CHIEF COMPLAINT: Fever

PRESENT ILLNESS: 85 yo male s/p recent hospitalization for colectomy and
splenectomy complicated by anastomotic leak and treated with a
diverting ileostomy with g-j tube placement and appendectomy. He
was discharged to rehab and returned less than 1 week later with
fever and acute renal failure.

MEDICAL HISTORY: HTN
Hiatal hernia
TIA (on Plavix)
Asthma
Spinal stenosis
AR and MR (requires SBE prophylaxis)

MEDICATION ON ADMISSION: Plavix 75'
Flomax 0.4'
Cozaar 50'
Lipitor 10'
Lopressor 25"

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Gen: NAD, AAOx3
CV: RRR
Pulm: some coarse BS bilat
Abd: soft, NT, wound open and packed, ostomy intact
Ext: no c/c/e

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Married and lives with wife
[**Name (NI) **] in [**Name (NI) 108**] during winter months
Other pulmonary embolism and infarction,Other colostomy and enterostomy complication,Mitral valve insufficiency and aortic valve insufficiency,Acute kidney failure, unspecified,Dehydration,Unspecified essential hypertension,Asthma, unspecified type, unspecified,Spinal stenosis, unspecified region,Personal history of malignant neoplasm of gastrointestinal tract, unspecified,Intestinal bypass or anastomosis status
Pulm embol/infarct NEC,Colstmy/enteros comp NEC,Mitral/aortic val insuff,Acute kidney failure NOS,Dehydration,Hypertension NOS,Asthma NOS,Spinal stenosis NOS,Hx of GI malignancy NOS,Intestinal bypass status
Admission Date:  [**2136-1-12**]              Discharge Date:   [**2136-1-23**]


Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
Fever

Major Surgical or Invasive Procedure:
None


History of Present Illness:
85 yo male s/p recent hospitalization for colectomy and
splenectomy complicated by anastomotic leak and treated with a
diverting ileostomy with g-j tube placement and appendectomy. He
was discharged to rehab and returned less than 1 week later with
fever and acute renal failure.

Past Medical History:
HTN
Hiatal hernia
TIA (on Plavix)
Asthma
Spinal stenosis
AR and MR (requires SBE prophylaxis)

Social History:
Married and lives with wife
[**Name (NI) **] in [**Name (NI) 108**] during winter months


Family History:
Noncontributory

Physical Exam:
Gen: NAD, AAOx3
CV: RRR
Pulm: some coarse BS bilat
Abd: soft, NT, wound open and packed, ostomy intact
Ext: no c/c/e

Pertinent Results:
[**2136-1-12**] 06:10PM   GLUCOSE-98 UREA N-49* CREAT-1.5* SODIUM-134
POTASSIUM-5.3* CHLORIDE-105 TOTAL CO2-20* ANION GAP-14
[**2136-1-12**] 06:10PM   CALCIUM-9.4 PHOSPHATE-4.1 MAGNESIUM-2.2
[**2136-1-12**] 06:10PM   WBC-13.9* RBC-3.75* HGB-11.9* HCT-35.0*
MCV-94 MCH-31.7 MCHC-33.9 RDW-17.1*
[**2136-1-12**] 06:10PM   PLT COUNT-418

    Cardiology Report ECHO Study Date of [**2136-1-13**]



PATIENT/TEST INFORMATION:
Indication: Left ventricular function. Pulmonary embolus. Right
ventricular function.
Height: (in) 67
Weight (lb): 185
BSA (m2): 1.96 m2
BP (mm Hg): 129/54
HR (bpm): 56
Status: Inpatient
Date/Time: [**2136-1-13**] at 10:41
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007W006-0:13
Test Location: West SICU/CTIC/VICU
Technical Quality: Adequate




REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]

MEASUREMENTS:
Left Atrium - Long Axis Dimension: *4.2 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *5.7 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *5.1 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.5 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.5 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.1 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 2.3 cm
Left Ventricle - Fractional Shortening: 0.44 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 60% to 65% (nl >=55%)
Aorta - Valve Level: *3.7 cm (nl <= 3.6 cm)
Aorta - Ascending: *3.7 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.7 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 0.9 m/sec
Mitral Valve - E/A Ratio: 0.89
Mitral Valve - E Wave Deceleration Time: 368 msec
TR Gradient (+ RA = PASP): 19 mm Hg (nl <= 25 mm Hg)

INTERPRETATION:

Findings:

This study was compared to the report of the prior study (images
not
available) of [**2134-6-29**].


LEFT ATRIUM: Mild LA enlargement. Elongated LA.

RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. The IVC is
normal in
diameter with >50% decrease collapse during respiration
(estimated RAP [**4-12**]
mmHg).

LEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size.
Normal regional
LV systolic function. Overall normal LVEF (>55%). Transmitral
Doppler and TVI
c/w Grade I (mild) LV diastolic dysfunction. No resting LVOT
gradient.

RIGHT VENTRICLE: Normal RV chamber size and free wall motion.

AORTA: Mildly dilated aortic sinus. Mildly dilated ascending
aorta.

AORTIC VALVE: Moderately thickened aortic valve leaflets. No AS.
Trace AR.

MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild mitral
annular calcification. Mild thickening of mitral valve chordae.
Trivial MR. LV
inflow pattern c/w impaired relaxation.

TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.

PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.

PERICARDIUM: Trivial/physiologic pericardial effusion.

GENERAL COMMENTS: Suboptimal image quality - poor apical views.
The patient
appears to be in sinus rhythm.

Conclusions:
The left atrium is mildly dilated. The left atrium is elongated.
The estimated
right atrial pressure is 5-10 mmHg. There is moderate symmetric
left
ventricular hypertrophy. The left ventricular cavity size is
normal. Regional
left ventricular wall motion is normal. Overall left ventricular
systolic
function is normal (LVEF>55%). Transmitral Doppler and tissue
velocity imaging
are consistent with Grade I (mild) LV diastolic dysfunction.
Right ventricular
chamber size and free wall motion are normal. The aortic root is
mildly
dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic
valve leaflets are moderately thickened with focal calcification
of the
noncoronary cusp. There is no aortic valve stenosis.Trace aortic
regurgitation
is seen. Trivial mitral regurgitation is seen. There is a
trivial/physiologic
pericardial effusion.

IMPRESSION: Moderate symmetric LVH. Normal left ventricular
systolic function.

Compared with the report of the prior study (images unavailable
for review) of
[**2134-6-29**], there is no significant change.

CTA CHEST W&W/O C&RECONS, NON-

Reason: r/o PE
Contrast: OPTIRAY

[**Hospital 93**] MEDICAL CONDITION:
85 year old man with concern for PE.
REASON FOR THIS EXAMINATION:
r/o PE
CONTRAINDICATIONS for IV CONTRAST: None.

EXAMINATION: CT of the chest with and without contrast dated
[**2136-1-13**].

COMPARISON: CT of the abdomen dated [**2136-1-12**].

INDICATION: Question pulmonary embolism.

TECHNIQUE: Axial imaging was obtained through the chest before
and after the administration of IV contrast.

FINDINGS FOR CT OF THE CHEST WITH AND WITHOUT IV CONTRAST: There
is heavy atherosclerotic calcification of the thoracic aorta and
great vessels. There is cardiomegaly and coronary artery
calcification. There is no pericardial effusion.

After administration of IV contrast there is evidence of
thrombus in the right main pulmonary artery as well as segmental
and subsegmental branches of the right upper lobe pulmonary
arteries. No thrombus is seen within the left pulmonary
arteries. Small mediastinal lymph nodes are demonstrated which
are numerous but not enlarged by CT criteria. Scattered air
space disease is seen within the right middle lobe and right
lower lobe which may represent atelectasis, infection, or
infarction given evidence of pulmonary embolism. There is
bibasilar atelectasis. There is no evidence of pneumothorax or
pleural effusion.

Limited imaging of the upper abdomen demonstrates evidence of
splenectomy with small fluid collection in the left upper
quadrant measuring 3 cm which contains gas consistent with
post-surgical changes. Small amount of fluid measuring 2.4 cm x
1.6 cm is seen adjacent to the pancreatic tail.

IMPRESSION:
1. Evidence of pulmonary embolism on the right as described with
air space consolidation within the right middle and right lower
lobes which may represent atelectasis, infection, or pulmonary
infarction given evidence of pulmonary embolism.

2. Limited evaluation of post-surgical changes in the left upper
quadrant as seen on prior CT abdomen and pelvis. Findings were
discussed with the resident taking care of the patient at
completion of the examination.

Reason: S/P RECENT SURGERY NOW TACHYPNEIC EVAL FOR PE

RADIOPHARMECEUTICAL DATA:
7.1 mCi Tc-[**Age over 90 **]m MAA ([**2136-1-12**]);
44.0 mCi Tc-99m DTPA Aerosol ([**2136-1-12**]);
HISTORY: S/P RECENT SURGERY NOW TACHYPNEIC EVAL FOR PE

INTERPRETATION:
Ventilation images obtained with Tc-[**Age over 90 **]m aerosol in 8 views
demonstrate marked
central clumping consistent with airways disease. There is
diffuse irregularity
of tracer uptake within the lung parenchyma.

Perfusion images in the same 8 views show multiple large
peripheral wedge-shaped
defects in the right lung. Perfusion irregularity of the left
lung is much less
pronounced than the right.

Chest x-ray shows a left lower lobe opacity.

While the above findings may in part be attributed to airways
disease, they are
concerning for pulmonary embolism and consistent with a
moderately high
probability for pulmonary embolism.

IMPRESSION: Moderate-High Likelihood for pulmonary embolism.






Brief Hospital Course:
He was admitted to the Surgery Service under the care of Dr.
[**Last Name (STitle) **]. He underwent a lung scan which revealed moderate to high
probability of pulmonary embolus. CTA of the chest was done
following the lung scan which revealed a thrombus in the right
pulmonary artery. He was started on a Heparin drip and later
started on Coumadin and Lovenox as a bridge until his INR
becomes therapeutic.

On HD #5 he experienced episode of increased shortness of breath
and chest pressure after performing morning ADL's; EKG and CXR
were all normal; his CK and troponin were flat. He again
experienced a similar episode on HD #7, EKG without change
compared to previous one; chest radiograph performed and pending
at time of this dictation. This episode was proceeded by a
session of chest physiotherapy and resolved shortly after that.
His supplemental oxygen was discontinued at that time as his
room air saturations were 95%.

On HD #8 he was noted to have guaiac positive stool via his
ileostomy. His Coumadin was stopped; the Lovenox was changed to
Heparin and he remained on the Plavix. His hematocrits were as
follows:

[**2136-1-20**] 01:20AM          32.6*
[**2136-1-19**] 09:00PM          34.6*
[**2136-1-19**] 07:14PM          32.6*
[**2136-1-19**] 09:30AM          33.5*
A GI consult was obtained and recommendations for scoping were
made. The scope showed: The first stoma was examined. We reached
50 cm and found no blood and normal ileal mucosa with bile.
The second the stoma was examined and initially normal ileal
mucosa was seen aprox 15 cm. Following 15 cm, colonic mucosa was
observed. Multiple polyps were seen.
Polyp in the 25 cm
Polyp in the 30 cm
Otherwise normal colonoscopy to anastomosis
Recommendations: Pt will need a repeat colonscopy once he is off
his coumadin
Monitor hct


Physical therapy was consulted and have recommended rehab stay
following his acute hospitalization.
The patient has continued to progrss well, tolerating a normal
diet and having O2 sats in the high 90's on room air. His HCt
has remained stable and he is discharged in stable condition to
rehab to followup with Dr. [**Last Name (STitle) **] and with Dr. [**First Name (STitle) 679**] of
gastroenterology. He will remain on lovenox until his INR is at
a therapeutic range of [**1-7**] at which point the lovenox will be
stopped and he will be continued on coumadin only for
anticoagulation.

Medications on Admission:
Plavix 75'
Flomax 0.4'
Cozaar 50'
Lipitor 10'
Lopressor 25"

Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol [**Date Range **]: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
2. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Date Range **]: Two (2)
Puff Inhalation QID (4 times a day).
3. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR [**Date Range **]: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
4. Atorvastatin 10 mg Tablet [**Date Range **]: One (1) Tablet PO at bedtime.

5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Date Range **]: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Acetaminophen 325 mg Tablet [**Date Range **]: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
7. Warfarin 2 mg Tablet [**Date Range **]: One (1) Tablet PO HS (at bedtime):
Adjust daily dose based on INR.
8. Metoprolol Tartrate 50 mg Tablet [**Date Range **]: Two (2) Tablet PO TID
(3 times a day): hold for HR <60; SBP <110.
9. Losartan 50 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily).
10. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup [**Date Range **]: Five
(5) ML PO Q6H (every 6 hours) as needed for cough.
11. Clopidogrel 75 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY
(Daily).
12. Colace 100 mg Capsule [**Date Range **]: One (1) Capsule PO twice a day as
needed for constipation.
13. Milk of Magnesia 800 mg/5 mL Suspension [**Date Range **]: Ten (10) ML's
PO twice a day as needed for constipation.
14. Enoxaparin 100 mg/mL Syringe [**Date Range **]: Seventy (70) mg
Subcutaneous Q12H (every 12 hours): discontinue after
therapeutic INR ([**1-7**]) reached on warfarin.


Discharge Disposition:
Extended Care

Facility:
[**Hospital **] rehab [**Location (un) 3915**]

Discharge Diagnosis:
Pulmonary embolus


Discharge Condition:
Stable


Discharge Instructions:
Please call or return if you have a fever >101.5, severe pain,
inability to pass gas or stool, nausea/vomiting, chest pain,
shortness of breath, drainage from the wound, or any other
concerns.

Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] in 2 weeks, call [**Telephone/Fax (1) 6439**] for an
appointment.
Please call for a followup with GI, Dr. [**First Name (STitle) 679**], ([**Telephone/Fax (1) 16940**] for
a repeat ileoscopy.



Completed by:[**2136-1-23**]
{'Other pulmonary embolism and infarction,Other colostomy and enterostomy complication,Mitral valve insufficiency and aortic valve insufficiency,Acute kidney failure, unspecified,Dehydration,Unspecified essential hypertension,Asthma, unspecified type, unspecified,Spinal stenosis, unspecified region,Personal history of malignant neoplasm of gastrointestinal tract, unspecified,Intestinal bypass or anastomosis 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: 85 yo male s/p recent hospitalization for colectomy and
splenectomy complicated by anastomotic leak and treated with a
diverting ileostomy with g-j tube placement and appendectomy. He
was discharged to rehab and returned less than 1 week later with
fever and acute renal failure.

MEDICAL HISTORY: HTN
Hiatal hernia
TIA (on Plavix)
Asthma
Spinal stenosis
AR and MR (requires SBE prophylaxis)

MEDICATION ON ADMISSION: Plavix 75'
Flomax 0.4'
Cozaar 50'
Lipitor 10'
Lopressor 25"

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Gen: NAD, AAOx3
CV: RRR
Pulm: some coarse BS bilat
Abd: soft, NT, wound open and packed, ostomy intact
Ext: no c/c/e

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Married and lives with wife
[**Name (NI) **] in [**Name (NI) 108**] during winter months 

### Response:
{'Other pulmonary embolism and infarction,Other colostomy and enterostomy complication,Mitral valve insufficiency and aortic valve insufficiency,Acute kidney failure, unspecified,Dehydration,Unspecified essential hypertension,Asthma, unspecified type, unspecified,Spinal stenosis, unspecified region,Personal history of malignant neoplasm of gastrointestinal tract, unspecified,Intestinal bypass or anastomosis status'}
