CHIEF COMPLAINT: Abdominal pain.

PRESENT ILLNESS: The patient is a 54-year-old
male, status post unrelated donor renal transplant in [**2105**]
for nephropathy of unclear etiology. He developed papillary
thyroid cancer in [**2114**]. This was treated with thyromegaly. In
[**2117-12-30**], he noted he was losing weight. He underwent
workup of this weight loss and was found to have an EBV-
driven posttransplant lymphoproliferative disorder with
Hodgkin-like features. He presented to [**Hospital1 18**] on [**2118-10-4**] after being hospitalized from [**9-19**] through
[**9-30**] with fatigue, and low platelets, and increased
LFTs. He returned on this admission with weakness, failure to
thrive and low platelets.

MEDICAL HISTORY: Thyroid papillary cancer, status post
thyromegaly,  chronic DIC,  hypertension,  depression,
squamous cell-like CA,  necrotizing pneumonia,  pancytopenia,
status post living unrelated renal transplant in [**2105**].
History of BAL with rhinovirus, status post IVIG in [**2118-9-30**].

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Chronic or unspecified duodenal ulcer with perforation, without mention of obstruction,Complications of transplanted kidney,Defibrination syndrome,Nutritional marasmus,Acute and subacute necrosis of liver,Unspecified peritonitis,Congestive heart failure, unspecified,Streptococcal septicemia,Severe sepsis,Other diseases of spleen,Vascular disorders of kidney,Disorder of bone and cartilage, unspecified,Personal history of malignant neoplasm of thyroid,Unspecified essential hypertension,Other malaise and fatigue,Late effects of other and unspecified infectious and parasitic diseases
Chr duoden ulcer w perf,Compl kidney transplant,Defibrination syndrome,Nutritional marasmus,Acute necrosis of liver,Peritonitis NOS,CHF NOS,Streptococcal septicemia,Severe sepsis,Spleen disease NEC,Renal vascular disorder,Bone & cartilage dis NOS,Hx of thyroid malignancy,Hypertension NOS,Malaise and fatigue NEC,Late eff infect dis NEC
Admission Date: [**2118-10-4**]        Discharge Date: [**2118-10-17**]

Date of Birth:  [**2064-4-29**]        Sex:  M

Service:  [**Last Name (un) **]


CHIEF COMPLAINT:  Abdominal pain.

HISTORY OF PRESENT ILLNESS:  The patient is a 54-year-old
male, status post unrelated donor renal transplant in [**2105**]
for nephropathy of unclear etiology. He developed papillary
thyroid cancer in [**2114**]. This was treated with thyromegaly. In
[**2117-12-30**], he noted he was losing weight. He underwent
workup of this weight loss and was found to have an EBV-
driven posttransplant lymphoproliferative disorder with
Hodgkin-like features. He presented to [**Hospital1 18**] on [**2118-10-4**] after being hospitalized from [**9-19**] through
[**9-30**] with fatigue, and low platelets, and increased
LFTs. He returned on this admission with weakness, failure to
thrive and low platelets.

PAST MEDICAL HISTORY:  Thyroid papillary cancer, status post
thyromegaly,  chronic DIC,  hypertension,  depression,
squamous cell-like CA,  necrotizing pneumonia,  pancytopenia,
status post living unrelated renal transplant in [**2105**].
History of BAL with rhinovirus, status post IVIG in [**2118-9-30**].

BRIEF HOSPITAL COURSE:  The patient was admitted to the
hospital for failure to thrive. In the 24 hours prior to
surgical consultation he developed a syncopal episodes. He
was transferred to the medical intensive care unit where he
was intubated and started on pressors. A CT scan demonstrated
free air in his abdomen. Based on this, he was taken to the
operating room on [**10-5**] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]; assisted
by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 103750**]. He underwent an exploratory
laparotomy, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] patch repair of a duodenal perforation
with irrigation. EBL was 300 cc. Please see operative report
for details. The patient was taken to the medical intensive
care unit in critical condition.

In the ICU he was intubated, on pressors. He received fresh
frozen plasma, packed red blood cells and platelets for a
hematocrit of 23.5. He was extubated. He was treated with
vancomycin, Flagyl and Zosyn. His abdomen was tender to
touch. Infectious disease, oncology, and nephrology followed
the patient very closely throughout this hospital course. It
was noted that the patient had PTLD, progressive, with lytic
bone lesions and splenic lesions of unclear etiology. He had
a staph coag-negative bacteremia. He continued on IV
antibiotics. He was also treated with micofungin. It was felt
could possibly be related to an infection. His sedation was
weaned off. He continued on stress-dose steroids as well as
IV levothyroxine.

A nutrition consult was obtained, and recommendations for
tube feedings were established. Tube feedings were gradually
advanced. He continued on total parenteral nutrition.

He was transferred out of the SICU as his condition improved.
LFTs were elevated. An ultrasound of his right upper quadrant
was done; and this demonstrated a right pleural effusion and
ascites, sludge within the gallbladder, and no evidence of
intra or extrahepatic biliary ductal dilatation. His liver
function tests continued to rise. This was felt  to be
related to total parenteral nutrition, and TPN was weaned
off. AST increased to __________, AST 72, alkaline
phosphatase remained relatively stable in the 150s to 170
range, total bilirubin continued to climb from approximately
6.8 as high as up to 27.2 on hospital day #12. He continued
to receive Neupogen almost on a daily basis for white blood
cell counts of 1.0. Platelet counts continued to remain in
the 30 range despite almost daily platelet transfusions. His
creatinine was stable at approximately 0.6.

__________ to assess for sources of coag-negative staph. No
vegetations were noted. The left atrium was mildly dilated,
and EF was greater than 55%. He had 1+ aortic regurgitation.
There was trivial mitral regurgitation, and no mitral valve
prolapse.

He continued to have large amounts of drainage and weeping
from generalized edema. Albumin was given as well as IV fluid
repletion. His incision continued to drain copious amounts of
serosanguineous fluid. This did slow down quite a bit. His
bilirubin was elevated, mostly direct. Direct bilirubin was
10.6, indirect 3.5.

He was transferred out of the surgical intensive care unit
where he continued to receive tube feedings and total
parenteral nutrition. His diet was advanced. He was unable to
tolerate much due to nausea. On postoperative day #6, he
underwent an abdominal CAT scan. This demonstrated a
subcapsular wedge-shaped lesion of the transplanted kidney
with concern for infarct. Air was seen within the collecting
system of the transplanted kidney; likely secondary to reflux
of air from bladder. There was interval decrease in the
amount of ascites within the abdomen and pelvis with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 406**]
drain positioned behind the left lobe of the liver. There
were small pockets of persistent air within the abdomen and
pelvis. Wedge-shaped splenic lesions consistent with splenic
infarct were noted; not significantly changed from previous
study. There was partially visualized right middle lobe with
small infiltrate as well as an irregular area of high
attentuation collection within the pelvis behind the bladder;
likely representing nonopacified segments of bowel. There was
a stable appearance of the pathologically enlarged
retroperitoneal lymphadenopathy.

Given persistent rise in LFTs, worsening jaundice and
cachexia, and persistent generalized pain, and malnutrition
his prognosis was very poor. After consultation with the
primary care team as well as oncology, a family meeting was
done; during which time the patient and his wife were
informed that his condition was extremely poor and the
feeling was that he would need hospice care. His wife agreed
to take Mr. [**Known lastname **] home with hospice. Palliative care was
consulted; and the patient was seen by [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 1764**], and pain
medication recommendations were made. [**Hospital **] hospice of
[**Hospital1 **] was consulted for hospice services. Arrangements were
made to transfer the patient home after delivery of pain
medication by hospice. A hospital bed, home oxygen and tube
feedings were arranged. The antibiotics were stopped. Of
note, he grew out VRE from blood on [**2118-10-12**].
Linezolid had been started on [**2118-10-14**]. This was
stopped on [**10-17**]. Vancomycin was stopped as well.

DISCHARGE STATUS:  In summary, the patient's condition was
very grave. Social service was consulted for support. A
comfort care form was signed by the patient's wife.

DISCHARGE MEDICATIONS:  Included Protonix 40 mg daily,
fentanyl 25-mcg patch to be reassessed with p.r.n. order for
1 to 2 patches to be changed every 72 hours, oxycodone 5 to
20 mg sublingually p.r.n. q.1h., Compazine 25-mg suppository
p.r.n. q.8h., Ativan 0.5- to 2-mg tablets p.o. p.r.n. q.2h.,
Levsin 0.125-mg tablets sublingually p.r.n. q.4 for
secretions, an alternate script was provided for scopolamine
1.5-mg patch to be changed every 72 hours. A script was
provided for tube feedings, oxygen and hospital bed.

DISCHARGE INSTRUCTIONS:  The patient's wife was instructed to
call Dr.[**Name (NI) 670**] office or Dr.[**Name (NI) 6001**] office for further
orders or any concerns for uncontrolled nausea, vomiting, or
abdominal pain.

DISCHARGE DIAGNOSES:  Include posttransplant
lymphoproliferative disease; Hodgkin's-like cancer; status
post duodenal perforation on [**2118-10-4**]; malnutrition;
chronic disseminated intravascular coagulopathy; status post
living unrelated renal transplant in [**2105**]; chronic pain.

DISCHARGE CONDITION:  Terminal.



                        [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**]

Dictated By:[**Name8 (MD) 4664**]
MEDQUIST36
D:  [**2118-10-17**] 14:53:21
T:  [**2118-10-17**] 15:54:58
Job#:  [**Job Number 103751**]
{'Chronic or unspecified duodenal ulcer with perforation, without mention of obstruction,Complications of transplanted kidney,Defibrination syndrome,Nutritional marasmus,Acute and subacute necrosis of liver,Unspecified peritonitis,Congestive heart failure, unspecified,Streptococcal septicemia,Severe sepsis,Other diseases of spleen,Vascular disorders of kidney,Disorder of bone and cartilage, unspecified,Personal history of malignant neoplasm of thyroid,Unspecified essential hypertension,Other malaise and fatigue,Late effects of other and unspecified infectious and parasitic diseases'}


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: Abdominal pain.

PRESENT ILLNESS: The patient is a 54-year-old
male, status post unrelated donor renal transplant in [**2105**]
for nephropathy of unclear etiology. He developed papillary
thyroid cancer in [**2114**]. This was treated with thyromegaly. In
[**2117-12-30**], he noted he was losing weight. He underwent
workup of this weight loss and was found to have an EBV-
driven posttransplant lymphoproliferative disorder with
Hodgkin-like features. He presented to [**Hospital1 18**] on [**2118-10-4**] after being hospitalized from [**9-19**] through
[**9-30**] with fatigue, and low platelets, and increased
LFTs. He returned on this admission with weakness, failure to
thrive and low platelets.

MEDICAL HISTORY: Thyroid papillary cancer, status post
thyromegaly,  chronic DIC,  hypertension,  depression,
squamous cell-like CA,  necrotizing pneumonia,  pancytopenia,
status post living unrelated renal transplant in [**2105**].
History of BAL with rhinovirus, status post IVIG in [**2118-9-30**].

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Chronic or unspecified duodenal ulcer with perforation, without mention of obstruction,Complications of transplanted kidney,Defibrination syndrome,Nutritional marasmus,Acute and subacute necrosis of liver,Unspecified peritonitis,Congestive heart failure, unspecified,Streptococcal septicemia,Severe sepsis,Other diseases of spleen,Vascular disorders of kidney,Disorder of bone and cartilage, unspecified,Personal history of malignant neoplasm of thyroid,Unspecified essential hypertension,Other malaise and fatigue,Late effects of other and unspecified infectious and parasitic diseases'}
