CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is a 48-year-old
man,  who was originally from the [**Country 13622**] Republic, who was
in  his  usual  state  of  health  until  two  days  prior to
admission when he had a fairly sudden onset of chills, fever,
and cough with blood-tinged sputum.

MEDICAL HISTORY: 

MEDICATION ON ADMISSION: Tylenol p.r.n.

ALLERGIES: The patient has no known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: History is noncontributory.

SOCIAL HISTORY: 
Abscess of liver,Other septicemia due to gram-negative organisms,Pneumonia due to Klebsiella pneumoniae,Urinary tract infection, site not specified,Defibrination syndrome,Esophageal reflux,Pure hypercholesterolemia,Anemia, unspecified
Abscess of liver,Gram-neg septicemia NEC,K. pneumoniae pneumonia,Urin tract infection NOS,Defibrination syndrome,Esophageal reflux,Pure hypercholesterolem,Anemia NOS
Name:  [**Known lastname 4269**], [**Known firstname **]                       Unit No:  [**Numeric Identifier 4270**]

Admission Date:  [**2134-3-5**]     Discharge Date:

Date of Birth:   [**2085-10-23**]     Sex:  M

Service:

Addendum on regarding his low platelets on admission, the
platelets reached nadir of 28 before spontaneously recovering
to normal levels (around 500).  He likely did have some DIC
when he was admitted which spontaneously recovered.

His hematocrit postextubation was stable around 31.  He
experienced a drop gradually to as low to around 22 on
[**2134-3-15**].  He was transfused 3 units of packed red blood
cells.  Hematocrit subsequently was stable.  It was felt that
the drop in his hematocrit was likely largely due to
frequently phlebotomy while he was in the Intensive Care
Unit.  He was guaiac negative and we did not suspect that he
had any sources of bleeding.

Regarding the original source of where the Klebsiella had
come from, this is not clear, although likely it originated
somewhere in his gastrointestinal tract.  He tested HIV
negative and there was no reason to suspect that he was
immunosuppressed.






                          [**First Name11 (Name Pattern1) 126**] [**Last Name (NamePattern4) 2098**], M.D.
[**MD Number(1) 2099**]

Dictated By:[**Name8 (MD) 2984**]

MEDQUIST36

D:  [**2134-3-19**]  14:20
T:  [**2134-3-22**]  06:09
JOB#:  [**Job Number 4271**]


Service:  [**Location (un) 259**]                  Date:  [**2134-3-19**]

Date of Birth:   [**2085-10-23**]         Sex:  M

Surgeon:  [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D.

DATE OF DISCHARGE:  Pending.

CHIEF  COMPLAINT:  Acute worsening of chronic abdominal pain.

HISTORY OF THE PRESENT ILLNESS:  The patient is a 48-year-old
man,  who was originally from the [**Country 13622**] Republic, who was
in  his  usual  state  of  health  until  two  days  prior to
admission when he had a fairly sudden onset of chills, fever,
and cough with blood-tinged sputum.

On the morning of the day prior to admission, he began having
diarrhea.   He had four to five loose, brown, nonbloody bowel
movements.    That  night,  he began having over 10 abdominal
pain; the worst abdominal pain of his life.  He noted that he
could  not  sleep  and  he  "could  not  find  a  comfortable
position."

At  baseline,  he  has  had abdominal pain for the past three
years.  It is a diffuse infraumbilical pain that occurs 10 to
15 minutes after he eats and it is accompanied by significant
abdominal  distention.    He  takes multiple over-the-counter
antacid  medications,  which provide some relief of symptoms.
He  tested  positive for H. pylori two years ago for which he
had   received  a  course  of  antibiotics.    He  felt  that
antibiotic  therapy  did  partly reduce his chronic abdominal
pain.

He denies sick contacts or any recent dietary changes.  He
denies  weight  loss or night sweats.  His most recent travel
was to the [**Country 13622**] Republic, where he visited for two weeks
in  [**Month (only) 216**],  [**2132**].    He denied having acquired any illnesses
while  there.    He  visits the [**Country 13622**] Republic about once
every two years.

PAST  MEDICAL  HISTORY:  In addition to what has already been
mentioned, it is significant only for hypercholesterolemia.

MEDICATIONS ON ADMISSION:  Tylenol p.r.n.

ALLERGIES:  The patient has no known drug allergies.

FAMILY HISTORY:  History is noncontributory.

SOCIAL  HISTORY:    The  patient  immigrated  from  [**Country 13622**]
Republic  23  years ago.  There is no history of tobacco use;
occasionally  has  beer on the weekends.  There is no history
drug  use.  He is a handyman doing maintenance and electrical
work.   He denies toxic or chemical exposures at work.  He is
married  and lives with his wife, college-age son and teenage
daughter.

PHYSICAL  EXAMINATION:    When  he presented to the emergency
department  he  appeared to be mild-to-moderate distress.  He
appeared uncomfortable, although he did not report difficulty
breathing.  He appeared dyspnea and when questioned confirmed
that his breathing was heavy.

VITAL  SIGNS:    6  foot  4  inches, 220 pounds.  Temperature
101.5,  blood pressure 130/70, pulse 130, respiratory rate 30
to 50, oxygen saturation 91% on five liters nasal cannula O2,
95%  to  96% in 100% face mask.  GENERAL:  This a middle-aged
man in mild-to-moderate distress, visibly tachypneic.  HEENT:
pupils  equal, round, and reactive to light.  Oropharynx dry.
CHEST:    Tachypneic,  taking  shallow  breaths, no wheezing.
CARDIOVASCULAR:    Tachycardiac, normal S1 and S2, no murmur.
ABDOMEN:    Mild-to-moderately distended (he states that this
is  his  baseline); diffusely tender, decreased bowel sounds.
EXTREMITIES:  Warm and well perfused, no edema.

EKG:  Tachycardiac, incomplete right bundle branch block with
slight left axis deviation.

LABORATORY  DATA:    Labs  on  presentation  to the emergency
department revealed the following:  WBC 8.8, hematocrit 45.3,
platelet  count  46,  differential  neutrophils 47, bands 38,
lymphocytes  9,  monocytes  4,  eosinophils  0,  sodium  136,
potassium  3.3,  chloride 95, CO2 26, BUN 48, creatinine 1.6,
glucose  130,  ALT  109, AST 91, CK 127, alkaline phosphatase
46, total bilirubin 2.1, lipase 22.

Urinalysis:     Specific  gravity  greater  than  1.003  with
moderate   blood,   nitrites   negative,  leukocyte  esterase
negative,  [**2-2**]  RBCs, 0-2 WBCs, many bacteria, no yeasts, 0-2
epithelials.    ABG:  7.42/34/81 on five liters nasal cannula
O2.  Lactate 4.4.

Imaging studies:
1.   Chest x-ray showed lateral left lower lobe opacity and a
rounded pulmonary nodule in the right upper lobe.  No pleural
effusions.
2.    Chest  CT  revealed multiple pulmonary nodules, largest
ones  at  the left and right apex, approximately 4 cm x 3 cm.
Focal  air-space  opacity  in  the left lower lobe.  Multiple
nodules  seen  at  the  lung  bases.   Nodules have clear-air
bronchograms through them.
3.    CT  of  abdomen  without  contrast:   Unenhanced liver,
gallbladder,  spleen,  pancreas,  and  adrenal glands normal.
There  was  no  significant  retroperitoneal  adenopathy,  no
ascites.
4.  CT of pelvis:  Rounded 3.7 cm lesion at the upper pole of
the  left kidney with fluid attenuation likely a cyst.  There
is  no hydronephrosis, no renal stones seen.  Note is made of
some  dependent  soft tissue thickening at the posterior wall
of  the  stomach.    Small  and  large bowel loops are normal
without  evidence for obstruction.  There is no free fluid or
mass lesions.
5.    X-ray of abdomen:  Small bowel loops are air filled and
slight  prominent  at the upper limits of normal in diameter.
A  few  air-fluid levels are also seen in the mid abdomen, no
intraperitoneal free air.
6.    He  tested  positive for old exposures to EBV, CMV, and
hepatitis  A,  but negative for recent exposure to EBV, T and
V, and hepatitis A.  He was hepatitis B, hepatitis C, and HIV
negative,  stool  ova and parasites were negative.  Acid fast
bacillus smears times three were negative.  Toxoplasmosis IgG
positive,  IgM  negative.   He was negative for C. difficile,
negative   for  urinary  Legionella  antigen  ascariasis  and
Strongyloides levels are pending.

HOSPITAL COURSE:  Impression and plan:  This is a 48-year-old
man, who presented with fever and tachypnea that were felt to
be due to pneumonia.

Given  the  patient's dyspnea and chest x-ray and CT findings
concerning  for  pneumonia,  he  was  brought  to the ICU for
observation.    He was placed on face mask oxygen and started
on  Ceftriaxone and Azithromycin to cover bacteria that could
cause  typical  and  atypical  pneumonia.  Because of his low
platelet  counts,  the  DIC labs were sent showing fibrinogen
662  (high);  FDP  320  to  640  (normal is 0 to 10); D-dimer
greater than [**2131**] (normal 0 to 500); haptoglobin 213.

HOSPITAL  COURSE:  On hospital day #2 he was still febrile to
102  and  he  continued  to  be  tachypneic  to  the  30s and
tachycardiac  in the 130s.  Arterial blood gas was 7.31/49/80
on  two  liters  of  oxygen.   He reported improvement in his
abdominal  pain,  but  this  was  in the setting of receiving
Dilaudid.    Blood  cultures  showed 4/4 bottles positive for
gram-negative  rods  and  his  antibiotics  were  switched to
Gentamicin and Levofloxacin.

Sputum  gram  stain was negative for micro-organisms.  Repeat
blood cultures were sent, which were later returned negative.

Labs on this day were significant for a platelet count of 30.

Given his tachycardia, as well as concern for endocarditis, a
cardiac echocardiogram was obtained showing ejection fraction
greater  than  55%,  1+  mitral  regurgitation,  no  valvular
vegetations, and no pericardial effusion.

On hospital day #3, he was still febrile.  Respiratory status
continued to decline and he appeared more fatigued.  Arterial
blood gas 7.34/46/164.  He was electively intubated.

Bronchoscopy  was  performed and showed that all airways were
patent   without  any  endobronchial  lesions.    Hemorrhagic
sections  were  aspirated  from  the left lower and the right
upper  lobe  orifices.  Sputum gram stain had 4+ PMNs, but no
micro-organisms.

Urine  culture  obtained on [**2134-3-5**] returned positive for 10
to 100,000 Klebsiella per ml, which were pansensitive. (urine
culture  obtained  [**2134-3-6**]  would  prove  negative).  He had
rising  bilirubin  to  2.5,  (direct  = 1.6, indirect = 0.9),
alkaline  phosphatase  to  134.      Abdominal ultrasound was
performed.    Results  were  normal  and bile duct was 40-mm;
liver  was  without  masses;  kidneys  were without stones or
hydronephrosis.  There were bilateral pleural effusions.

HOSPITAL  COURSE:    On  hospital  day #4, the blood cultures
obtained   on   [**2134-3-5**]   were   positive  for  pansensitive
Klebsiella pneumonia.  Total bilirubin had edged up to 2.9 so
an abdominal CT was performed.  The CT, with contrast, showed
a  heterogenously-enhancing  7  x 6.3 cm mass at the level of
the  porta hepatis; no intrahepatic ductal dilation; mild fat
stranding in mesentery surrounding the appendix; however, the
appendix fills with contract.

Because of the hepatic abscess, he was started on Flagyl.

Repeat  CT  of the chest showed increase in size of bilateral
pleural effusions and air-space consolidation.

LABORATORY  DATA:    The labs were significant for a platelet
count that had been gradually rising.  It was 69 this day.

On hospital day #6, he was febrile to 102.7.  Transesophageal
echocardiogram was obtained vegetations on his valve and none
were seen.  He was started on Ampicillin for empiric coverage
of Enterococcus and Levofloxacin was stopped.

During  his  subsequent  course,  he was persistently febrile
from 102 to 103, although he defervesced to 100 on [**2134-3-19**].
He  had  multiple  repeat  abdominal  CT  scans,  which  were
negative  for  any  change  in  the  abscess.  Interventional
radiology  assessed  the  patient's  hepatic  abscess  at the
bedside  and  twice  attempted  drainage percutaneously.  The
abscess did not appear liquified and each time interventional
radiology  was  only  able to drain 1 cc of bloody pus.  Gram
stain of the pus obtained during the first sampling showed 2+
gram-negative rods, which were later found to be pansensitive
to Klebsiella.

The  patient  was  also evaluated by the Gastroenterology and
the  Surgical Services.  The surgical service felt that there
was  no  indication to take the patient to the operating room
at  this  time  given  that  they  felt serial imaging of the
abscess with interventional radiology drainage of the abscess
when it liquified, was the best course of action.

MRCP was performed on [**2134-3-11**] to assess the biliary tree to
see  if  there  were  any  lesions that could account for the
hepatic  abscess.    The  MRCP results were normal and showed
only   the   hepatic  abscess,  which  was  heterogenous  and
unchanged in size.

He  had  a  thoracentesis performed on [**2134-3-9**], which showed
exudative fluid consistent with parapneumonic effusion.

He  had significant labs during the remainder of the hospital
course  where  the  total  bilirubin  peaked  at 4.4 on [**3-12**],
before  beginning to trend down.  Alkaline phosphatase peaked
to  799 on [**2134-3-15**] before beginning to trend down.  AST and
ALT  peaked  at  213  on  [**3-15**] before starting to trend down.
Blood  and urine cultures obtained after his day of admission
were all negative.

Respiratory  status  began  improving  around  [**2134-3-13**] with
decreasing  oxygenation and ventilation requirements.  He was
extubated   on   [**2134-3-18**]   without   difficulty.    He  was
oxygenating and ventilating adequately.  After extubation, he
was eating and drinking without difficulty.

Because   his  Klebsiella  is  pansensitive,  the  Infectious
Disease   Service   recommended   that   his  antibiotics  be
Ceftriaxone  and  Flagyl.    As of [**2134-3-19**], he is day #3 of
Ceftriaxone  and  day  #12  of  Flagyl.   He will continue to
require IV antibiotics until at least the time of drainage of
his  hepatic  abscess  (which  could  take  several  weeks to
liquify).

He  did  not  have  any  complaints  of  abdominal  pain post
extubation,  although  he did have significant abdominal pain
prior to his intubation.  He was started on Fentanyl patch on
[**2134-3-17**]  for  pain  control  of  the hepatic abscess.  Pain
control  regimen will continue to be titrated after he leaves
the Intensive Care Unit to go to the regular medical floor.

From  a  nutritional standpoint, he received tube feeds while
he  was  intubated.  From a renal standpoint, he had elevated
BUN  and  creatinine  on  the  day  of  admission,  but  they
subsequently  resolved  suggesting  that  they  were  due  to
dehydration.




He will be discharged to the medical floor on [**2134-3-19**].

Addendum to this discharge summary will later follow.




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

Dictated By:[**Name8 (MD) 4123**]

MEDQUIST36

D:  [**2134-3-19**]  14:08
T:  [**2134-3-19**]  14:13
JOB#:  [**Job Number 25106**]


Admission Date:  [**2134-3-5**]       Discharge Date:  [**2134-3-23**]

Date of Birth:   [**2085-10-23**]       Sex:  M

Service:  [**Location (un) 259**]

NOTE:  This is an addendum to a discharge summary dictated
previously.

On [**2134-3-19**], the patient was transferred from intensive
medical care to regular medical floor.  His course in the
Intensive Care Unit was as described in the discharge summary
from [**2134-3-19**].  While on the floor, the patient remained
afebrile.  His hematocrit stayed stable, around 25 to 27
mark.  His stools remained guaiac negative.  He was continued
on his ceftriaxone and Flagyl for Klebsiella, sepsis/liver
abscess/pneumonia.  He underwent an abdominal ultrasound
which revealed non liquefied abscess at the level of the
porta hepatis that measured 4.3 x 5.5 cm.  It was unchanged
in its characteristic an appearance in comparison to prior
exam dated [**3-12**].  There was no intra or extraductal dilation.
The gallbladder was unremarkable.  There was no
hydronephrosis or nephrolithiasis.

The general plan for this patient was to continue for an
additional two weeks on intravenous antibiotics.  He is to
have a repeat ultrasound of his liver to evaluate the
progress of liquefaction of the liver abscess.  He will be
followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (STitle) 481**] from the infectious disease
division.  He has an appointment with the fellow as well as
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 15716**] on [**Last Name (LF) 2974**], [**4-9**] at 10:00 in the morning
in [**Doctor Last Name 780**] Building on the [**Location (un) **].  At that time, decision
about further antibiotic treatment as well as possible
interventional radiology drainage will be made.  The patient
is to complete additional two weeks of intravenous
antibiotics in attempt to liquefy the abscess for easier
interventional radiology drainage.  In case interventional
radiology would not be able to drain the abscess, surgery may
have to become involved.

DISCHARGE MEDICATIONS:
1.  Flagyl 500 mg tid intravenous
2.  Ceftriaxone 1 gm qd intravenous
3.  Protonix 40 mg po qd
4.  Colace 100 mg po bid
5.  Fentanyl patch wean 75 mcg x1, followed by 25 mcg x1 then
off and will recover for breakthrough pain with Percocet 1 to
2 tablets po q 4 to 6 hours prn
6.  Fleet's enema prn
7.  Atrovent inhaler prn
8.  Albuterol inhaler prn

FOLLOW UP APPOINTMENTS:  Dr. [**Last Name (STitle) **] as well as Dr. [**Last Name (STitle) 15716**]/Dr.
[**Last Name (STitle) 481**] on [**Last Name (LF) 2974**], [**4-9**] at 10 a.m. in [**Doctor Last Name 780**] Building [**Location (un) **].

DISCHARGE DIAGNOSES:
1.  Liver abscess
2.  Klebsiella pneumonia
3.  Status post two week intubation
4.  Klebsiella urinary tract infection
5.  Klebsiella sepsis
6.  Gastroesophageal reflux disease
7.  Anemia



                   DR [**Last Name (STitle) 25107**],[**First Name3 (LF) **] 12.983


Dictated By:[**Last Name (NamePattern1) 1762**]
MEDQUIST36

D:  [**2134-3-22**]  15:35
T:  [**2134-3-22**]  15:46
JOB#:  [**Job Number 25108**]
{'Abscess of liver,Other septicemia due to gram-negative organisms,Pneumonia due to Klebsiella pneumoniae,Urinary tract infection, site not specified,Defibrination syndrome,Esophageal reflux,Pure hypercholesterolemia,Anemia, 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: The patient is a 48-year-old
man,  who was originally from the [**Country 13622**] Republic, who was
in  his  usual  state  of  health  until  two  days  prior to
admission when he had a fairly sudden onset of chills, fever,
and cough with blood-tinged sputum.

MEDICAL HISTORY: 

MEDICATION ON ADMISSION: Tylenol p.r.n.

ALLERGIES: The patient has no known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: History is noncontributory.

SOCIAL HISTORY:  

### Response:
{'Abscess of liver,Other septicemia due to gram-negative organisms,Pneumonia due to Klebsiella pneumoniae,Urinary tract infection, site not specified,Defibrination syndrome,Esophageal reflux,Pure hypercholesterolemia,Anemia, unspecified'}
