CHIEF COMPLAINT: Vomiting.

PRESENT ILLNESS: This is a 57-year-old male with
history of insulin dependent diabetes, status post renal
transplant in [**2130**], recent admits for fever of unknown
origin, who now presents with a three day history of nausea,
vomiting, diarrhea, and fever of up to 101.8.  As already
noted, the patient was recently admitted in late [**Month (only) 359**] for
workup of fever of unknown origin including a VATS procedure,
and readmitted in mid [**2140-12-9**] with similar
complaints without significant elucidation of his fever of
unknown origin.  The patient was afebrile for five days prior
to discharge.

MEDICAL HISTORY: 1. Insulin dependent diabetes.
2. End-stage renal disease, status post kidney transplant in
[**2130**], baseline creatinine is 4-4.5.
3. Status post VATS in [**2140-11-8**].
4. Recent admissions for FUO with negative workup.
5. History of empyema/septic emboli.
6. Congestive heart failure.
7. Coronary artery disease, status post myocardial
infarction, status post left anterior descending artery PTCA
and stent in [**2139-10-10**].
8. History of Clostridium difficile colitis.
9. Osteoarthritis.
10. History of aspiration pneumonia.
11. MGUS.
12. History of methicillin-resistant Staphylococcus aureus,
Vancomycin resistant Staph, cleared.
13. History of gallstones.
14. History of right eye blindness.

MEDICATION ON ADMISSION: 

ALLERGIES: Dicloxacillin which leads to dry heaves,
Compazine leads to hallucinations.

PHYSICAL EXAM: 

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: No tobacco in the last 18 years, very rare
EtOH, no IV drug use, lives with wife and daughter.
Diabetes with ketoacidosis, type I [juvenile type], not stated as uncontrolled,Bacteremia,Acute kidney failure, unspecified,Congestive heart failure, unspecified,Other postoperative infection,Kidney replaced by transplant,Unspecified pleural effusion,Hyperosmolality and/or hypernatremia
DMI keto nt st uncntrld,Bacteremia,Acute kidney failure NOS,CHF NOS,Other postop infection,Kidney transplant status,Pleural effusion NOS,Hyperosmolality
Admission Date:  [**2141-1-6**]     Discharge Date:  [**2141-1-14**]

Date of Birth:   [**2083-10-25**]     Sex:  M

Service:  MEDICINE

CHIEF COMPLAINT:  Vomiting.

HISTORY OF PRESENT ILLNESS:  This is a 57-year-old male with
history of insulin dependent diabetes, status post renal
transplant in [**2130**], recent admits for fever of unknown
origin, who now presents with a three day history of nausea,
vomiting, diarrhea, and fever of up to 101.8.  As already
noted, the patient was recently admitted in late [**Month (only) 359**] for
workup of fever of unknown origin including a VATS procedure,
and readmitted in mid [**2140-12-9**] with similar
complaints without significant elucidation of his fever of
unknown origin.  The patient was afebrile for five days prior
to discharge.

After discharge, the patient had been in his usual state of
health until a few nights prior to admission when he noted
progressive nausea and vomiting, and inability to tolerate
oral intake.  He states that he has not been able to keep
anything down, and has noted almost projectile vomiting
approximately two hours after ingesting food.  He states that
the emesis is compromised of undigested food.  He has been
able to drink water and had red jello without any problem.

In the Emergency Department, he had laboratories consistent
with diabetic ketoacidosis.  He was given 3 liters of
intravenous fluids, Phenergan, Zofran, and insulin.  He was
transferred to the MICU for management of his diabetic
ketoacidosis.

PAST MEDICAL HISTORY:
1. Insulin dependent diabetes.
2. End-stage renal disease, status post kidney transplant in
[**2130**], baseline creatinine is 4-4.5.
3. Status post VATS in [**2140-11-8**].
4. Recent admissions for FUO with negative workup.
5. History of empyema/septic emboli.
6. Congestive heart failure.
7. Coronary artery disease, status post myocardial
infarction, status post left anterior descending artery PTCA
and stent in [**2139-10-10**].
8. History of Clostridium difficile colitis.
9. Osteoarthritis.
10. History of aspiration pneumonia.
11. MGUS.
12. History of methicillin-resistant Staphylococcus aureus,
Vancomycin resistant Staph, cleared.
13. History of gallstones.
14. History of right eye blindness.

MEDICATIONS:
1. Midodrine 10 mg po tid.
2. Prednisone 5 mg po q day.
3. Neurontin 300 mg po bid.
4. Lopressor 75 mg [**Hospital1 **].
5. Pravachol 40 mg po q day.
6. Humalog sliding scale.
7. Sodium bicarbonate 1300 mg po bid.
8. Glargine 38 units subQ q hs.
9. Procrit 10,000 units subQ 3x a week.
10. Protonix 40 mg po q day.
11. Aspirin 325 mg po q day.
12. [**Hospital1 **] sulfate 325 mg po q day.
13. Lasix 20 mg po q day.
14. Norvasc 5 mg po q day.
15. Colace 100 mg po bid.

ALLERGIES:  Dicloxacillin which leads to dry heaves,
Compazine leads to hallucinations.

SOCIAL HISTORY:  No tobacco in the last 18 years, very rare
EtOH, no IV drug use, lives with wife and daughter.

FAMILY HISTORY:  Noncontributory.

REVIEW OF SYSTEMS:  Positive for fevers up to 101.8, negative
chills or rigors, negative upper respiratory infection
symptoms, negative headache, negative shortness of breath,
positive chest pain localized to his right chest at the site
of the recent VATS procedure, extending to the anterior chest
wall, treated with Tylenol #3 without success.  Review of
systems is also positive for nausea, vomiting, abdominal
cramps, loose nonwatery stools x2 days, but negative for
bright red blood per rectum, melena, urinary symptoms, lower
extremity edema.

LABORATORIES:  White count 11.8 with 84% neutrophils, 11%
lymphocytes, hematocrit 33.9, platelets 247.  Sodium 143,
potassium 4.5, chloride 113, bicarb 16, BUN 86, creatinine
5.3, glucose 104, PT 13.5, PTT 27.1, INR 1.2.  ALT 12, AST
19, alkaline phosphatase 125, total bilirubin 0.5, lipase 7.
CK 31, troponin is less than 0.3.

Urinalysis:  Slightly hazy, trace blood, greater than 300
protein, 250 glucose, small bilirubin, negative leukocyte
esterase or nitrate, 3 red blood cells, 2 white blood cells,
few bacteria, 2 epi's.  Urine sodium 54, urine creatinine
104, urine urea 516.  Arterial blood gas:  PH 7.13, CO2 28,
O2 93.

ELECTROCARDIOGRAM:  Normal sinus rhythm at 79 beats per
minute, normal axis with PVCs, pseudonormalization of T waves
in I, V5 and V6, new T-wave inversion in V1.

CHEST X-RAY:  Patchy density in the left middle lung zone,
questionable development of pneumonia, stable density in the
right lung base, 7th rib abnormality posteriorly which could
represent fracture.

HOSPITAL COURSE:  In short, this is a 57-year-old male with a
history of insulin dependent diabetes, end-stage renal
disease status post renal transplant in [**2130**] with chronic
renal insufficiency with baseline creatinine of 4.0 to 4.5,
who presents with three days of nausea and vomiting,
decreased po intake, and fever up to 101.8, found to be in
diabetic ketoacidosis, transferred to the unit for further
management.

1. Endocrine:  As already noted, the patient was found to be
in diabetic ketoacidosis on admission.  His initial anion gap
was calculated to be 23.  Etiologies behind the diabetic
ketoacidosis were thought to be infection given the fever
versus ischemia given the new electrocardiogram changes.
Patient received 8 units of insulin IV push, and then 8 units
per hour insulin drip.  He also received 3 liters of normal
saline in the Emergency Department, in addition to another
liter in the MICU.  Patient's gap quickly closed.  He was
converted to sliding scale insulin, and his fluids were
continued at maintenance of D5 normal saline.

2. Infectious Disease:  While in house, the patient started
spiking with fevers up to 105 degrees F.  Patient's combined
blood cultures from [**1-6**] and [**2141-1-7**] grew 12/12 bottles of
Staphylococcus aureus, sensitive to oxacillin with a MIC of
0.25.  Given the positive blood cultures, patient's fever was
not thought to be related to his recent FUO.  The most likely
sources of the bacteremia were thought to be the site of the
VATS procedure, especially given that a small amount of pus
was noted coming from the site.  In addition, a cardiac
source could not be ruled out.

Patient had a chest CT scan on [**2141-1-9**].  This showed
increased patchy ground-glass infiltrate in the right upper
lobe and left lower lobes, and a new 7th rib fracture.
Patient also had a staple right sided effusion.  Recent chest
CT scan imaging for evaluation of empyema was negative.
Patient also had a transthoracic echocardiogram on [**2141-1-10**].
This showed a mild AR and MR, but no vegetations.

On [**2141-1-11**], the patient received a right sided
thoracentesis.  This showed an essentially clear fluid, with
1,000 white blood cells, and 5,000 red blood cells.  Also
total protein is 3.2, glucose 272, LDH 164, and pH of 7.44.
No organisms were seen, and culture was negative.  Pleural to
serum total protein and LDH ratios were consistent with
slightly exudative fluid.

Patient last spiked on [**2141-1-9**].  Patient was kept on
oxacillin 2 grams IV q4h.  He received a PICC line on his
left.  The plan was to keep the patient on intravenous
oxacillin for at least one month's time given his bacteremia.
Subsequent surveillance cultures were negative.

3. Given the patient's new onset diabetic ketoacidosis and
electrocardiogram changes, he was ruled out by cardiac
enzymes.  The patient ruled out successfully.  He is
continued on aspirin, Lopressor, and the Pravachol.

4. Renal:  The patient has a history of chronic renal
failure.  The patient presented with acute and chronic
failure.  His [**Doctor Last Name **] was not useful because the patient is on
chronic Lasix.  His fractional excretion of urea was 31,
consistent with prerenal state as the value is less than 35.
The patient responded to IV fluids, and his creatinine
returned to a baseline of [**5-12**].5.

5. Right sided chest pain:  The patient was admitted with
pleuritic right sided chest pain, correlating with the site
of his recent VATS and likely secondary to his newly found
fractured 7th rib.  Given the patient's history of monoclonal
gammopathy of unknown significance, there is concern that the
patient may be converting to multiple myeloma.  He may need a
bone marrow [**Date Range **] in the near future.  Patient was
successfully treated with Percocet for the pain.

CONDITION ON DISCHARGE:  Good.

DISCHARGE MEDICATIONS:
1. Midodrine 10 mg po tid.
2. Prednisone 5 mg po q day.
3. Oxacillin 2 grams IV q4h x1 month.
4. Neurontin 300 mg po bid.
5. Lopressor 75 mg po bid.
6. Pravachol 40 mg po q day.
7. Humalog sliding scale.
8. Bicarb 1300 mg po bid.
9. Glargine 38 units subQ q hs.
10. Procrit 10,000 units subQ 3x a week.
11. Protonix 40 mg po q day.
12. Aspirin 325 mg po q day.
13. [**Date Range **] sulfate 325 mg po q day.
14. Lasix 20 mg po q day.
15. Norvasc 5 mg po q day.
16. Colace 100 mg po bid.

DISCHARGE INSTRUCTIONS:  The patient is to followup with Dr.
[**First Name (STitle) 805**] in [**2-10**] weeks.  Patient will need to followup sooner
if he redevelops a fever, nausea, vomiting, decreased po
intake.  He will also need to followup with Infectious
Disease.

DISCHARGE DIAGNOSES:
1. Staphylococcus aureus bacteremia, now cleared.
2. Insulin dependent diabetes.
3. End-stage renal disease, status post kidney transplant in
[**2130**].
4. Recent fever of unknown origin with negative workup.
5. Coronary artery disease, status post myocardial
infarction.




                          [**Name6 (MD) 251**] [**Last Name (NamePattern4) 11865**], M.D.  [**MD Number(1) 11866**]

Dictated By:[**Name8 (MD) 4990**]

MEDQUIST36

D:  [**2141-3-1**]  16:52
T:  [**2141-3-2**]  07:23
JOB#:  [**Job Number **]
{'Diabetes with ketoacidosis, type I [juvenile type], not stated as uncontrolled,Bacteremia,Acute kidney failure, unspecified,Congestive heart failure, unspecified,Other postoperative infection,Kidney replaced by transplant,Unspecified pleural effusion,Hyperosmolality and/or hypernatremia'}


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: Vomiting.

PRESENT ILLNESS: This is a 57-year-old male with
history of insulin dependent diabetes, status post renal
transplant in [**2130**], recent admits for fever of unknown
origin, who now presents with a three day history of nausea,
vomiting, diarrhea, and fever of up to 101.8.  As already
noted, the patient was recently admitted in late [**Month (only) 359**] for
workup of fever of unknown origin including a VATS procedure,
and readmitted in mid [**2140-12-9**] with similar
complaints without significant elucidation of his fever of
unknown origin.  The patient was afebrile for five days prior
to discharge.

MEDICAL HISTORY: 1. Insulin dependent diabetes.
2. End-stage renal disease, status post kidney transplant in
[**2130**], baseline creatinine is 4-4.5.
3. Status post VATS in [**2140-11-8**].
4. Recent admissions for FUO with negative workup.
5. History of empyema/septic emboli.
6. Congestive heart failure.
7. Coronary artery disease, status post myocardial
infarction, status post left anterior descending artery PTCA
and stent in [**2139-10-10**].
8. History of Clostridium difficile colitis.
9. Osteoarthritis.
10. History of aspiration pneumonia.
11. MGUS.
12. History of methicillin-resistant Staphylococcus aureus,
Vancomycin resistant Staph, cleared.
13. History of gallstones.
14. History of right eye blindness.

MEDICATION ON ADMISSION: 

ALLERGIES: Dicloxacillin which leads to dry heaves,
Compazine leads to hallucinations.

PHYSICAL EXAM: 

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: No tobacco in the last 18 years, very rare
EtOH, no IV drug use, lives with wife and daughter. 

### Response:
{'Diabetes with ketoacidosis, type I [juvenile type], not stated as uncontrolled,Bacteremia,Acute kidney failure, unspecified,Congestive heart failure, unspecified,Other postoperative infection,Kidney replaced by transplant,Unspecified pleural effusion,Hyperosmolality and/or hypernatremia'}
