CHIEF COMPLAINT: Fever.

PRESENT ILLNESS: This is a 63 year old primarily
Spanish speaking male with a history of end-stage renal
disease secondary to diabetes mellitus on dialysis.  The
patient also has a history of coronary artery disease,
chronic obstructive pulmonary disease, recurrent Methicillin
resistant Staphylococcus aureus/VRE dialysis catheter
infection and status post Methicillin resistant
Staphylococcus aureus epidural abscess of L2 to 3, status
post incision and drainage in [**2144-7-15**].  The patient is
now here from his outpatient hemodialysis center with a fever
up to 103.3 F., lethargy and back pain.  Per the hemodialysis
center notes the patient had a temperature the previous night
at home, however, he was afebrile at the beginning of his
hemodialysis session.  The patient was given Tylenol for his
back pain which did not help.  The patient also complained of
increased back pain.  His pain was mostly between the
shoulders.  Temperature came down to 101.8 F.  Blood cultures
were drawn times two.  The patient was given one gram of
Kefzol and 80 mg of intravenous Gentamicin and sent to the
[**Hospital1 69**] Emergency Department.

MEDICAL HISTORY: 1.  End-stage renal disease on hemodialysis.
2.  Diabetes mellitus, non-insulin dependent.
3.  Chronic obstructive pulmonary disease.
4.  One vessel coronary artery disease, status post
catheterization in [**8-/2145**]; status post left circumflex
percutaneous transluminal coronary angioplasty and stent.
5.  Congestive heart failure.
6.  History of Methicillin resistant Staphylococcus aureus L2
to 3 epidural abscess with incision and drainage in [**2144-7-15**].
7.  Recurrent line infections with Methicillin resistant
Staphylococcus aureus, VRE and Klebsiella.
8.  Thrombosis in right internal jugular, right subclavian
and right brachiocephalic veins in 10/[**2144**].
9.  Peptic ulcer disease.
10. Hypertension.
11. History of medication noncompliance.

MEDICATION ON ADMISSION: 1.  Epogen.
2.  Coumadin 4 mg p.o. q. day.
3.  Ambien 5 mg q. h.s.
4.  Amitriptyline 25 mg p.o. q. day.
5.  Protonix 40 mg p.o. q. day.
6.  Aspirin 325 mg p.o. q. day.
7.  Plavix 75 mg p.o. q. day.
8.  Norvasc 10 mg p.o. q. day.
9.  Enalapril 20 mg p.o. q. day.
10. Metoprolol 25 mg p.o. three times a day.
11. Tylenol p.r.n.
12. Senna p.r.n.
13. Colace p.r.n.
14. Tums with meals.
15. Regular insulin sliding scale.

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: The patient is married and is a nonsmoker
and nondrinker.
Infection and inflammatory reaction due to other vascular device, implant, and graft,Bacteremia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic airway obstruction, not elsewhere classified,Congestive heart failure, unspecified,Unspecified osteomyelitis, other specified sites,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Percutaneous transluminal coronary angioplasty status
React-oth vasc dev/graft,Bacteremia,Hyp kid NOS w cr kid V,Chr airway obstruct NEC,CHF NOS,Osteomyelit NOS-oth site,DMII renl nt st uncntrld,Status-post ptca
Admission Date:  [**2145-10-27**]       Discharge Date:  [**2145-11-13**]

Date of Birth:   [**2082-10-25**]       Sex:  M

Service:  MEDICINE

CHIEF COMPLAINT:   Fever.

HISTORY OF PRESENT ILLNESS:  This is a 63 year old primarily
Spanish speaking male with a history of end-stage renal
disease secondary to diabetes mellitus on dialysis.  The
patient also has a history of coronary artery disease,
chronic obstructive pulmonary disease, recurrent Methicillin
resistant Staphylococcus aureus/VRE dialysis catheter
infection and status post Methicillin resistant
Staphylococcus aureus epidural abscess of L2 to 3, status
post incision and drainage in [**2144-7-15**].  The patient is
now here from his outpatient hemodialysis center with a fever
up to 103.3 F., lethargy and back pain.  Per the hemodialysis
center notes the patient had a temperature the previous night
at home, however, he was afebrile at the beginning of his
hemodialysis session.  The patient was given Tylenol for his
back pain which did not help.  The patient also complained of
increased back pain.  His pain was mostly between the
shoulders.  Temperature came down to 101.8 F.  Blood cultures
were drawn times two.  The patient was given one gram of
Kefzol and 80 mg of intravenous Gentamicin and sent to the
[**Hospital1 69**] Emergency Department.

At [**Hospital1 69**], the patient was
given 1 gram of Vancomycin and 2 grams of ceftriaxone.  A
lumbar puncture was performed.  A head CT scan was performed
and was negative.  The patient received about a liter of
intravenous fluids.  Initially, the patient was only
minimally responsive and could only open his eyes, however,
he quickly perked up and after the antibiotics, he was alert
and oriented times three.  He complained of mild headache,
mostly bifrontal and mild neck pain as well as the thoracic
back pain.  The patient denied any chest pain or shortness of
breath.

PAST MEDICAL HISTORY:
1.  End-stage renal disease on hemodialysis.
2.  Diabetes mellitus, non-insulin dependent.
3.  Chronic obstructive pulmonary disease.
4.  One vessel coronary artery disease, status post
catheterization in [**8-/2145**]; status post left circumflex
percutaneous transluminal coronary angioplasty and stent.
5.  Congestive heart failure.
6.  History of Methicillin resistant Staphylococcus aureus L2
to 3 epidural abscess with incision and drainage in [**2144-7-15**].
7.  Recurrent line infections with Methicillin resistant
Staphylococcus aureus, VRE and Klebsiella.
8.  Thrombosis in right internal jugular, right subclavian
and right brachiocephalic veins in 10/[**2144**].
9.  Peptic ulcer disease.
10. Hypertension.
11. History of medication noncompliance.

MEDICATIONS ON ADMISSION:
1.  Epogen.
2.  Coumadin 4 mg p.o. q. day.
3.  Ambien 5 mg q. h.s.
4.  Amitriptyline 25 mg p.o. q. day.
5.  Protonix 40 mg p.o. q. day.
6.  Aspirin 325 mg p.o. q. day.
7.  Plavix 75 mg p.o. q. day.
8.  Norvasc 10 mg p.o. q. day.
9.  Enalapril 20 mg p.o. q. day.
10. Metoprolol 25 mg p.o. three times a day.
11. Tylenol p.r.n.
12. Senna p.r.n.
13. Colace p.r.n.
14. Tums with meals.
15. Regular insulin sliding scale.

SOCIAL HISTORY:  The patient is married and is a nonsmoker
and nondrinker.

FAMILY HISTORY:  Noncontributory.

PHYSICAL EXAMINATION:  Temperature 103.2 F.; blood pressure
128/44; pulse 88; respiratory rate 14; O2 saturation 100% on
two liters.  In general, the patient is alert and oriented
times three in no apparent distress.  HEENT:  Oropharynx
clear; anicteric.  Pupils equally round and reactive to light
and accommodation.  Extraocular movements are intact.  Neck
supple; no lymphadenopathy.  Generalized plethora and edema
of neck.  Cardiovascular:  Regular rate and rhythm, no
murmurs, gallops or rubs.  Lungs are clear to auscultation
bilaterally.  Chest:  Left sided Quinton dialysis catheter
without any surrounding erythema or exudate, nontender.  Back
with no costovertebral angle tenderness.  Minimal paraspinal
thoracic tenderness to palpation.  Extremities:  Cachectic;
no cyanosis, clubbing or edema.  Left sided AV fistula with
positive thrill.  Abdomen soft, nontender, nondistended.
Normoactive bowel sounds.  No hepatosplenomegaly, masses or
bruits.  Neurologic:  Alert and oriented times three.  No
focal signs.

LABORATORY:  White blood cell count 14.7 with a differential
of 92% neutrophils, 11% lymphocytes, hematocrit 34.3,
platelets 127, sodium 141, potassium 3.5, chloride 99,
bicarbonate 27, BUN 25, creatinine 3.5, glucose 224.  CK 22,
PT 16.4, PTT 42.7, INR 1.8.

Lumbar puncture tube #1, 9 white blood cells with 6% polys,
48% lymphocytes, 46% monocytes, 18 red blood cells.  Glucose
173.  Tube #2, white blood cells 9 with a differential of 2%
polys, 51% lymphocytes, 47% monocytes, 3 red blood cells and
a protein of 37.

Chest x-ray with poor inspiration, diffuse haziness but no
focal infiltrates.  Head CT scan with no evidence of bleeding
or masses.

EKG with normal sinus rhythm at 99 beats per minute.  T wave
inversions in I and AVL, [**Street Address(2) 4793**] depressions with T wave
inversions in V4 through V6.  Biphasic T waves in V2 to V3.
No old electrocardiograms accessible for comparison.

HOSPITAL COURSE:  In short, this is a 63 year old Spanish
speaking male with a history of end-stage renal disease on
hemodialysis, diabetes mellitus, coronary artery disease
status post left circumflex stent, chronic obstructive
pulmonary disease, history of recurrent dialysis catheter
infections with Methicillin resistant Staphylococcus aureus
and VRE, and history of Methicillin resistant Staphylococcus
aureus epidural abscess, who now presents with fever,
lethargy, back pain and headache.

1.  INFECTIOUS DISEASE:  The patient did not have any further
high spikes after being admitted.  He had only low spikes for
a couple of days and then was afebrile afterwards.  The
patient had blood cultures drawn in the Emergency Department.
These were negative without any growth.  The patient's fever
was presumed to be secondary to his left sided Quinton
catheter, even though it did not show any obvious signs of
infection.  The patient was kept on a regimen of Vancomycin
and Gentamicin for broad coverage.

Of note, the patient's blood cultures from his dialysis
center were found to be positive, growing four out of four
tubes of Methicillin sensitive Staphylococcus aureus.  This
was found to be overall pan sensitive, only resistant to
penicillin, Ampicillin and tetracycline.  However, the MIC
was only low for oxacillin at a level of 0.25.  For this
reason, the patient was switched from Vancomycin and
Gentamicin to intravenous Oxacillin at a dose of 1 gram q.
four hours.  His Quinton dialysis line was pulled after
dialysis was started with his left AV fistula.  The Quinton
tip also grew Methicillin sensitive Staphylococcus aureus.

The patient was unable to have a right sided PICC line placed
because of the extensive network of clots in his right
internal jugular, subclavian and brachiocephalic veins.
However, a midline catheter was successfully placed on [**11-4**].
The patient was continued on intravenous Oxacillin.

Because the patient was also having back pain, and given his
history of an epidural abscess, there was a concern that he
might have seeded his vertebrae, thus causing osteomyelitis.
The patient received an MRI of the spine.  This was negative
for an epidural abscess, but did show increased signal and
paravertebral swelling anterior to C3 through 5, suspicious
for osteomyelitis.  Even though this is not the area where
the patient was having pain, it was decided that the patient
should be treated for presumed osteomyelitis for a total of
six weeks on antibiotics.

Given that the patient was bacteremic with Methicillin
sensitive Staphylococcus aureus, there was also concern that
he may have seeded his heart valves.  The patient had a
transthoracic echocardiogram a couple of days after
admission.  This showed low normal left ventricular ejection
fraction, small ASD, but only mild mitral regurgitation and
no change in his valves.  A transesophageal echocardiogram
was planned for [**11-4**], but during the procedure, the patient
was unable to tolerate the tube and therefore it was aborted.

2.  ACCESS:  As already noted, the patient came in with a
left sided Quinton catheter.  He also had an AV fistula with
a positive thrill that had been placed in [**2145-7-15**], but
had not been used yet.  The Quinton catheter was taken out
after the AV fistula was tested and found to be usable.  A
midline catheter was placed in the right side for intravenous
antibiotics.  Unfortunately, after a couple of sessions of
dialysis, it was realized that there was not good blood flow
going through the left sided AV fistula.

The patient initially had an AV fistula ultrasound and then
an AV fistulogram.  This revealed the stenosis between the
arterial and venous components.  The patient had an
angioplasty to open up the AV fistula.  This was performed by
Transplant Surgery.  As a temporary measure, the patient
received a central line for dialysis through his left sided
EJ.  Transplant Surgery's recommendation was to leave the AV
fistula alone for one to two weeks following the angioplasty
and then to retest it.

3.  CARDIOVASCULAR:  The patient's initial presentation had
some concerning T wave and ST changes on his EKG even though
an old EKG was not accessible.  The patient was ruled out by
serial cardiac enzymes.  He had no episodes of chest pain or
shortness of breath.  The patient was kept on his regimen of
aspirin, Plavix, Lopressor, and Enalapril for cardiac health.
The patient also received a Nitroglycerin patch.

4.  HEMATOLOGIC:  The patient has a history of right sided
clots in his internal jugular, subclavian, brachiocephalic
veins; for this reason, he is on anticoagulation.  Because of
all the interventional procedures performed, the patient was
mostly off of Coumadin, but was kept on a heparin drip
towards the end of his stay.  We were just waiting for his
Coumadin to become therapeutic.  He was placed on 7.5 mg of
Coumadin.  His INR on [**2145-11-12**], was 1.6.  It was expected
to become therapeutic by [**2145-11-13**], with a goal range of
probably between 2.0 to 3.0.

5.  RENAL:  The patient is followed closely by the Renal
Team.  He received hemodialysis every Monday, Wednesday and
Friday.  There were no further complications during
hemodialysis including fever, hypotension, or volume
overload.

CONDITION AT DISCHARGE:   Good.

DISCHARGE MEDICATIONS:
1.  Coumadin 7.5 mg p.o. q. day.
2.  Calcium carbonate 1000 mg p.o. three times a day, taken
with meals.
3.  Oxacillin 1 gram intravenous q. four hours, to be taken
until [**2145-12-13**].
4.  Sarna lotion, one application topically twice a day
p.r.n.
5.  Nitroglycerin Ointment 2%, 0.5 inches topically q. six
hours.
6.  Ambien 5 mg p.o. q. h.s. p.r.n.
7.  Percocet one tablet p.o. q. four to six hours p.r.n. back
pain.
8.  Nitroglycerin 0.3 mg sublingually p.r.n. chest pain.
9.  Milk of Magnesia 15 to 30 ml p.o. four times a day p.r.n.
10. Bisacodyl 10 mg p.o./p.r. q. day p.r.n.
11. Lopressor 100 mg p.o. three times a day; hold for
systolic blood pressure less than 100, pulse less than 60.
12. Norvasc 10 mg p.o. q. day.
13. Enalapril 20 mg p.o. q. day.
14. Plavix 75 mg p.o. q. day.
15. Enteric coated aspirin 325 mg p.o. q. day.
16. Protonix 40 mg p.o. q. 24 hours.
17. Amitriptyline 25 mg p.o. q. h.s.
18. Colace 100 mg p.o. twice a day.
19. Senna two tablets p.o. q. day.
20. Tylenol 325 to 650 mg p.o. q. four to six hours p.r.n.
21. Lantus 15 units subcutaneously q. a.m.
22. Regular insulin sliding scale.

DISCHARGE INSTRUCTIONS:
1.  The patient is to be discharged to East Point
Rehabilitation once his INR is within therapeutic range.
2.  The patient will follow-up with his renal doctors.
3.  The patient will continue to receive hemodialysis every
Monday, Wednesday and Friday.
4.  The patient will also need to be seen for removal of his
temporary external jugular dialysis catheter once his AV
fistula is retested and working again.

DISCHARGE DIAGNOSES:
1.  Methicillin sensitive Staphylococcus aureus bacteremia,
now resolved.
2.  Osteomyelitis.
3.  End-stage renal disease on hemodialysis.
4.  Diabetes mellitus.
5.  Coronary artery disease, status post left circumflex
stent.


                            [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D.  [**MD Number(1) 736**]

Dictated By:[**Name8 (MD) 3839**]
MEDQUIST36

D:  [**2145-11-12**]  13:40
T:  [**2145-11-12**]  13:49
JOB#:  [**Job Number 34027**]
{'Infection and inflammatory reaction due to other vascular device, implant, and graft,Bacteremia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic airway obstruction, not elsewhere classified,Congestive heart failure, unspecified,Unspecified osteomyelitis, other specified sites,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Percutaneous transluminal coronary angioplasty status'}


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: Fever.

PRESENT ILLNESS: This is a 63 year old primarily
Spanish speaking male with a history of end-stage renal
disease secondary to diabetes mellitus on dialysis.  The
patient also has a history of coronary artery disease,
chronic obstructive pulmonary disease, recurrent Methicillin
resistant Staphylococcus aureus/VRE dialysis catheter
infection and status post Methicillin resistant
Staphylococcus aureus epidural abscess of L2 to 3, status
post incision and drainage in [**2144-7-15**].  The patient is
now here from his outpatient hemodialysis center with a fever
up to 103.3 F., lethargy and back pain.  Per the hemodialysis
center notes the patient had a temperature the previous night
at home, however, he was afebrile at the beginning of his
hemodialysis session.  The patient was given Tylenol for his
back pain which did not help.  The patient also complained of
increased back pain.  His pain was mostly between the
shoulders.  Temperature came down to 101.8 F.  Blood cultures
were drawn times two.  The patient was given one gram of
Kefzol and 80 mg of intravenous Gentamicin and sent to the
[**Hospital1 69**] Emergency Department.

MEDICAL HISTORY: 1.  End-stage renal disease on hemodialysis.
2.  Diabetes mellitus, non-insulin dependent.
3.  Chronic obstructive pulmonary disease.
4.  One vessel coronary artery disease, status post
catheterization in [**8-/2145**]; status post left circumflex
percutaneous transluminal coronary angioplasty and stent.
5.  Congestive heart failure.
6.  History of Methicillin resistant Staphylococcus aureus L2
to 3 epidural abscess with incision and drainage in [**2144-7-15**].
7.  Recurrent line infections with Methicillin resistant
Staphylococcus aureus, VRE and Klebsiella.
8.  Thrombosis in right internal jugular, right subclavian
and right brachiocephalic veins in 10/[**2144**].
9.  Peptic ulcer disease.
10. Hypertension.
11. History of medication noncompliance.

MEDICATION ON ADMISSION: 1.  Epogen.
2.  Coumadin 4 mg p.o. q. day.
3.  Ambien 5 mg q. h.s.
4.  Amitriptyline 25 mg p.o. q. day.
5.  Protonix 40 mg p.o. q. day.
6.  Aspirin 325 mg p.o. q. day.
7.  Plavix 75 mg p.o. q. day.
8.  Norvasc 10 mg p.o. q. day.
9.  Enalapril 20 mg p.o. q. day.
10. Metoprolol 25 mg p.o. three times a day.
11. Tylenol p.r.n.
12. Senna p.r.n.
13. Colace p.r.n.
14. Tums with meals.
15. Regular insulin sliding scale.

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: The patient is married and is a nonsmoker
and nondrinker. 

### Response:
{'Infection and inflammatory reaction due to other vascular device, implant, and graft,Bacteremia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic airway obstruction, not elsewhere classified,Congestive heart failure, unspecified,Unspecified osteomyelitis, other specified sites,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Percutaneous transluminal coronary angioplasty status'}
