+ Pertinent Results: ADMISSION LABS -------------- LABS CHEM [**2152-8-22**] 07:00PM BLOOD Glucose-146* UreaN-64* Creat-7.2*# Na-139 K-5.7* Cl-105 HCO3-20* AnGap-20 [**2152-8-24**] 06:00AM BLOOD Glucose-98 UreaN-68* Creat-7.8* Na-140 K-4.4 Cl-104 HCO3-24 AnGap-16 [**2152-8-30**] 07:02AM BLOOD Glucose-160* UreaN-73* Creat-7.0* Na-135 K-4.6 Cl-100 HCO3-24 AnGap-16 [**2152-9-3**] 06:51AM BLOOD Glucose-91 UreaN-59* Creat-4.1* Na-136 K-4.9 Cl-99 HCO3-25 AnGap-17 [**2152-8-23**] 01:39AM BLOOD Calcium-10.2 Phos-4.4 Mg-2.2 . CBC [**2152-8-22**] 07:00PM BLOOD Neuts-55.1 Lymphs-37.2 Monos-4.6 Eos-2.4 Baso-0.6 [**2152-8-22**] 07:00PM BLOOD WBC-7.3 RBC-2.93* Hgb-9.2* Hct-26.0* MCV-89 MCH-31.3 MCHC-35.3* RDW-15.3 Plt Ct-293 [**2152-9-3**] 06:51AM BLOOD WBC-8.1 RBC-3.39* Hgb-10.5* Hct-31.1* MCV-92 MCH-31.1 MCHC-33.9 RDW-14.8 Plt Ct-356 [**2152-8-23**] 04:53AM BLOOD Hapto-192 [**2152-8-23**] 04:53AM BLOOD Ret Aut-1.1* . COAG [**2152-8-22**] 08:25PM BLOOD PT-12.1 PTT-23.6 INR(PT)-1.0 . LFTS [**2152-8-23**] 01:39AM BLOOD ALT-15 AST-15 LD(LDH)-257* CK(CPK)-294* AlkPhos-98 TotBili-0.4 . Urine [**2152-8-22**] 07:30PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.006 [**2152-8-22**] 07:30PM URINE Blood-SM Nitrite-NEG Protein-TR Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [**2152-8-22**] 07:30PM URINE RBC-<1 WBC-<1 Bacteri-NONE Yeast-NONE Epi-0 [**2152-8-23**] 12:24AM URINE Eos-NEGATIVE [**2152-8-25**] 03:36PM URINE U-PEP-MULTIPLE P IFE-NO MONOCLO [**2152-8-23**] 11:27AM URINE U-PEP-NEGATIVE F [**2152-8-23**] 12:24AM URINE Osmolal-312 [**2152-8-23**] 11:27AM URINE Hours-RANDOM Creat-62 TotProt-34 Prot/Cr-0.5* Albumin-8.4 Alb/Cre-135.5* [**2152-8-23**] 12:24AM URINE Hours-RANDOM UreaN-196 Creat-36 Na-95 K-28 Cl-99 . Cardiac [**2152-8-22**] 07:00PM BLOOD CK-MB-5 cTropnT-0.03* [**2152-8-23**] 01:39AM BLOOD CK-MB-5 cTropnT-0.05* [**2152-8-22**] 07:00PM BLOOD CK(CPK)-378* . MISC [**2152-8-23**] 04:01PM BLOOD [**Doctor First Name **]-POSITIVE * Titer-1:40 [**2152-8-30**] 07:02AM BLOOD CRP-19.8* [**2152-8-24**] 06:00AM BLOOD Cortsol-12.6 [**2152-8-23**] 04:53AM BLOOD TSH-1.6 [**2152-8-30**] 07:02AM BLOOD ESR-83* . DISCHARGE LABS -------------- [**2152-9-9**] 05:47AM BLOOD WBC-7.8 RBC-3.12* Hgb-9.5* Hct-28.2* MCV-90 MCH-30.5 MCHC-33.8 RDW-15.0 Plt Ct-314 [**2152-8-22**] 07:00PM BLOOD Neuts-55.1 Lymphs-37.2 Monos-4.6 Eos-2.4 Baso-0.6 [**2152-9-8**] 06:15AM BLOOD PT-12.9 PTT-26.1 INR(PT)-1.1 [**2152-9-9**] 05:47AM BLOOD Glucose-114* UreaN-31* Creat-2.8* Na-138 K-4.5 Cl-102 HCO3-25 AnGap-16 [**2152-8-23**] 04:53AM BLOOD TSH-1.6 [**2152-8-24**] 06:00AM BLOOD Cortsol-12.6 [**2152-8-30**] 07:02AM BLOOD CRP-19.8* [**2152-8-23**] 04:01PM BLOOD [**Doctor First Name **]-POSITIVE * Titer-1:40 [**2152-8-31**] 08:35AM BLOOD PEP-TRACE ABNO b2micro-10.0* IgG-1266 IgA-249 IgM-145 IFE-TRACE MONO . [**2152-8-31**] 08:35 IGG SUBCLASSES 1,2,3,4 Test Result Reference Range/Units IMMUNOGLOBULIN G SUBCLASS 1 577 382-929 mg/dL IMMUNOGLOBULIN G SUBCLASS 2 429 241-700 mg/dL IMMUNOGLOBULIN G SUBCLASS 3 125 22-178 mg/dL IMMUNOGLOBULIN G SUBCLASS 4 18.9 4.0-86.0 mg/dL IMMUNOGLOBULIN G, SERUM 1[**Telephone/Fax (1) 108890**] mg/dL THIS TEST WAS PERFORMED AT: [**Company **]/CHANTILLY [**Numeric Identifier 14272**] CHANTILLY, [**Numeric Identifier 14273**] [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 14274**], MD . ALDOSTERONE Test Result Reference Range/Units ALDOSTERONE, LC/MS/MS 2 ng/dL Adult Reference Ranges for Aldosterone, LC/MS/MS: Upright 8:00-10:00 am < or = 28 ng/dL Upright 4:00-6:00 pm < or = 21 ng/dL Supine 8:00-10:00 am [**2-23**] ng/dL THIS TEST WAS PERFORMED AT: [**Company **]/[**Numeric Identifier 42067**] [**Doctor Last Name 42068**] HWY [**Location (un) **] CAPISTRANO, [**Numeric Identifier 42069**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 42070**], MD [**First Name (Titles) **] [**Last Name (Titles) **]: Source: Line-L angio . FREE KAPPA AND LAMBDA, WITH K/L RATIO Test Result Reference Range/Units FREE KAPPA, SERUM 62.2 H 3.3-19.4 mg/L FREE LAMBDA, SERUM 107.0 H 5.7-26.3 mg/L FREE KAPPA/LAMBDA RATIO 0.58 0.26-1.65 Free kappa/lambda ratio in serum of normal individuals is 0.26-1.65. Excess production of free kappa or lambda light chains alters the ratio. Ratios outside the normal range are attributed to the presence of monoclonal free light chains. Monoclonal free light chains are found in the serum of patients with multiple myeloma, Waldenstrom's macroglobulinemia, mu-heavy chain disease, primary amyloidosis, light chain deposition disease, monoclonal gammopathy of undetermined significance, and lymphoproliferative disorders. Measurement of free light chain concentration in serum is useful for diagnosis, prognosis,monitoring disease activity and following response to therapy of these disorders. THIS TEST WAS PERFORMED AT: [**Company **] [**Last Name (un) 63583**]-CL 0091 [**Location (un) 63584**] [**Last Name (un) 63583**], [**Numeric Identifier 63585**] [**Name6 (MD) 63586**] [**Name8 (MD) 9529**], MD Comment: Source: Line-L angio . RENIN Test Result Reference Range/Units PLASMA RENIN ACTIVITY, 0.68 0.25-5.82 ng/mL/h LC/MS/MS THIS TEST WAS PERFORMED AT: [**Company **]/[**Numeric Identifier 42067**] [**Doctor Last Name 42068**] HWY [**Location (un) **] CAPISTRANO, [**Numeric Identifier 42069**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 42070**], MD [**First Name (Titles) **] [**Last Name (Titles) **]: HEM# 0200A [**8-23**] . MICROBIOLOGY ------------ [**2152-8-30**] 7:02 am SEROLOGY/BLOOD **FINAL REPORT [**2152-8-31**]** RAPID PLASMA REAGIN TEST (Final [**2152-8-31**]): NONREACTIVE. Reference Range: Non-Reactive. . IMAGING ------- [**2152-8-22**] CXR IMPRESSION: Mild-to-moderate interstitial pulmonary edema. . [**2152-8-23**] TTE The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). No aortic regurgitation. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. . IMPRESSION: Mild symmetric left ventricular hypertrophy with low normal left ventricular systolic function. Mild mitral regurgitation. Mild aortic stenosis. Borderline pulmonary hypertension. . [**2152-8-23**] Renal artery Doppler IMPRESSION: Severe left and moderate right hydronephrosis with limited Dopplers demonstrating normal main renal arterial waveforms bilaterally. . [**2152-8-23**] CT Abd/Pelvis without contrast IMPRESSION: 1. Bilateral hydronephrosis and hydroureter extending to the mid at ureters,at the level of L5-S1. There are no stones identified. Questionable increased periaortic soft tissue at L5-S1 which may represent retroperitoneal fibrosis. Consider MRI without contrast for further evaluation. 2. Left iliac venous stent. 3. Lumbar spine DJD with anterolisthesis of L4 on L5. . [**2152-8-25**] Skeletal Survey IMPRESSION: 1. Degenerative changes as described above. 2. No focal lytic lesions to indicate myelomatous deposits. . [**2152-8-25**] Bilateral nephrostomy tubes CONCLUSION: 1. Uncomplicated insertion of bilateral percutaneous 8 French nephrostomy catheters. 2. Bilateral mid-to-distal high-grade ureteral obstruction with no passage of contrast material into the urinary bladder. . [**2152-8-31**] MRI Abd w/out contrast IMPRESSION: 1. Soft tissue draped over the aortic bifurcation, likely involving both ureters. Given the absence of intravenous contrast, findings are nonspecific; however, overall features favor a benign process, such as retroperitoneal fibrosis, rather than malignant or lymphoid tissue. Interval imaging in six months is advised to ensure stability. 2. Left upper pole renal cyst as described. Brief Hospital Course: 70 yo F with a h/o of [**First Name8 (NamePattern2) 116**] [**Last Name (un) 87639**] Syndrome who presents with new TWI, hypertension and pulmonary edema. After medical stabilization in the CCU, she was transferred to Medicine for work up and management of acute renal failure and MGUS. . #Pulmonary Edema: Patient was acutely hypertensive in the ED with systolic blood pressure in 200s, with infiltrates on chest X-ray consistent with flash pulmonary edema. Patient was given IV lasix and had a decreasing oxygen requirement. There was no evidence of right heart strain on EKG and concern for pulmonary embolus was low. By transfer to the general medical service, problem had resolved; patient was satting well on room air for the remainder of her hospitalization. . # Acute on chronic kidney injury: Patient had baseline renal insufficency which acutely worsened to a creatinine >7. A renal ultrasound was obtained which showed marked bilateral hydronephrosis. CT abdomen/pelvis was also preformed which did not show clear etiology of the obstruction as it was a non-contrast study, but raised the possibility of retroperitoneal fibrosis. Patient likely has both extrinsic renal failure from obstruction and intrinsic renal failure of an unknown etiology. Both Nephrology and Urology were consulted. Percutaneous nephrostomy tubes were placed on [**8-25**] and replaced on [**8-29**]. Drainage from the tubes and Foley gradually became non-bloody, with small amounts of bloody drainage at the time of discharge. During the procedure, Interventional Radiology noted a near complete obstruction of the ureters. Creatinine gradually decreased following the procedure. Nephrology did not believe patient needed dialysis at any point. Creatinine downtrended to [**1-13**] at time of discharge. A follow-up with Nephrology was recommended for the patient upon discharge, to be arranged by the patient's primary care provider. [**Name10 (NameIs) **] will also be contact[**Name (NI) **] by Interventional Radiology following discharge to manage her nephrostomy tubes, which are still in place at the time of discharge. Patient will receive VNA services for further management of nephrostomy tubes. Patient was instructed to stop using losartan and chlorthalidone due to her renal function. She was also instructed to cease use of ibuprofen. . who described her MGUS as "anemia, small IgG lambda monoclonal protein, elevated light chains, elevated B2M, transient mild hypercalcemia suggest either an MGUS, an early multiple myeloma, or a low-grade lymphoma. Bone marrow biopsy was non-diagnostic." Pt had negative SPEP, UPEP, and mildly elevated light chains. IgG subclasses were examined and all normal. A CT-guided biopsy of the retroperitoneal fibrosis was performed on [**9-8**], with cytologic and pathologic testing pending at the time of dishcharge. Patient will follow up with [**Location (un) 2274**] Hematology/Oncology after discharge to follow up results of biopsy. . # Acute on chronic anemia: Patient was admitted with a hematocrit of 26 which was noted to fall to 20 over the course of her CCU stay. Hemolysis labs were negative and there was no evidence of acute bleed. The acute drop in hematocrit may have been related to resolved hemoconcentration on admission. Patient subsequently had gradual decline in hematocrit on the floor following placement of percutaneous nephrostomy tubes. Patient required a total of 4 units PRBC transfused. Most likely, anemia stems from anemia of chronic disease and kidney failure, combined with acute blood loss from procedure. Uremic platlet dysfunction may have contributed to the prolonged bleeding. We gave ddAVP x 1 over course of admission. By [**8-31**], patient's hematocrit stabilized at ~28-30, where it remained for the rest of her hospitalization. She will follow up this problem with her primary care provider. . # Hypertension: Patient was hypertensive to the 200s systolic while in the ED and likely had flash pulmonary edema. Patients blood pressure was initially controlled with nitroglycerin drip and transitioned to PO 200 mg metolporol [**Hospital1 **]. On the medical floor, her blood pressures were controlled with labetalol and hydralazine and home Losartan and chlorthalidone were held. Patient's blood pressures remained well controlled until time of discharge. Patient was instructed to stop using losartan and chlorthalidone due to her renal function. . # Likely herpetic infection: patient was noted to have a vesicular rash on her lower back during admission. DFA was attempted but uninterpretable. Patient completed an empiric seven day course of valacyclovir for HSV/VZV. . INACTIVE ISSUES --------------- # Diabetes mellitus: patient was maintained on insulin sliding scale. Her metformin was held during admission and it was found that she is not on this medication at home. She is on insulin and will continue this as an outpatient. . TRANSITIONS IN CARE ------------------- . # Follow-up: patient has follow-up appointment with her PCP. [**Name10 (NameIs) **] will be contact[**Name (NI) **] by Interventional Radiology for a follow-up appointment for her nephrostomy tubes. Her PCP should help her arrange a Nephrology follow-up as well as Heme/Onc follow-up. Her cytologic and pathologic results are pending for her retroperitoneal biopsy, which will be followed up by her PCP and Heme/Onc. Her hematocrit should also be followed, as well as her creatinine going forward. Patient should also have age-appropriate cancer screening, including a colonoscopy. . # Code status: patient is confirmed full code. . # Contact: daughter [**Name (NI) 33933**] [**Telephone/Fax (1) 108891**] Medications on Admission: - Chlorthalidone 25 daily - Colace [**Hospital1 **] prn - Lantus 20 SQ hs - Metformin 1000 daily - Oxycodone 5mg q4 prn - Percocet 5/325 [**12-12**] q4-6 prn - B12 - Benadryl 25 mg prn allergies - Ibuprofen 200 2-4 tabs prn Atrius records: - Losartan 100 mg Oral Tablet Take 1 tablet daily - Chlorthalidone 25 mg daily - Warfarin 1 mg Oral Tablet take 8 tablets daily or as directed - Lovenox 80 mg q12 hrs - Lantus 15u hs - Ibuprofen 400 mg prn pain - ASA 81 daily Discharge Medications: 1. Benadryl 25 mg Capsule Sig: One (1) Capsule PO every [**5-17**] hours as needed for allergy symptoms. 2. labetalol 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Hold for sbp <100 or pulse <55 . Disp:*120 Tablet(s)* Refills:*0* 3. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours): hold for sbp<100 . Disp:*90 Tablet(s)* Refills:*0* 4. metformin 1,000 mg Tablet Sig: One (1) Tablet PO once a day. 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 6. Lantus 100 unit/mL Solution Sig: Twenty (20) units Subcutaneous at bedtime. 7. metformin 1,000 mg Tablet Sig: One (1) Tablet PO once a day. 8. oxycodone 5 mg Capsule Sig: One (1) Capsule PO every four (4) hours as needed for pain: Do not drink alcohol or drive while on this medication. 9. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain: Do not drive or drink alcohol while on this medication. 10. Vitamin B-12 Oral 11. Outpatient Lab Work Please have CBC, Chem7 drawn on [**9-12**] and fax to attn: [**First Name8 (NamePattern2) 22997**] [**Last Name (NamePattern1) 31**] at [**Telephone/Fax (1) 6808**] Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: PRIMARY DIAGNOSIS Retroperitoneal fibrosis Acute on chronic renal failure SECONDARY DIAGNOSIS Pulmonary edema Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname **], It was a pleasure taking care of you during your admission to the [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1675**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **]. You came to the hospital with difficulty breathing and were found to have fluid in your lungs and your heart was having difficulty pumping because of a kidney obstruction. You were admitted to the medical intensive care unit, where we gave you lasix and nitroglycerin to help you safely get rid of the fluid from your lungs. After that, you had no concerns from a heart or lung perspective and were transferred to the general medicine service. A CT scan showed that you had a process obstructing the ureter, the tube running between the kidneys and the bladder. We consulted with nephrologists, urologists, and rheumatologists to help us care for you. We placed nephrostomy tubes into your kidneys to help you urinate given that you had an obstruction. Over time, your kidney function continued to improve while you were in the hospital. We then ran several tests to determine why you were having this process causing kidney obstruction, including blood tests and an MRI. We got a small sample of tissue from the area, and there are tests pending on this sample, which will be followed up by your primary care provider and hematologist/oncologist. PLEASE CONTINUE -all of your home medications EXCEPT as below PLEASE STOP losartan chlorthalidone ibuprofen PLEASE START Labetalol 300 mg by mouth twice a day HydrALAzine 25 mg by mouth every 8 hours You should not take non-steroidal anti-inflammatory medications (NSAIDs) in the future, such as ibuprofen, Aleve, or Advil. Please keep the follow up appointments as recommended below. Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] A. Location: [**Hospital1 641**] Address: [**University/College 2899**], [**Location (un) **],[**Numeric Identifier 2900**] Phone: [**Telephone/Fax (1) 2115**] When: Thursday, [**9-14**], 3:40 *Please discuss seeing a Nephrologist with Dr. [**Last Name (STitle) 31**]. Dr. [**Last Name (STitle) 31**] will also help you set up an appointment with your Hematologist/Oncologist Interventional Radiology will get in touch with you within one week to determine what happens next with your nephrostomy tubes. If you do not hear from them in one week, please call them at [**Telephone/Fax (1) **]. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

593,428,584,514,591,273,272,276,403,585,250,280,599

{'Other ureteric obstruction,Acute diastolic heart failure,Acute kidney failure, unspecified,Pulmonary congestion and hypostasis,Hydronephrosis,Monoclonal paraproteinemia,Pure hypercholesterolemia,Hyperpotassemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Diabetes with unspecified complication, type II or unspecified type, uncontrolled,Iron deficiency anemia secondary to blood loss (chronic),Hematuria, 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: dyspnea, acute renal failure PRESENT ILLNESS: 70yoF with h/o DM2, HTN, L iliac artery stenosis s/p stent who presented with DOE and exertional chest tightness x1 wk. . She saw her PCP today where she c/o new onset exertional chest tightness [**7-19**] associated with neck pain. Also complaining of DOE which was also new and has been progressively worsening as well. She denied diaphoresis, nausea/vomiting, arm / jaw pain. Her vitals were significant for BP 179/88, p105, 100% RA NC. There was concern for new TWI's laterally, and sent to ED. . In the ED: 99.2 98 170/88 18 100% on RA. She denied chest pain, nausea, vomiting, diarrhea, black or bloody stools. She was initially well appearing and exam was reportedly non-focal initially, with clear lungs, RRR, no edema. Labs showed Trop 0.03, ARF with BUN/Cr 64/7.2 (up from Cr 1.4-1.7 baseline), HCO3 20, and K 5.7. EKG concerning for lateral strain pattern STD's with concomitant R precordial J point elevation. Renal consulted; CCU fellow and Atrius Cards notified. . In the ED, she became acutely dyspneic, tachypneic to 30-40's, and satting mid 80% on RA. Exam showed diffuse crackles and increased WOB; she was placed on NRB and given a trial of albuterol inhaler without much effect. Her BP was noted to be 200/100 and there was concern for flash pulmonary edema vs PE vs COPD/asthma. An EJ PIV was placed. CXR showed pulmonary edema. She was given SL NTG then started on Nitro gtt, and given 40 mg IV Lasix x1. BP's improved, then hypoTN to 70/40's and gtt stopped, then restarted when BP's went up to 180/100's; goal SBP 120's. Unable to place arterial line. She was also given 325 ASA. . Vitals before transfer: 97.4 p100 150/87 100% on 4L NC. Currently on Nitro 0.5 mcg/kg/min, and looking much better. . Review of Atrius records shows that she is followed by Atrius Oncologist [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 349**]. Per his most recent notes, she was seen in [**6-/2152**] and per his note: "anemia, small IgG lambda monoclonal protein, elevated light chains, elevated Beta 2 Microglobulin, transient mild hypercalcemia suggest either an MGUS, an early MM, or a low-grade lymphoma. Bone marrow biopsy was non-diagnostic." However, there was question whether these were due to the venous obstruction in her iliacs or an evolving lymphoproliferative disorder. Her kidney function was deteriorating as early as [**4-/2152**]; per Atrius records: Cr [**11/2151**]: 0.83 [**12/2151**]: 0.95 [**4-/2152**]: 1.67 [**4-/2152**]: 1.44 [**6-/2152**]: 1.72 . On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. MEDICAL HISTORY: # Diabetes Mellitus type II on insulin with renal complications (last A1c 7.5 [**6-/2152**]) # HTN # [**Month (only) 116**]-[**Last Name (un) 87639**] Syndrome: an inherited thrombophilic syndrome; compression of the L common iliac vein between overlying right common iliac artery and overlying vertebral body; associated with unprovoked L iliofemoral DVT and chronic venous insufficiency # L common and external iliac veins angioplasty and stenting on [**2152-3-29**], discharged on Coumadin # Asthma "anemia, small IgG lambda monoclonal protein, elevated light chains, elevated B2M, transient mild hypercalcemia suggest either an MGUS, an early MM, or a low-grade lymphoma. Bone marrow biopsy was non-diagnostic." # Lymphadenopathy: multiple enlarged L inguinal LN's noted on pelvic MRV in [**7-/2151**] -> s/p LN biopsy showing reactive LN # SPONDYLOLISTHESIS, ACQUIRED # SCIATICA # RHINITIS, ALLERGIC MEDICATION ON ADMISSION: - Chlorthalidone 25 daily - Colace [**Hospital1 **] prn - Lantus 20 SQ hs - Metformin 1000 daily - Oxycodone 5mg q4 prn - Percocet 5/325 [**12-12**] q4-6 prn - B12 - Benadryl 25 mg prn allergies - Ibuprofen 200 2-4 tabs prn Atrius records: - Losartan 100 mg Oral Tablet Take 1 tablet daily - Chlorthalidone 25 mg daily - Warfarin 1 mg Oral Tablet take 8 tablets daily or as directed ALLERGIES: Lisinopril PHYSICAL EXAM: VS: BP= 178/94 HR= 98 RR=16 O2 sat= 99% 3 L GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: Sclera anicteric. PERRL, EOMI. no pallor or cyanosis of the oral mucosa. No NECK: Supple no tracheal deviation CARDIAC: PMI located in 5th intercostal space, midclavicular line. RRR, normal S1, S2. No m/r/g. No thrills, lifts. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. crakles at bases ABDOMEN: Soft, NTND. No tenderness. BS+ EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 2+ Left: Carotid 2+ DP 2+ FAMILY HISTORY: FAMILY HISTORY: Brother Deceased at 69 Diabetes - Type II Father Deceased train accident Mother Deceased at 72 of MI Son Type 2 diabetes SOCIAL HISTORY: SOCIAL HISTORY From [**Country 3594**] - Tobacco history: quit 30yrs ago, claims to only smoke [**12-12**] cig/day - ETOH: denies - Illicit drugs: denies ### Response: {'Other ureteric obstruction,Acute diastolic heart failure,Acute kidney failure, unspecified,Pulmonary congestion and hypostasis,Hydronephrosis,Monoclonal paraproteinemia,Pure hypercholesterolemia,Hyperpotassemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Diabetes with unspecified complication, type II or unspecified type, uncontrolled,Iron deficiency anemia secondary to blood loss (chronic),Hematuria, unspecified'}