CHIEF COMPLAINT: 

PRESENT ILLNESS: This is a 23-year-old male with
a history of anxiety and heroin use who was found
unresponsive at home.  He was last seen 48 hours previously.
There was a Serax bottle with 13 pills missing found at the
bedside, as well as some unknown substance in his safe.

MEDICAL HISTORY: 

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Acute kidney failure, unspecified,Intestinal infection due to Clostridium difficile,Acidosis,Drug withdrawal,Opioid abuse, continuous
Food/vomit pneumonitis,Acute respiratry failure,Acute kidney failure NOS,Int inf clstrdium dfcile,Acidosis,Drug withdrawal,Opioid abuse-continuous
Admission Date:  [**2192-7-22**]     Discharge Date:  [**2192-8-10**]

Date of Birth:   [**2168-11-24**]     Sex:  M

Service:  Medicine

HISTORY OF PRESENT ILLNESS:  This is a 23-year-old male with
a history of anxiety and heroin use who was found
unresponsive at home.  He was last seen 48 hours previously.
There was a Serax bottle with 13 pills missing found at the
bedside, as well as some unknown substance in his safe.

He was taken to an outside hospital where his temperature
was 92.9, pulse was 130, respiratory rate 12, blood pressure
was 133/113, saturating 88% on room air with a 100%
nonrebreather.  At that point, he was found to have a
creatine kinase of 50,000, potassium was 7.4, and a
creatinine was 3.2.  He had a minimal response to Narcan.

He was started on ceftriaxone secondary to a chest x-ray
showing a left-sided aspiration pneumonia.  A head CT was
also obtained and was negative.  An electrocardiogram had
peaked T waves which improved once at the [**Hospital1 346**] Emergency Department.

At this point, the patient was transferred to [**Hospital1 346**].  Here his temperature was 98.6,
pulse was 83, respiratory rate was 18, blood pressure
was 100/53, with an oxygen saturation of 97% on 100%
nonrebreather.

While in the Emergency Department, his blood pressure dropped
to 60/palpable, and he was given dopamine and fluids.  His
oxygen saturations dropped.  At this point, his arterial
blood gas was 7.16, CO2 was 52, O2 was 110 on the 100%
nonrebreather.  Intravenous fluids were given in the
Emergency Department in combination with the renal failure
which prompted respiratory hypoxia; therefore, the patient
was intubated.

With the chest x-ray showing a left-sided aspiration
pneumonia; medications of levofloxacin and Flagyl were
started.

PHYSICAL EXAMINATION ON PRESENTATION:  Head, eyes, ears,
nose, and throat revealed pupils were 2 mm bilaterally.
Sclerae were anicteric.  Cardiovascular examination revealed
a regular rhythm, tachycardic.  No murmurs.  Pulmonary was
positive for rales at the left base with decreased breath
sounds.  The abdomen was soft, nontender, and nondistended,
positive bowel sounds.  Extremities revealed 1+ lower
extremity edema and 2+ pules throughout.

PERTINENT LABORATORY DATA ON PRESENTATION:   Laboratories
revealed white blood cell count was 21.2, hematocrit
was 47.1, platelets were 168.  Sodium was 138, potassium
was 7.2, chloride was 105, bicarbonate was 18, blood urea
nitrogen was 40, creatinine was 2.9, blood glucose was 156.
Calcium was 5.3, magnesium was 1.6, phosphate was 5.6.  ALT
was 170, AST was 608, alkaline phosphatase was 62.  Creatine
kinase was 101,860; creatine kinase peaked at 120,000.  MB
fraction was 0.8%.  Troponin I was 8.3.  INR was 2, PT
was 16, and PTT was 32.6.  Urinalysis was amber with a pH
of 5, with a specific gravity of 1.03, a large amount of
blood, 100 protein, small bilirubin, trace leukocytes, many
bacteria; otherwise negative.  Toxicology screen was positive
for opiates only.

RADIOLOGY/IMAGING:   Abdominal film had no free air.

Electrocardiogram had no signs of ischemia.

HOSPITAL COURSE:  The patient was admitted to the Medical
Intensive Care Unit.  He received emergent hemodialysis which
corrected the metabolic acidosis and the electrolyte
abnormalities.  The patient was also diuresed.

His course was complicated by bilateral pulmonary infiltrates
consistent with acute respiratory distress syndrome.
Dopamine was discontinued on hospital day four.  A sputum
culture at this time returned methicillin-resistant
Staphylococcus aureus positive.  He was given 12 days of
vancomycin.  He was able to be extubated on hospital day
seven.

Once extubated the patient had withdrawal from
benzodiazepines, and maintenance clonidine was begun and was
eventually tapered off.  He was oxygenating well; however, he
continued to spike temperatures along with an elevated white
blood cell count that resolved over a few days without
antibiotics.  A pleurocentesis was performed prior to the
resolution, and it showed 201 white blood cells and [**Pager number **] red
blood cells, but no growth on culture.

Also, during the course, he had upper and lower extremity
edema.  An ultrasound ruled out deep venous thrombosis.

Neurology was consulted secondary to decreased mental status.
A magnetic resonance imaging of the head was obtained which
was negative for blood, infection, or edema.
Electroencephalogram was also negative.

Psychiatry came in and felt that his mental status change was
delirium.  Neurology was also involved with the patient's
left-sided weakness that was found once awake and alert.
Electromyogram showed a L5-S1 plexopathy, which did not
explain the entire physical examination picture.

Therefore, a magnetic resonance imaging of the lumbar spine
was obtained.  This showed no osteomyelitis, but there was a
5-cm region suspicious for a hematoma in the left gluteal
region.  An ultrasound was obtained to rule out an abscess in
this area.  It showed no focal fluid collection, and no
evidence of an abscess.  It was positive for a left gluteal
hematoma; although, a mass could not be ruled out.

A magnetic resonance imaging of the thoracic and cervical
spine was obtained when the weakness persisted.  It showed no
spinous central canal stenosis or neuroforaminal narrowing.
He has continued with physical therapy to regain function.

Over the course of his hospital stay, his renal function
improved.  Creatine kinase trended down; last checked
was 6274, and his electrolyte abnormalities resolved.

CONDITION AT DISCHARGE:  Condition on discharge was stable.

DISCHARGE DIAGNOSES:
1.  Status post rhabdomyolysis.
2.  Acute renal failure.
3.  Left-sided weakness.
4.  Depression.
5.  Left gluteal hematoma.

MEDICATIONS ON DISCHARGE:
1.  Celexa 20 mg p.o. q.d.
2.  Remeron 15 mg p.o. q.h.s.
3.  Protonix 40 mg p.o. q.d.
4.  Heparin 5000 units subcutaneous b.i.d. (to continue until
the patient has a moderate amount of activity).

DISCHARGE STATUS:  He was to be discharged to a
rehabilitation facility.

DISCHARGE FOLLOWUP:   He was to follow up with neurologist
(Dr. [**Last Name (STitle) 28841**] in about four weeks, as well as seeing a
nephrologist, and primary care physician (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]).

DISCHARGE RECOMMENDATIONS:  Between two to four months the
patient should have a repeat ultrasound of the left gluteal
region to assess for absorption of hematoma versus a mass
that would prompt an outpatient workup.





                          [**Last Name (LF) **],[**First Name3 (LF) 734**] J. M.D. [**MD Number(1) **]

Dictated By:[**Last Name (NamePattern1) 43539**]

MEDQUIST36

D:  [**2192-8-9**]  19:14
T:  [**2192-8-9**]  20:00
JOB#:  [**Job Number 43540**]


Name:  [**Known lastname 7936**], [**Known firstname 7937**]                  Unit No:  [**Numeric Identifier 7938**]

Admission Date:  [**2192-7-20**]     Discharge Date:  [**2192-8-15**]

Date of Birth:   [**2168-11-24**]     Sex:  M

Service:  [**Hospital1 248**]

Patient remained in the hospital from [**8-11**] through
the 25th.  Since [**8-11**], the patient has had
intermittent low-grade fevers from 99 to 100.5 with
persistent tachycardia and hypertension following the
discontinuation of clonidine.  The heart rate and blood
pressure were unresponsive IV fluid boluses.

The etiology of the tachycardia and hypertension in the
setting of low-grade fevers was felt likely to be
multifactorial including clonidine withdrawal, poorly
controlled pain, and infection.  The patient continued to
report poorly controlled left lower extremity pain while
taking Neurontin and oxycodone prn.

Ultram 50 mg q4-6 hours prn was added for breakthrough pain
with modest relief.  Repeat chest x-ray and urinalysis were
unremarkable for signs of infection.  However, stool studies
from [**8-13**] were notable for Clostridium difficile
toxin.  The patient was started on a 10 day course of oral
Flagyl for Clostridium difficile colitis.

With improved pain control and time off of clonidine, the
patient's blood pressure and heart rate curve trended
downward.  It is felt that the treatment of the Clostridium
difficile colitis will also contribute to normalize the
patient's hemodynamics.  The patient continued to work with
Occupational and Physical Therapy with progress in activities
of daily living and weightbearing exercises.

The patient's acute renal failure continued to resolve with
persistently adequate urine output and continued decrease in
the creatinine level to within the normal range.  At this
point, the patient is considered medically clear for transfer
to an acute rehabilitation center for further intense work on
his left lower extremity weakness and occupational therapy
needs.

The patient will be scheduled for followup with [**Hospital 2996**]
Clinic in [**1-23**] weeks postdischarge.






                          [**Last Name (LF) **],[**First Name3 (LF) 520**] E. M.D. [**MD Number(1) 628**]

Dictated By:[**Name8 (MD) 2285**]

MEDQUIST36

D:  [**2192-8-14**]  21:37
T:  [**2192-8-20**]  06:52
JOB#:  [**Job Number **]


Name:  [**Known lastname 7936**], [**Known firstname 7937**]                  Unit No:  [**Numeric Identifier 7938**]

Admission Date:  [**2192-7-22**]     Discharge Date:  [**2192-8-29**]

Date of Birth:   [**2168-11-24**]     Sex:  M

Service:  [**Hospital1 **]

ADDENDUM:  This is a Discharge Summary Addendum from prior
Discharge Summary Addendum of [**2192-8-15**]; starting
with the remainder of the hospital course.

The patient remained in the hospital through [**2192-8-29**].
Since [**8-15**], the patient was continued with left lower
extremity pain (predominantly foot) with some left buttock
pain as well.  The patient's neurologic examination remained
unchanged for the remainder of the hospitalization with
minimal sensation in the left later foot, minimal voluntary
movement below the left ankle, and pain on passive movement.

The patient required multiple revisions in his pain regimen
including titration of Neurontin, nonsteroidal
antiinflammatory medications, as well as narcotics with
modest improvement in pain.

A hip/pelvic CAT scan from [**8-5**], on re-read,
demonstrated swelling and potential fluid collection in the
region of the left piriformis.  With concern for potential
piriformis syndrome, the Pain Service was consulted for
evaluation and potential injection.

A subsequent magnetic resonance imaging of the pelvis and
left hip was obtained on [**8-21**] which again demonstrated
swelling in the region of the piriformis, however, decreased
swelling since prior CAT scan.  The study also demonstrated
persistent collection in the left gluteus medias consistent
with myonecrosis and fibrosis with normal sacral roots.

After consultation with both the Neurosurgical Service and
Pain Service, the patient was continued on medical management
for chronic pain with physical therapy.  The patient worked
regularly with physical therapy with the help of a foot
prosthesis and demonstrated significant progress over the
course of the hospitalization.

Also, during the latter portion of the hospitalization, the
patient continued with low but stable hematocrits.  Given the
patient's general sense of fatigue, the patient was
transfused one unit of packed red blood cells to maintain a
hematocrit of greater than 27.  The patient's hematocrit
remained stable at greater than 30 for the remainder of the
hospitalization with an appropriate reticulocyte count.  The
patient's anemia was felt secondary to acute renal failure
documented in the earlier portion of the hospitalization.

The patient was diagnosed with Clostridium difficile colitis
and treated with a 10-day course of oral Flagyl with complete
resolution of both diarrhea, fever, and white blood cell
count.

The patient was followed by Psychiatry for depression and
anxiety.  Per Psychiatry, the patient's Celexa was tapered to
off, and the patient was continued on Remeron on discharge.

CONDITION AT DISCHARGE:  Condition on discharge was good.

DISCHARGE DIAGNOSES:
1.  Heroin overdose.
2.  Rhabdomyolysis
3.  Acute renal failure.
4.  Aspiration pneumonia (methicillin-resistant
Staphylococcus aureus).
5.  Clostridium difficile colitis.
6.  Anxiety.
7.  Depression.

MEDICATIONS ON DISCHARGE:
1.  Remeron 30 mg p.o. q.h.s.
2.  Protonix 40 mg p.o. q.d.
3.  Neurontin 400 mg p.o. t.i.d.
4.  Ibuprofen 800 mg p.o. t.i.d.
5.  Percocet 5/325 mg p.o. q.4h. as needed (for pain).
6.  MS Contin 15 mg p.o. b.i.d.
7.  Colace 100 mg p.o. b.i.d.

DISCHARGE STATUS:   The patient was discharged to home.

DISCHARGE INSTRUCTIONS/FOLLOWUP:
1.  The patient was discharged to home with instructions to
follow up with a new primary care physician in one week
status post discharge.  The primary care physician was
arranged by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] with direct communication.
2.  The patient was to continue with outpatient physical
therapy through an outpatient rehabilitation program.
3.  The patient was also to continue with outpatient
counseling and therapy; initially through [**Hospital1 960**].





                          [**First Name11 (Name Pattern1) 520**] [**Last Name (NamePattern4) 521**], M.D.  [**MD Number(1) 522**]

Dictated By:[**Name8 (MD) 7939**]

MEDQUIST36

D:  [**2192-11-30**]  13:08
T:  [**2192-11-30**]  23:13
JOB#:  [**Job Number 7940**]
{'Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Acute kidney failure, unspecified,Intestinal infection due to Clostridium difficile,Acidosis,Drug withdrawal,Opioid abuse, continuous'}


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 23-year-old male with
a history of anxiety and heroin use who was found
unresponsive at home.  He was last seen 48 hours previously.
There was a Serax bottle with 13 pills missing found at the
bedside, as well as some unknown substance in his safe.

MEDICAL HISTORY: 

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Acute kidney failure, unspecified,Intestinal infection due to Clostridium difficile,Acidosis,Drug withdrawal,Opioid abuse, continuous'}
