CHIEF COMPLAINT: 

PRESENT ILLNESS: This is a 45 year old female
patient with a history of bipolar disease and idiopathic
tachycardia who was transferred to [**Hospital6 649**] from [**Hospital6 19155**] where she
presented with left lower quadrant and left flank pain,
nausea and thrombocytopenia.  The patient initially presented
to the outside hospital with a three day history of [**Location (un) 2452**]
urine and loose [**Location (un) 2452**] stools with a more recent development
of a lower extremity rash.  In addition, the patient noted
fatigue with increasing dyspnea on exertion over the last
three to six weeks.  She also endorsed a one day history of
nausea with a development of crampy searing left lower
quadrant and flank pain associated with [**Location (un) 2452**] loose stools.
The patient denied any fever, chills, nightsweats, upper
respiratory tract symptoms, sore throat.  She also denied any
epistaxis or bleeding gums.  The patient similarly denied any
new medications or changes in her medications.

MEDICAL HISTORY: 1.  Bipolar disorder.
2.  Tachycardia.

MEDICATION ON ADMISSION: 

ALLERGIES: Demerol leads to anaphylaxis.

PHYSICAL EXAM: 

FAMILY HISTORY: Positive for coronary artery disease.  No
family history of hematologic disorders.

SOCIAL HISTORY: The patient denies any tobacco, alcohol or
drug use.  She currently lives alone in [**Location (un) 8957**] and is not
currently sexually active.
Thrombotic microangiopathy,Hemolytic-uremic syndrome,Acute respiratory failure,Acute kidney failure, unspecified,Unspecified septicemia,Severe sepsis,Septic shock,Iron deficiency anemia secondary to blood loss (chronic),Pneumonia, organism unspecified
Thrombot microangiopathy,Hemolytic uremic synd,Acute respiratry failure,Acute kidney failure NOS,Septicemia NOS,Severe sepsis,Septic shock,Chr blood loss anemia,Pneumonia, organism NOS
Admission Date:  [**2120-3-15**]       Discharge Date: [**2120-3-31**]

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

Service:  MICU

HISTORY OF PRESENT ILLNESS:  This is a 45 year old female
patient with a history of bipolar disease and idiopathic
tachycardia who was transferred to [**Hospital6 649**] from [**Hospital6 19155**] where she
presented with left lower quadrant and left flank pain,
nausea and thrombocytopenia.  The patient initially presented
to the outside hospital with a three day history of [**Location (un) 2452**]
urine and loose [**Location (un) 2452**] stools with a more recent development
of a lower extremity rash.  In addition, the patient noted
fatigue with increasing dyspnea on exertion over the last
three to six weeks.  She also endorsed a one day history of
nausea with a development of crampy searing left lower
quadrant and flank pain associated with [**Location (un) 2452**] loose stools.
The patient denied any fever, chills, nightsweats, upper
respiratory tract symptoms, sore throat.  She also denied any
epistaxis or bleeding gums.  The patient similarly denied any
new medications or changes in her medications.

At the outside hospital, the patient's laboratory data was
notable for a platelet count of 7, INR 1.2, and large blood
on a urinalysis.  An abdominal computerized tomography scan
was performed which showed no evidence of hydronephrosis, no
renal stones and a cyst in the right kidney.  The patient was
given 1 gm intravenously of Solu-Medrol and was transferred
to [**Hospital6 256**].

PAST MEDICAL HISTORY:
1.  Bipolar disorder.
2.  Tachycardia.

MEDICATIONS:
1.  Seroquel 75 mg q.h.s.
2.  Topamax 100 mg.
3.  Mirtazapine 15 mg.
4.  Verapamil 80 mg p.o. b.i.d.
5.  Oral contraceptives.
6.  Flonase.
7.  Echinacea started one month ago.

ALLERGIES:  Demerol leads to anaphylaxis.

SOCIAL HISTORY:  The patient denies any tobacco, alcohol or
drug use.  She currently lives alone in [**Location (un) 8957**] and is not
currently sexually active.

FAMILY HISTORY:  Positive for coronary artery disease.  No
family history of hematologic disorders.

PHYSICAL EXAMINATION:  On physical examination temperature
was 99.7, heart rate 104, blood pressure 123/83, respirations
10, oxygen saturation is 100% on room air.  General:  The
patient is in mild distress, lying on her back.  Head, eyes,
ears, nose and throat:  Oropharynx is clear.  Pupils equal,
round and reactive to light.  Extraocular movements intact.
Dry mucous membranes.  Neck:  No evidence of supraclavicular
lymphadenopathy.  Lungs:  Clear to auscultation bilaterally.
Cardiovascular:  Regular rate and rhythm.  Abdomen:  Obese,
normoactive bowel sounds.  Mild tenderness to palpation in
the right upper quadrant.  Negative [**Doctor Last Name 515**] sign.  No
evidence of hepatosplenomegaly, no rebound tenderness or
guarding.  Extremities:  There are petechiae evident on the
patient's lower extremities bilaterally, right more than
left, no evidence of edema or cyanosis.  Back:  Scattered
petechiae, no costovertebral angle tenderness.  Neurologic:
Alert and oriented times three, bilateral upper and lower
extremity strength is symmetric and [**5-1**].  Cranial nerves II
through XII are intact.  Sensation is intact to light touch
throughout.

LABORATORY DATA:  White blood cell count 18.2, hematocrit
35.4, platelets 13, MCV 79.  Chemistries, sodium 138,
potassium 3.9, chloride 104, bicarbonate 28, BUN 38,
creatinine 1.2, glucose 158, anion gap of 14, ALT 18, AST 46,
alkaline phosphatase 120, amylase 33, total bilirubin 2.2,
lipase 35, albumin 3.6.  PT 13.5, PTT 21.1, INR 1.2.
Fibrinogen 611.  Urinalysis:  Red, protein over 300, trace
glucose, moderate bilirubin, red blood cells over 50, white
blood cells [**3-1**], few bacteria.

HOSPITAL COURSE:  1.  Heme - The patient was transferred to
[**Hospital6 256**] from an outside hospital
with a platelet count of 7 there and 13 on admission here.
She was admitted to the General Medicine Service with a
diagnosis of thrombotic thrombocytopenic purpura.  A
hematology and transfusion medicine consult was obtained and
the patient was initiated on plasmapheresis for idiopathic
thrombotic thrombocytopenic purpura.  The patient had stool
cultures sent which were negative for Escherichia coli and
Shigella.  Her heme studies were consistent with a hemolytic
anemia in addition to her thrombocytopenia.  The patient
underwent five cycles of plasmapheresis which were
uncomplicated and her platelet count eventually increased to
244.  During the patient's sixth plasmapheresis she
experienced hives on her face and upper chest which were
treated with Benadryl and steroids.  On the following day,
during her seventh plasmapheresis the patient was
premedicated with Benadryl and Tylenol.  The first 45 minutes
of the patient's pheresis were uneventful but the patient
subsequently began to cough continuously and became acutely
short of breath.  The patient was given an additional
intravenous dose of Benadryl and 200 mg of Hydrocortisone and
was noted to have an oxygen saturation of 87% on room air.
The patient was placed on 5 liters of nonrebreather and her
oxygen saturations increased only to 93%.  Respiratory
therapy was called and gave the patient a Combivent nebulizer
treatment and the patient began coughing up pink frothy
sputum.  A Code Blue was called and the patient became more
uncomfortable appearing with expiratory grunting and
paradoxical movements.

The patient was urgently transported to the Emergency
Department where she was intubated for respiratory failure.
While in the MICU the patient was continued on plasmapheresis
per the recommendations of the transfusion medicine consult
service and the hematology consult service.  The patient's
platelet count remained relatively stable for several days in
the MICU and the hematology service recommended Rituximib
which the patient received on [**2120-3-27**].  The patient's
platelet count subsequently increased with subsequent
plasmapheresis.  In addition, her other markers of hemolytic
anemia including LDH, total bilirubin and haptoglobin
improved.

2.  Respiratory failure - As noted earlier, the patient
became acutely short of breath with expiratory grunting and
paradoxical breathing patterns during her seventh
plasmapheresis and was urgently transferred to the Emergency
Department where she was intubated.  The etiology of the
patient's respiratory failure was considered likely secondary
to Trali with adult respiratory distress syndrome.  The
patient was initiated on pressure control ventilation with
several recruitment maneuvers and was paralyzed due to
continuous difficulty oxygenating and ventilating.  Over her
stay in the MICU the patient's oxygenation and ventilation
improved and she was eventually switched over to assist
control ventilation which she tolerated quite well.  Over her
MICU course, the patient's driving pressures and positive
end-expiratory pressure as well as her FIO2 were titrated
down.  The patient was continued on unprotected ventilation
for adult respiratory distress syndrome.  With large volume
diuresis with CVVH the patient's respiratory status improved
dramatically and at the time of dictation, the patient is
tolerating pressure support, ventilation of [**5-1**] and
oxygenating quite well.

3.  Septic shock - The patient was noted on transfer to the
MICU to be in septic shock requiring pressors and large fluid
boluses.  The etiology of the patient's septic shock is not
entirely clear at this time but is considered likely
secondary to her transfusion-related acute lung injury
associated with a massive cytokine release.  The patient was
placed on Ceftriaxone, Vancomycin, Flagyl and Levofloxacin
for broad empiric coverage.  She had blood, urine and sputum
cultures which are all negative to date.  She received a even
day course of steroids for relative adrenal insufficiency.
The patient was noted to have an elevated lactate on
admission to the MICU likely secondary to hypoperfusion of
tissues.  Her lactate level and metabolic acidosis improved
through her extended stay in the MICU and she had an
improving white blood cell count with increased bandemia.
Once stable, the patient was taken for a chest and abdominal
computerized tomography scan on [**2120-3-26**] for continuing
low-grade fevers.  This computerized tomography scan revealed
no nidus of infection.  There became a concern for sinusitis,
given the use of nasal packing for epistaxis and evidence of
fluid on her head computerized tomography scan.
Otorhinolaryngology was consulted and removed the nasal
packing and the patient was started on Afrin for subsequent
oozing from her nares.  At the time of dictation the patient
has been afebrile for over 72 hours.  On transfer to the MICU
the patient's Apache score was calculated at 31 and a trial
of Xigris was considered but was eventually not used
secondary to the patient's DIC.

4.  Acute renal failure - The patient was admitted to the
General Medical Service with a creatinine of 1.2, felt likely
secondary to her thrombotic thrombocytopenic purpura.  On
transfer to the Medical Intensive Care Unit after the Code
Blue, the patient's creatinine was 2.2 and eventually
increased to 4.4.  The Renal Consult Service was contact[**Name (NI) **]
and the etiology of the patient's acute renal failure was
considered likely from hypotension given her severe septic
shock.  The patient was initiated on CVVH dosed and managed
by the Renal Consult Service.  Over the course of her stay in
the MICU the patient has had modest improvement in her
creatinine and a gradual increase in her urine output.  The
patient's acid base status was consistent with metabolic
acidosis, likely secondary from septic shock as well as a
metabolic alkalosis that was considered likely secondary to
large infusions of bicarbonate in her CVVH dialysate.

5.  Cardiovascular - In the setting of the patient's Trali
and septic shock her cardiac enzymes were noted to bump.  The
patient had a peak creatinine kinase of 1001 which eventually
trended down and a peak troponin of 0.92 which also trended
down.  The patient had no electrocardiogram changes and this
was considered likely cardiac enzyme leak in the setting of
demand ischemia.  As noted earlier, the patient was acutely
hypotensive in septic shock and was placed on Levophed and
Vasopressin for maintenance of her blood pressures.  Over the
course of her MICU stay, these pressors were titrated off and
the patient became hemodynamically stable and normotensive.

6.  Gastrointestinal - In the setting of the patient's septic
shock and adult respiratory distress syndrome, her liver
enzymes became elevated.  Consistent with shock liver, the
patient's liver function tests eventually decreased to within
normal limits.

7.  Fluids, electrolytes and nutrition - The patient was
started on tube feeds on her second day in the MICU which she
tolerated at goal.  Her electrolytes were repleted
aggressively.  The patient was placed on a calcium gluconate
drip with frequent ionized calcium checks given the citrate
in her plasmapheresis and multiple blood transfusions.

The remainder of the [**Hospital 228**] hospital course as well as her
discharge medications and follow up plans will be dictated at
the time of discharge.


                            [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D.  [**MD Number(1) 7585**]

Dictated By:[**Last Name (NamePattern1) 4950**]
MEDQUIST36

D:  [**2120-3-31**]  17:15
T:  [**2120-3-31**]  16:44
JOB#:  [**Job Number 54610**]


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

Admission Date:  [**2120-4-14**]     Discharge Date:  [**2120-4-28**]

Date of Birth:                  Sex:

Service:

NOTE:  This addendum will cover the period of [**2120-4-14**] to
[**2120-4-28**].

HOSPITAL COURSE:  The patient is a 45 year old female who is
diagnosed with TTPHUS on [**3-16**] and admitted to the medicine
service at our hospital for plasmapheresis.  During phoresis
on [**3-22**], she became acutely short of breath, in acute
respiratory distress. She was transferred to the Medical
Intensive Care Unit and intubated.

Her Medical Intensive Care Unit course at that time was
complicated by [**Female First Name (un) **] fungemia/sepsis.  She slowly improved
and was extubated. She was transferred out to the floor by
[**2120-4-5**]. The patient continued plasmapheresis and Prednisone
treatment.  The patient's hematocrit began to drop and she
also began to complain of epigastric pain.

On [**2120-4-10**], the patient developed epigastric pain with clots
and bright red blood per rectum.  She was transferred again
to the Medical Intensive Care Unit.  The patient had a
colonoscopy on [**2120-4-13**] in the Medical Intensive Care Unit,
which showed ulcers in the transverse colon and proximal
splenic flexure, deep with heaped up edges of the mucosa,
concerning for an ischemic colitis versus infectious colitis.
The patient was begun on a 14 day course of Levofloxacin and
Flagyl. She received two more units of packed red blood cells
during that Medical Intensive Care Unit stay and was
transferred out to the floor to our service on [**2120-4-14**] in
stable condition.

On [**2120-4-15**], the patient began to complain of mild abdominal
pain. We obtained a CT scan of her abdomen, which did not
show any evidence of hepatic inflammation or pancreatitis but
it did show small lesions within the liver and the spleen.
We had a follow-up magnetic resonance scan done of her
abdomen on [**2120-4-23**] which showed that the liver cysts had
actually improved and had actually shrunk, which was
suggestive of a possible infectious etiology.

On [**2120-4-21**], the patient started experiencing increasing
tachycardia in the 110 to 120 range. We obtained a contrast
CT scan of her lungs on [**2120-4-25**] which showed a moderate sized
pulmonary embolus in the right lower lobe. She was started on
intravenous heparin. Throughout this time, the patient never
had decreased oxygenation.  Pulse oxygen saturations always
remained in the high 90's on room air.  At the time of this
dictation, the patient had improved in terms of her abdominal
pain. She remained on intravenous heparin, in stable
condition, oxygenating well on room air, with plans to
discharge to a rehabilitation fairly soon.






                          [**First Name4 (NamePattern1) 77**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) **]

Dictated By:[**Last Name (NamePattern1) 1061**]

MEDQUIST36

D:  [**2120-4-30**]  10:17
T:  [**2120-5-1**]  05:08
JOB#:  [**Job Number 10174**]


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

Admission Date: [**2120-4-29**]        Discharge Date: [**2120-5-8**]

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

Service:


HOSPITAL COURSE BY PROBLEM:
1. GI bleed:  Patient was on anticoagulation as previously
   described, which developed a brisk bleed and diarrhea on
   the afternoon of [**4-29**].  Given her recent complications
   from blood products, transfusion was avoided.  Hepatitis
   gtt. was stopped and all anticoagulation held.  Patient
   went to IR and had a temporary IVC filter put in place on
   the evening of [**4-29**].  She underwent colonoscopy on [**4-30**]
   that demonstrated colonic ulcers.  Biopsy was consistent
   with chronic colitis with mild activity.  No granulomas
   were noted.  This finding is strange as patient was
   without history of inflammatory bowel disease.

It will be followed further by the GI team as an outpatient.
Plan is to restart Lovenox two weeks after GI bleed.  Will
need to hold Lovenox 12 hours prior to IVC filter removal,
then restart six hours after and initiate Coumadin after
removal.  D/C Lovenox when INR is [**1-30**] on Coumadin.  Will need
to be on Coumadin for six months.

1. TTP/HUS:  Patient's hematocrit trended down to 25 and
   platelets down to 130s, but recovered without
   intervention.  Hematology/Oncology team followed and
   evaluated blood smear, and found no evidence of TTP or
   HUS.  The patient did not require any blood transfusions.
   She is on Epogen for her anemia.  The patient has followup
   arranged with Dr. [**Last Name (STitle) 703**].  Should get q week CBC
   checks.

1. Pulmonary embolus:  As described above, IVC filter in
   place.  The patient will need to begin Lovenox therapy on
   [**5-11**].  During that time, she should be on Lovenox 110 mg
   q.12h.  The Lovenox should be held on the morning prior to
   her IVC filter removal 12 hours prior.  After IVC filter
   removal, the patient was to begin Lovenox 110 mg q.12h.
   and start Coumadin.  Continue Lovenox until goal INR [**1-30**]
   and then D/C Lovenox.  Patient needs Coumadin for six
   months' time.

1. Cardiovascular:  The patient changed to atenolol and the
   dose is titrated up without negative effect.  Cardiology
   did not feel that patient had any shunt and does not
   recommend further studies.

1. Diabetes:  Followed by [**Last Name (un) 616**], very stable.

1. Hand edema:  Right hand calcifications causing chronic
   pain, but additional swelling was noted on [**5-4**].  Upper
   extremity ultrasound done was negative for clot.  Edema
   improved with elevation.  Wrist now in a soft brace.

1. Hepatic abscesses:  Elevated white count resolved on its
   own without intervention.  Followup MRI arranged for [**4-2**]
   weeks.  Primary care to get the results.

1. Followup at rehab:  The patient must have q week CBC, call
   [**Hospital 10175**] Clinic if hematocrit or platelets fall from baseline.
   Must begin Lovenox therapy on [**5-11**], will need Lovenox
   therapy until removal of IVC filter.  At that time, it
   should be held prior to filter.  After filter removal,
   patient must be on Lovenox until Coumadin is therapeutic,
   INR [**1-30**].  Please check INRs while titrating up warfarin
   dose.


APPOINTMENTS:
1. MRI requested for mid [**Month (only) **] to follow liver abscesses, call
   [**Telephone/Fax (1) 491**] to confirm the time and date.  Results should
   go to the primary care doctor for review.  Attending is to
   be setup for [**6-4**], same day as GI followup.
2. Will need removal of IVC filter after therapeutic.  Plan
   to followup with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10176**] at the [**Hospital Ward Name **]
   Center Radiology, [**Telephone/Fax (1) 491**], attempted to arrange for
   [**2120-5-23**].  The patient should call to confirm this date.
   He will need to hold the a.m. dose of Lovenox.
3. Follow up with Dr. [**Last Name (STitle) 703**] of Hematology/Oncology for
   TTP/HUS, appointment on [**2120-5-20**] at 9 [**Initials (NamePattern5) **] [**Last Name (NamePattern5) **]
   Clinical Center [**Hospital 10175**] Clinic, [**Telephone/Fax (1) 6737**].
4. GI followup with Dr. [**First Name4 (NamePattern1) 9540**] [**Last Name (NamePattern1) 10177**], [**Telephone/Fax (1) 1368**] on [**2120-6-4**]
   at 2:40, to followup of the colonic ulcer as well as liver
   abscesses.
5. Dr. [**Last Name (STitle) 10178**] on [**2120-7-18**] at 1:30 p.m., [**Hospital 616**] Clinic as
   well as nurse [**Doctor Last Name 690**] at [**Hospital 616**] Clinic 3 p.m., [**2120-7-18**].


DISCHARGE CONDITION:  The patient is working well with PT and
OT.  Hematocrit and platelets are stable, no bleeding off
anticoagulation.

DISCHARGE STATUS:  The patient was discharged to rehab.

DISCHARGE MEDICATIONS:
1. Quetiapine fumarate 25 mg three tablets p.o. h.s.
2. Topiramate 25 mg two tablets p.o. b.i.d.
3. Mirtazapine 15 mg one tablet p.o. q.h.s.
4. Folic acid 1 mg p.o. q.d.
5. Calcium carbonate 500 two tablets p.o. q.i.d.
6. Miconazole powder b.i.d. as needed.
7. Ativan 0.5 mg tablet one tablet p.o. q6 prn.
8. Ferrous sulfate 325 mg one tablet p.o. q.d.
9. Bismuth subsalicylate 525 mg/30 mL take 15 mL p.o. t.i.d.
   prn.
10.      EPO 10,000 units/mL one dose Monday, Thursday, and
   Saturday.
11.      Simethicone 80 mg tablet 1.5 tablets p.o. t.i.d.
   prn.
12.      Oxycodone 5 mg two tablets p.o. q.4-6h. prn pain.
13.      Diphenhydramine 25 mg one capsule q.6h. prn.
14.      Aluminum magnesium hydroxide prn.
15.      Docusate 100 b.i.d.
16.      Atenolol 25 take three tablets p.o. q.d.  Hold for
   blood pressure less than 110, heart rate less than 55.
17.      Lisinopril 20 take two tablets p.o. q.d.  Hold for
   systolic blood pressure less than 110.
18.      Protonix 40 q.d.
19.      Glargine 15 units q.h.s.
20.      Prednisone 10 mg take two tablets p.o. q.d. or as
   directed by Hematology.
21.
   Humalog sliding scale.
22.      Lovenox 110 subQ twice a day.



                        [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 10179**]

Dictated By:[**Last Name (NamePattern1) 1200**]
MEDQUIST36
D:  [**2120-5-16**] 10:37:06
T:  [**2120-5-17**] 08:00:03
Job#:  [**Job Number 10180**]
{'Thrombotic microangiopathy,Hemolytic-uremic syndrome,Acute respiratory failure,Acute kidney failure, unspecified,Unspecified septicemia,Severe sepsis,Septic shock,Iron deficiency anemia secondary to blood loss (chronic),Pneumonia, organism 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: 

PRESENT ILLNESS: This is a 45 year old female
patient with a history of bipolar disease and idiopathic
tachycardia who was transferred to [**Hospital6 649**] from [**Hospital6 19155**] where she
presented with left lower quadrant and left flank pain,
nausea and thrombocytopenia.  The patient initially presented
to the outside hospital with a three day history of [**Location (un) 2452**]
urine and loose [**Location (un) 2452**] stools with a more recent development
of a lower extremity rash.  In addition, the patient noted
fatigue with increasing dyspnea on exertion over the last
three to six weeks.  She also endorsed a one day history of
nausea with a development of crampy searing left lower
quadrant and flank pain associated with [**Location (un) 2452**] loose stools.
The patient denied any fever, chills, nightsweats, upper
respiratory tract symptoms, sore throat.  She also denied any
epistaxis or bleeding gums.  The patient similarly denied any
new medications or changes in her medications.

MEDICAL HISTORY: 1.  Bipolar disorder.
2.  Tachycardia.

MEDICATION ON ADMISSION: 

ALLERGIES: Demerol leads to anaphylaxis.

PHYSICAL EXAM: 

FAMILY HISTORY: Positive for coronary artery disease.  No
family history of hematologic disorders.

SOCIAL HISTORY: The patient denies any tobacco, alcohol or
drug use.  She currently lives alone in [**Location (un) 8957**] and is not
currently sexually active. 

### Response:
{'Thrombotic microangiopathy,Hemolytic-uremic syndrome,Acute respiratory failure,Acute kidney failure, unspecified,Unspecified septicemia,Severe sepsis,Septic shock,Iron deficiency anemia secondary to blood loss (chronic),Pneumonia, organism unspecified'}
