CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is a 45-year-old
female discharged on [**5-8**] after a long hospitalization
course for thrombotic thrombocytopenic purpura, hemolytic-
uremic syndrome, septic shock, ____________, pulmonary
embolus, deep venous thrombosis, gastrointestinal bleed from
colonic ulcer, off anticoagulation from [**4-30**] to [**5-11**], with
an inferior vena cava filter temporarily placed on [**4-29**].
The patient was discharged to an acute rehabilitation and was
to start Lovenox b.i.d. 110 subcu on [**5-11**].  This was to be
continued until the filter was removed and the patient
transitioned to Coumadin.  However, at the rehab she did not
receive any Lovenox and thought she was on Coumadin although
it is unclear from her records if she was ever on Coumadin.

MEDICAL HISTORY: Bipolar disease.

MEDICATION ON ADMISSION: 

ALLERGIES: Demerol.

PHYSICAL EXAM: 

FAMILY HISTORY: No acute diseases.

SOCIAL HISTORY: No tobacco, no alcohol, no intravenous drug
abuse.  Comes from acute rehabilitation.
Iron deficiency anemia secondary to blood loss (chronic),Ulcer of heel and midfoot,Acute kidney failure, unspecified,Thrombotic microangiopathy,Bipolar I disorder, most recent episode (or current) unspecified,Long-term (current) use of anticoagulants,Other specified disorders of pancreatic internal secretion
Chr blood loss anemia,Ulcer of heel & midfoot,Acute kidney failure NOS,Thrombot microangiopathy,Bipolor I current NOS,Long-term use anticoagul,Pancreatic disorder NEC
Admission Date: [**2120-5-20**]        Discharge Date: [**2120-5-29**]

Date of Birth:  [**2075-2-10**]        Sex:  F

Service:  MED


This is all per notes as I was not the primary intern during
this time.

HISTORY OF PRESENT ILLNESS:  The patient is a 45-year-old
female discharged on [**5-8**] after a long hospitalization
course for thrombotic thrombocytopenic purpura, hemolytic-
uremic syndrome, septic shock, ____________, pulmonary
embolus, deep venous thrombosis, gastrointestinal bleed from
colonic ulcer, off anticoagulation from [**4-30**] to [**5-11**], with
an inferior vena cava filter temporarily placed on [**4-29**].
The patient was discharged to an acute rehabilitation and was
to start Lovenox b.i.d. 110 subcu on [**5-11**].  This was to be
continued until the filter was removed and the patient
transitioned to Coumadin.  However, at the rehab she did not
receive any Lovenox and thought she was on Coumadin although
it is unclear from her records if she was ever on Coumadin.

The patient reports increasing lower extremity edema, left
much greater than right, over the last week.  The rehab M.D.
attributed this to patient being out of bed and from physical
therapy.  The patient reports that she walked the entire
length of the parking lot yesterday.  The edema increased,
however, with mild discomfort noting dyspnea and shortness of
breath.  No chest pain.  The patient saw Dr. [**Last Name (STitle) 6160**] as an
outpatient today and, as he was concerned, he sent her to the
Emergency Department.  Her __________ were negative for
multiple clots bilaterally.

PAST MEDICAL HISTORY:  Bipolar disease.

Thrombotic thrombocytopenic purpura in [**2120-3-28**].

Hemolytic-uremic syndrome in [**2120-3-28**].

Pulmonary embolus and deep venous thrombosis per PE on [**4-21**].

Hypertension.

Diabetes likely secondary to steroids.

Recent gastrointestinal bleed with colonic ulcer.

Septic shock with disseminated intravascular coagulopathy.

Acute renal failure.

___________ with plasmapheresis.

Hepatic abscesses.

Right hand calcifications.

Edema secondary to infusion of calcium.

ALLERGIES:  Demerol.

PHYSICAL EXAMINATION ON ADMISSION:  Temperature 98.0, blood
pressure 130/94, heart rate 108, respiratory rate 16, 98
percent on room air.  General:  The patient was obese in no
apparent distress, pleasant and in bed.  HEENT:  Moist mucus
membranes.  Extraocular motions intact.  No icterus.  No
lymphadenopathy.  Cardiovascular:  Regular rate.  No murmurs,
rubs or gallops.  Normal S1, S2.  Pulmonary:  Clear to
auscultation with poor inspiration.  Abdomen:  Obese, soft,
non-tender, non-distended.  Extremities:  Right hand with
healing calcium ulcerations.  Large edematous non-pitting
lower extremity edema, left greater than right.  Pulses
intact.  Neurological:  Awake, alert and oriented times
three.  Strength 5/5 bilaterally.  Cranial nerves II through
XII intact.

DISCHARGE MEDICATIONS:  On [**5-9**]:
1. Seroquel 75 q. hs.
2. Topiramate 50 b.i.d.
3. Mirtazepine 15 q. hs.
4. Folic acid one q. day.
5. Calcium carbonate 1000 t.i.d.
6. Miconazole powder.
7. Ativan 0.5 q. 6h. p.r.n.
8. Ferrous sulfate 325 q. day.
9. Bismuth p.r.n.
10.      Epo-Alpha 10,000 units three times a week.
11.      Simethicone p.r.n.
12.      Oxycodone 10 q. 4-6h. p.r.n.
13.      Benadryl.
14.      Maalox.
15.      Docusate two b.i.d.
16.      Atenolol 75 q. day.
17.      Lisinopril 40 q. day.
18.      Protonix 40 q. day.
19.      Glargine 15 q. hs.
20.      Prednisone 20 q. day.
21.      Lovenox which patient did not receive.


SOCIAL HISTORY:  No tobacco, no alcohol, no intravenous drug
abuse.  Comes from acute rehabilitation.

FAMILY HISTORY:  No acute diseases.

RADIOLOGY:  Bilateral lower extremity ultrasound showed
occlusive thrombus in the left common femoral vein, greater
femoral vein, superior femoral vein and right common femoral
vein and popliteal.

HOSPITAL COURSE:
1. Deep venous thrombosis:  The patient had a large clot
   present on initial examination as mentioned above.  The
   patient subsequently had a venogram on [**5-23**] which showed
   persistent clot.  In the setting of inferior vena cava
   filter with extensive lower extremity DVT,
   Hematology/Oncology was consulted in addition to
   Interventional Radiology being consulted.  IR,
   Hematology/Oncology and the primary team recommended
   proceeding with TPA to break these clots.  TPA was
   initiated with transfers to the Intensive Care Unit.  TPA
   was given 1 mg per hour times two hours and then decreased
   to 0.5 mg per hour.  The patient was also initiated on a
   heparin drip at this time.  The patient, after given TPA,
   returned to IR on [**5-23**] for a repeat venogram which
   showed good results with only a small amount of residual
   thrombus in the left femoral vein and common femoral vein.
   The common femoral vein, iliac vein and inferior vena cava
   were all patent.  The patient was subsequently started on
   a heparin drip and Coumadin until the INR was therapeutic
   with INR between 2 and 3 as goal.  The patient was
   overlapped with heparin and Coumadin for 24 hours.
   Additionally, the patient was maintained on a heparin drip
   for at least five days in order for INR to become
   therapeutic.  On day before discharge interventional
radiology attempted to remove her er
   IVC filter, however it had spontaneously become lodged in a
position that did not allow retrieval despite multiple attempt.
Vascular surgery also reviewed the angiogram and agreed that this
would be extremely difficult if at all possible to retrieve.
IVIR offered the patient to try a second approach that they felt
had < 50% chance of success, however she refused. The patient is
to continue on Coumadin
   with goal INR 2 to 3 for indefinitely given her IVC filter
and there prothrombic state.
   Hematology/Oncology.

1. Pulmonary embolus/inferior vena cava filter:  No clinical
   evidence of PE during this admission.  Again, patient had
   her IVC filter removed during this admission with
   anticoagulation as above.

1. Anemia:  Patient has a history of colonic ulcers and
   gastrointestinal bleeds.  The patient was not transfused
   while on the floor and maintained a stable hematocrit
   during this admission.

1. History of thrombotic thrombocytopenic purpura/hemolytic-
   uremic syndrome:  Patient's platelet count remained stable
   during this admission.  Hematology/Oncology was consulted
   during this admission and followed the patient throughout
   this whole hospitalization course.  Patient was continued
   on a steroid taper per Hematology/Oncology
   recommendations.  The patient's prednisone was continued
   at 10 mg p.o. q. day on discharge.  Per
   Hematology/Oncology, patient can slowly taper down her
   prednisone by 5 mg every two weeks.  Therefore, patient on
   [**6-10**] should be changed to 5 mg p.o. q. day.

1. Diabetes type 2:  This is most likely steroid induced as
   patient's hemoglobin A1C is less than 5.  The patient is
   to continue Lentis on sliding scale for right now.  At
   acute rehabilitation can slowly be tapered off as patient
   is weaned off steroids.

1. Status post acute renal failure:  The patient had acute
   renal failure likely secondary to hypovolemia.  The
   patient's creatinine is back to baseline on discharge.

1. Hypertension:  Patient was stable on a beta blocker and
   ACE inhibitor which were both increased during this
   admission.  A third [**Doctor Last Name 360**], hydrochlorothiazide, was added
   three days before discharge to goal blood pressure less
   than 130/80.

1. History of bipolar disorder and anxiety:  Patient was
   continued on her Seroquel and Remeron.


DISCHARGE DIAGNOSES:  Include:
Deep venous thrombosis.

Diabetes type 2.

Hypertension.

Hemolytic-uremic syndrome/thrombotic thrombocytopenic
purpura.

Colonic ulcer.

Hypertension.

Bipolar disorder.

Anxiety disorder.

FOLLOW-UP PLAN:  The patient is to follow up with Dr. [**Last Name (STitle) 12590**]
on [**6-4**] at 2:40 p.m.  The patient is to follow up with
primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 54611**], in one to two weeks
and should call to schedule an appointment.

DISCHARGE MEDICATIONS:  Include:
1. Seroquel 35 mg p.o. q. hs.
2. Mirtazapine 50 mg p.o. q. hs.
3. Folic acid 1 mg p.o. q. day.
4. Calcium carbonate 1000 mg p.o. q.i.d.
5. Miconazole powder one application b.i.d.
6. Lorazepam 0.5 mg p.o. q. 6h. p.r.n.
7. Bismuth subsalicylate 262 mg tablets two tablets p.o.
   t.i.d.
8. Epo-Alpha 10,000 units three times a week.
9. Simethicone 80 mg p.o. t.i.d. p.r.n.
10.      Oxycodone 5 mg p.o. q. 4-6h. p.r.n.
11.      Maalox 15-30 cc p.o. q.i.d. p.r.n.
12.      Lisinopril 40 mg p.o. q. day.
13.      Pantoprazole 40 mg p.o. q. day.
14.      Senna one tablet p.o. b.i.d.
15.      Prednisone 10 mg p.o. q. day until [**6-10**] where
   patient is to be changed to 5 mg p.o. q. day which should
   end on [**6-24**].
16.      Docusate sodium 100 mg p.o. b.i.d.
17.      Bisacodyl two tablets b.i.d. p.r.n.
18.      Atenolol 100 mg p.o. q. day.
19.      Coumadin 5 mg p.o. q. hs.; however, INR should be
   checked q.o.d. for the next one week to stabilize INR
   between 2 and 3.  After that M.D. can choose how often to
   check INR values.
20.      Hydrochlorothiazide 25 mg p.o. q. day.
21.      Lentis.
22.      Glargine 15 units q. hs.




                     DR.[**Last Name (STitle) 5613**],[**First Name3 (LF) **] 12-AHU

Dictated By:[**Doctor Last Name 11001**]
MEDQUIST36
D:  [**2120-5-29**] 21:19:03
T:  [**2120-5-30**] 01:54:18
Job#:  [**Job Number 54612**]


Name:  [**Known lastname 10171**], [**Known firstname 10172**] A         Unit No:  [**Numeric Identifier 10173**]

Admission Date: [**2120-5-20**]        Discharge Date: [**2120-5-31**]

Date of Birth:  [**2075-2-10**]        Sex:  F

Service:  MED


ADDENDUM:  This is an addendum to the Discharge Summary.
Discharge date is now [**2120-5-31**].

HOSPITAL COURSE:
1. Deep venous thrombosis with inferior vena cava filter. The
   day before discharge, the patient's INR was therapeutic at
   2.4. IR was consulted to remove the inferior vena cava
   filter. After three hours of attempting to remove the
   inferior vena cava filter, IR, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], INT, was
   unable to remove the inferior vena cava filter and
   additionally stated that due to the new positioning of the
   inferior vena cava filter, she will not be a candidate for
   removal of this filter. Thus, secondary to this
   complication, she will stay on prolonged Coumadin
   indefinitely with a goal INR of [**1-30**]. Her Coumadin dosing
   will be alternating 5 mg and 7.5 mg with a goal INR of [**1-30**]
   lifelong. The patient will need every other day INR follow-
   up until this INR range is within the therapeutic level
   and then can have her INR checked less frequently.

1. Diabetes mellitus secondary to steroids. The patient will
   be sent out on a decreased dose of Lantus from 15 to 7
   units q h.s. The reasoning for decreasing her Lantus dose
   and adding on a regular insulin sliding scale is the
   patient will be slowly weaned off her steroids and thus
   will require less use of Lantus.

1. HUS/TTP:  The patient per Hematology/Oncology
   recommendations is to slowly taper off her prednisone. The
   plan is since the patient is currently on 10 mg q day, the
   patient every two weeks should decrease by 5 mg to off
   within four weeks. Hematology/Oncology will follow her as
   an outpatient.


NEW DISCHARGE MEDICATIONS:
1. Clotiapine fumarate 75 mg p.o. q h.s.
2. Mirtazepine 15 mg p.o. q h.s.
3. Folic acid 1 mg p.o. q day.
4. Calcium carbonate 1,000 mg p.o. q.i.d.
5. Miconazole nitrate one application b.i.d. p.r.n.
6. Lorazepam 0.5 mg p.o. q six hours p.r.n.
7. Bismuth subsalicylate two tablets p.o. t.i.d.
8. Epoetin alfa 10,000 units injection three times a week,
   Monday, Thursday and Saturday.
9. Simethicone 40-80 mg p.o. t.i.d. p.r.n.
10.      Oxycodone 5 mg p.o. q 4-6 hours p.r.n.
11.      Diphenhydramine HCL 25 mg p.o. q six hours p.r.n.
12.      Maalox 15-30 cc p.o. q.i.d. p.r.n.
13.      Lisinopril 40 mg p.o. q day.
14.      Pantoprazole 40 mg p.o. q day.
15.      Senna two tablets p.o. b.i.d.
16.      Prednisone 10 mg p.o. q day. This should be changed
   on [**2120-6-8**] to 5 mg p.o. q day and then should be
   changed again on [**2120-6-22**] to zero mg q day.
17.      Docusate 100 mg p.o. b.i.d.
18.      Bisacodyl two tablets p.o. q day p.r.n.
   constipation.
19.      Atenolol 100 mg p.o. q day.
20.      ___________ointment one application topically t.i.d.
   p.r.n. right hand.
21.      Hydrochlorothiazide 25 mg p.o. q day.
22.      Glargine seven units q h.s. plus a regular insulin
   sliding scale.
23.      Coumadin 5 mg p.o. q o.d., 7.5 mg p.o. q o.d. These
   doses of 5 mg and 7.5 mg should be alternated.


OUTPATIENT FOLLOW UP:  The patient is to follow-up with Dr.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10181**], MD on [**2120-6-4**] at 2:40 p.m. The patient is
also to follow-up with Dr. [**Last Name (STitle) 703**] on [**2120-6-10**] at 12:00
p.m. on the ninth floor of the [**Hospital Ward Name **] Building. Finally, the
patient is to follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10182**] on [**2120-6-17**]
at 2:00 p.m.

ADDITIONAL FOLLOW-UP LABS:  The patient is to have INR
checked every other day until INR is stable with a goal INR
of [**1-30**]. The patient needs to receive lifelong
anticoagulation.

Please consider weaning Glargine as steroids are tapered off.
This patient is to have q.i.d. finger sticks until her finger
sticks remain stable and M.D. feels comfortable discontinuing
the finger sticks.





                        [**First Name11 (Name Pattern1) 84**] [**Last Name (NamePattern4) **], MD [**MD Number(2) 5233**]

Dictated By:[**Doctor Last Name 10183**]
MEDQUIST36
D:  [**2120-5-30**] 16:30:04
T:  [**2120-5-30**] 17:15:58
Job#:  [**Job Number 10184**]
{'Iron deficiency anemia secondary to blood loss (chronic),Ulcer of heel and midfoot,Acute kidney failure, unspecified,Thrombotic microangiopathy,Bipolar I disorder, most recent episode (or current) unspecified,Long-term (current) use of anticoagulants,Other specified disorders of pancreatic internal secretion'}


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 45-year-old
female discharged on [**5-8**] after a long hospitalization
course for thrombotic thrombocytopenic purpura, hemolytic-
uremic syndrome, septic shock, ____________, pulmonary
embolus, deep venous thrombosis, gastrointestinal bleed from
colonic ulcer, off anticoagulation from [**4-30**] to [**5-11**], with
an inferior vena cava filter temporarily placed on [**4-29**].
The patient was discharged to an acute rehabilitation and was
to start Lovenox b.i.d. 110 subcu on [**5-11**].  This was to be
continued until the filter was removed and the patient
transitioned to Coumadin.  However, at the rehab she did not
receive any Lovenox and thought she was on Coumadin although
it is unclear from her records if she was ever on Coumadin.

MEDICAL HISTORY: Bipolar disease.

MEDICATION ON ADMISSION: 

ALLERGIES: Demerol.

PHYSICAL EXAM: 

FAMILY HISTORY: No acute diseases.

SOCIAL HISTORY: No tobacco, no alcohol, no intravenous drug
abuse.  Comes from acute rehabilitation. 

### Response:
{'Iron deficiency anemia secondary to blood loss (chronic),Ulcer of heel and midfoot,Acute kidney failure, unspecified,Thrombotic microangiopathy,Bipolar I disorder, most recent episode (or current) unspecified,Long-term (current) use of anticoagulants,Other specified disorders of pancreatic internal secretion'}
