CHIEF COMPLAINT: 

PRESENT ILLNESS: Mr. [**Known lastname **] is a 54 year old
gentleman with a history of supraventricular tachycardia,
hypothyroidism, hypercholesterolemia who was transferred from
[**Hospital 1263**] Hospital to [**Hospital6 256**]
[**2132-11-20**] for failure to wean from ventilator and
persistent fevers.  Please see [**Hospital 1263**] Hospital discharge
summary for further details of his initial presentation and
hospital course there.

MEDICAL HISTORY: 1.  History of supraventricular tachycardia
2.  Hypothyroidism, status post thyroidectomy in [**2120**]
3.  Hypercholesterolemia
4.  Neuralgia

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies on admission.  During
admission Haldol was noted to cause seizures.

PHYSICAL EXAM: 

FAMILY HISTORY: Mother has diabetes mellitus and coronary
artery disease.

SOCIAL HISTORY: Mr. [**Known lastname **] works as a history professor at a
nearby community college.  He smokes two packs per day.  He
drinks occasional alcohol.  He has a wife and two children.
Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia],Pneumococcal septicemia [Streptococcus pneumoniae septicemia],Acute respiratory failure,Iatrogenic pulmonary embolism and infarction,Other convulsions,Other specified cardiac dysrhythmias,Acute bronchitis,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Unspecified acquired hypothyroidism
Pneumococcal pneumonia,Pneumococcal septicemia,Acute respiratry failure,Iatrogen pulm emb/infarc,Convulsions NEC,Cardiac dysrhythmias NEC,Acute bronchitis,Mth sus Stph aur els/NOS,Hypothyroidism NOS
Admission Date:  [**2132-11-20**]       Discharge Date:  [**2132-12-10**]

Date of Birth:   [**2078-9-26**]       Sex:  M

Service:

HISTORY OF PRESENT ILLNESS:  Mr. [**Known lastname **] is a 54 year old
gentleman with a history of supraventricular tachycardia,
hypothyroidism, hypercholesterolemia who was transferred from
[**Hospital 1263**] Hospital to [**Hospital6 256**]
[**2132-11-20**] for failure to wean from ventilator and
persistent fevers.  Please see [**Hospital 1263**] Hospital discharge
summary for further details of his initial presentation and
hospital course there.

In brief, he presented to [**Hospital 1263**] Hospital [**2132-11-8**]
complaining of shortness of breath for two days following a
recent upper respiratory tract infection two weeks prior to
admission.  On admission he was tachypneic to the 40s,
hypoxic to 93% on 100% nonrebreather, tachycardiac to 180 and
hypotensive.  Labs were notable for a white blood count of 5
with 49% neutrophils and 40% bands.  Chest x-ray revealed
left lower lobe and possibly right lower lobe infiltrates.
Blood cultures grew out six out of six bottles with
Streptococcus pneumoniae.  He was begun empirically on Unasyn
and the Azithromycin which was subsequently switched to
Vancomycin when an organism was identified.  On [**11-11**],
he was switched to Penicillin when the organism was found to
be pansensitive.  Despite therapy, he continued to spike
fevers to 101 to 102 on a daily basis despite subsequent
cultures being negative.  He had an exhaustive workup for
alternative etiology of his persistent fevers including right
upper quadrant ultrasound which was negative for
cholecystitis, lower extremity noninvasives which were
negative for deep vein thrombosis, chest computerized
tomography scan which was negative for empyema.  An
echocardiogram was negative for endocarditis.  He did have a
head computerized axial tomography scan which revealed
sinusitis.  Gram stain and cultures of sputum and nasal swabs
revealed Pseudomonas aeruginosa and so Levofloxacin was added
to his regimen.  On [**11-19**], per Infectious Disease
consult recommendation, Penicillin and Levofloxacin were
discontinued and he was switched to Ceftazidime and
Gentamicin to treat his pneumococcal pneumonia and
Pseudomonas sinusitis.  On the day of transfer, he was also
started on empirically on Flagyl and p.o. Vancomycin for
oppression of Clostridium difficile, however, Clostridium
difficile toxin subsequently returned negative.  Despite all
of these treatments, he continued to spike fevers on a daily
basis.

His hospital course at [**Doctor Last Name 1263**] was also notable for
respiratory failure.  He was intubated on admission for
hypoxic respiratory failure which was felt to be due to his
pneumonia, presumably from pneumococcus, although this
organism was never cultured from his sputum, only from his
blood.  It is not clear whether he was attempted to be weaned
from the ventilator, but he required persistent sedation, due
to tachypnea to the 50s and desaturation whenever attempts at
weaning sedation were made.

His tachycardia and hypotension on admission was felt likely
due to sepsis.  His hemodynamics stabilized with fluids,
Dopamine, and antibiotics by hospital day #3 and he was able
to be weaned off of Dopamine at that time.  He ruled out for
a myocardial infarction and echocardiogram [**11-17**]
revealed ejection fraction of 75% with mild left ventricular
hypokinesis.

Mr. [**Known lastname **] was transferred to [**Hospital6 2018**] [**2132-11-20**] for persistent fevers and inability
to wean from the ventilator.

PAST MEDICAL HISTORY:
1.  History of supraventricular tachycardia
2.  Hypothyroidism, status post thyroidectomy in [**2120**]
3.  Hypercholesterolemia
4.  Neuralgia

ALLERGIES:  No known drug allergies on admission.  During
admission Haldol was noted to cause seizures.

MEDICATIONS ON TRANSFER:
1.  Ceftazidime 1 gm intravenously q. 8 hours (day #2)
2.  Gentamicin 160 mg intravenously q. 12 hours (day #2)
3.  Vancomycin 250 mg p.o. q. 6 hours, (day #1)
4.  Flagyl 500 mg intravenously q. 6 hours (day #1)
5.  Albuterol metered dose inhaler 4 to 6 puffs q.i.d. prn
6.  Tylenol prn
7.  Propofol drip (3 mcg/kg)
8.  Ativan drip (3 mg/hr)
9.  Pepcid 20 mg q.d.
10. Heparin 5000 units subcutaneously b.i.d.
11. Haldol prn agitation
12. Total parenteral nutrition

SOCIAL HISTORY:  Mr. [**Known lastname **] works as a history professor at a
nearby community college.  He smokes two packs per day.  He
drinks occasional alcohol.  He has a wife and two children.

FAMILY HISTORY:  Mother has diabetes mellitus and coronary
artery disease.

PHYSICAL EXAMINATION:  On admission he was intubated and
sedated.  Temperature is 101.4, heartrate 78, blood pressure
128/50, respiratory rate 20 to 30.  Ventilatory settings were
pressure support 20, positive end-expiratory pressure 5, FIO2
40%, pulling title volumes of 850 cc.  Pupils were equal,
round, and reactive to light.  Neck was supple.  There was no
jugulovenous distension or lymphadenopathy.  Heart had a
regular rate and rhythm with normal S1 and S2 and no murmurs,
rubs or gallops.  Lungs had decreased breathsounds at the
left base with bronchial breathsounds in the left lower lobe.
Abdomen had normoactive bowel sounds, was obese and soft.
There was no hepatosplenomegaly.  Extremities showed no
edema, clubbing or cyanosis.  On neurological examination he
was sedated without spontaneous movements.

LABORATORY DATA:  (On transfer)  White blood cell count was
8.9, hematocrit 27.5, platelets 415, sodium 142, potassium
3.7, chloride 109, bicarbonate 24, BUN 27, creatinine 0.8,
glucose 166, calcium 8, magnesium 2.1, phosphate 3.6.
Arterial blood gases showed pH 7.46, pCO2 31, pO2 128.
Culture data and imaging studies as in history of present
illness and hospital course.

HOSPITAL COURSE:  (By system)  1.  Infectious disease - On
transfer his antibiotics were switched to Levofloxacin 500 mg
intravenously q.d. and Ceftazidime 1 gm intravenously q. 8
hours.  It was issued adequately that two organisms had been
cultured to date - 1.  Streptococcus pneumoniae which had
been cultured from his blood at [**Doctor Last Name 1263**] and was presumed for
sepsis pneumonia and sepsis; 2.  Pseudomonas which had been
cultured from endotracheal secretions at [**Doctor Last Name 1263**] and was felt
to be a cause of sinusitis.  Despite this coverage, he
remained persistently febrile to 101 to 102 on a daily basis.
The Infectious Disease Service was consulted, and an
exhaustive workup was continued to determine the source of
these fevers.  He underwent a chest computerized tomography
scan to evaluate for possible empyema, which revealed
resolving left lower lobe infiltrate and only small
uncomplicated pleural effusion, not enough fluid to tap
safely.  Sinus computerized tomography scan was repeated here
which did reveal sinusitis and Otorhinolaryngology was
consulted.  They were not too impressed with the sinusitis as
the cause of his fevers.  An abdominal computerized
tomography scan was negative for any intra-abdominal source.
The lumbar puncture was negative.  Head magnetic resonance
imaging scan was negative for intracranial source other than
the known sinusitis.  Transthoracic and transesophageal
echocardiograms were negative for endocarditis.  All of his
lines were switched on more than one occasion.  He was
repeatedly pancultured and all cultures were negative at this
hospital, with the exception of one culture from an arterial
line which subsequently grew out Staphylococcus
epidermidis-the arterial line was discontinued and Vancomycin
was begun on [**2132-11-26**].  Sputum cultures from [**11-26**] also grew out Methicillin-resistant Staphylococcus aureus,
and this in the setting of increasing respiratory secretion
became an indication for continuing Vancomycin for
Methicillin-resistant Staphylococcus aureus
tracheobronchitis.  Furthermore, when he developed worsening
purulent nasal secretions on [**11-27**] and head imaging
revealed worsening sinusitis, Otorhinolaryngology was
reconsulted and performed maxillary sinus biopsy.  The gram
stain was negative, but the culture subsequently grew out
Methicillin-resistant Staphylococcus aureus.  Drugs were also
considered as a cause of his fevers and on [**11-26**],
Ceftazidime was discontinued given that the Pseudomonas was
only grown from endotracheal suctioning at an outside
hospital and was not felt to be a pathogen.  Finally, chest
computerized tomography scan on [**11-26**] was positive for
bilateral pulmonary emboli suggesting this as a possible
contributing source of his fevers.

In summary, his fevers were felt to be multifactorial due to
pneumococcal pneumonia and sepsis initially followed by
pulmonary emboli and Methicillin-resistant Staphylococcus
aureus tracheobronchitis.  There also might have been some
contribution of a reaction to medications.  By [**2132-12-6**], his fever curve had decreased to only lowgrade
temperature to 99.  He did have a transient fever spike to
102 in the setting of a seizure on [**2132-12-8**], but has
since defervesced.  At the present time, he had only lowgrade
fevers to 99 and his white blood cell count is normal.  He
finished a 21 day course of Levofloxacin for pneumococcal
pneumonia and sepsis on [**2132-12-3**], and a one course
of Vancomycin for Methicillin-resistant Staphylococcus aureus
tracheobronchitis [**2132-12-6**].  Finally, he is being
anticoagulated for pulmonary emboli.

2.  Respiratory - He was intubated on admission to [**Hospital 1263**]
Hospital [**2132-11-8**] for hypoxic respiratory failure
felt to be due to pneumococcal pneumonia and sepsis.  At
[**Doctor Last Name 1263**] he remained sedated and unable to be weaned from the
ventilator due to tachypnea and desaturation.  Upon transfer
to [**Hospital6 256**] his sedation was
weaned but he was noted to have difficulty weaning from the
ventilator due to rapid shallow breathing.  He was
subsequently diagnosed with bilateral pulmonary emboli by
chest computed tomographic angiography [**2132-11-26**] and
begun on heparin.  Despite heparin treatment for his
pulmonary emboli and antibiotics for his pneumonia with
evidence of resolving pneumonia by computerized tomography
scan, he remained unable to be weaned due to rapid shallow
breathing.  It was felt that there was also a component of
muscular weakness to prolonged illness and intubation
contributing to this difficulty.  He is status post
tracheostomy [**2132-11-28**].  By [**2132-12-5**] he was
able to be weaned off of the ventilator and doing well on
tracheostomy mask.  He was transiently placed back on the
ventilator [**12-8**] to [**12-9**] in the setting of a
seizure, but has since been transitioned back to the
tracheostomy mask on which he is doing well.

3.  Cardiovascular - He has been stable from a cardiovascular
standpoint throughout his hospitalization at [**Hospital6 1760**] on Lopressor 50 mg b.i.d. for
hypertension and paroxysmal supraventricular tachycardia.

4.  Hematologic - As noted above, he had chest computed
tomographic angiography [**11-26**], which was positive for
bilateral pulmonary emboli.  He was begun on a heparin drip.
On [**12-3**], once all procedures were felt to be
completed, he was started on Coumadin load.  He was also
switched from a heparin drip to low molecular weight heparin
subcutaneously to prepare him for discharge until his
coumadin is therapeutic.  On [**2132-12-3**] he was
transfused with 2 units of packed red blood cells for slowly
declining hematocrit felt to be due to prolonged hospital
stay and phlebotomy.

5.  Neurology - On [**2132-12-8**] he had new onset of
three generalized tonic clonic seizures in the setting of
respiratory distress from mucous plugging and 8 mg of Haldol
the night prior for agitation.  He was loaded on Dilantin
given the recurrent seizures.  He underwent extensive workup
to look for etiologies of his seizures including head
computerized tomography scan which was negative for bleed,
lumbar puncture, head magnetic resonance imaging scan,
electroencephalogram all of which are negative.  He was also
evaluated by the Neurology Service.  It is felt that the
seizures were likely due to hypoxia/respiratory distress in
combination with lowered seizure threshold from Haldol in the
setting of prolonged illness.  It is recommended that he
continue on Dilantin for six months and then be re-evaluated
by the neurologist at which time he will likely be able to
come off of this medication.

6.  Nutrition - For unclear reasons, he was unable to
tolerate tube feeds via nasogastric or orogastric tube
throughout his hospital stay both at [**Doctor Last Name 1263**] and here at [**Hospital6 1760**].  Abdominal computerized
tomography scan was negative for evidence of obstruction and
he has been passing stool.  He was maintained on daily total
parenteral nutrition while unable to give tube feeds.  He is
status post J-tube placement on [**2132-12-2**] and was
started on Promote with fiber tube feeds on [**2132-12-3**].  He has been advanced to his goal which is 80 cc/hr
which he has been tolerating well.  He has been evaluated by
the Speech and Swallow Service here and they recommend trying
judiciously some custard and sips of water p.o. and advancing
his diet slowly as tolerated.

7.  Endocrine - He has a history of hypothyroidism status
post thyroidectomy, however, he was not on thyroid
replacement medication on admission.  TSH and free T4 were
checked and were within normal limits.

8.  Access - He currently has a right arm PICC line which was
placed on [**2132-12-3**].

DISPOSITION:  Mr. [**Known lastname **] was discharged to [**Location (un) 511**] [**Hospital 13247**]
Rehabilitation in stable condition.

DISCHARGE INSTRUCTIONS:
1.  He should continue to receive aggressive pulmonary toilet
and should undergo pulmonary rehabilitation.
2.  He should continue Coumadin load 7.5 mg p.o. per J-tube
q.d. and adjust dose as needed for goal INR 2 to 3 for
pulmonary emboli.  He should be maintained on Lovenox 120 mg
subcutaneously b.i.d. until Coumadin is therapeutic.  He
should remain on Coumadin for six months and his
anticoagulation can then be discontinued as they were the
clear predisposing cause for his pulmonary emboli immobilized
in the hospital.
3.  He should continue on Dilantin 500 mg per J-tube q.d.
(divided t.i.d. 200/200/100).  Follow levels and adjust dose
as needed for goal level of about 15.  He should follow up
with neurologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Hospital6 649**] once he is discharged from rehabilitation.
Call [**Telephone/Fax (1) 44**] to schedule an appointment.
4.  He should be placed on Methicillin-resistant
Staphylococcus aureus precautions.
5.  He should receive both influenza and pneumococcal
vaccines.
6.  He should follow up with his primary care physician, [**Last Name (NamePattern4) **].
[**First Name8 (NamePattern2) 745**] [**Last Name (NamePattern1) 13248**] outside discharge from rehabilitation.

DISCHARGE MEDICATIONS:
1.  Coumadin 7.5 mg p.o./per J-tube q.d.  Follow INR and
adjust dose as needed for goal INR between 2 and 3.  He
should be continued on this for six months.
2.  Lovenox 120 mg subcutaneously b.i.d.  This should be
continued only until INR is therapeutic.
3.  Dilantin 500 mg per J-tube q.d., (divided t.i.d.
200/200/100)  Follow Dilantin levels until stable and
therapeutic at goal level around 15.
4.  Lopressor 50 mg p.o./per J-tube b.i.d.
5.  Protonix 40 mg p.o./per J-tube q.d.
6.  Promote with fiber tube feeds (goal 80 cc/hr)

DISCHARGE DIAGNOSIS:
1.  Streptococcus pneumoniae pneumonia and sepsis
2.  Methicillin-resistant Staphylococcus aureus
tracheobronchitis
3.  Bilateral pulmonary emboli
4.  Respiratory failure and inability to wean from ventilator
due to diagnoses 1, 2 and 3 as well as muscular weakness
5.  New onset generalized tonic clonic seizures
6.  Hypertension
7.  Supraventricular tachycardia



                            [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D.  [**MD Number(1) 7512**]

Dictated By:[**Name8 (MD) 13249**]
MEDQUIST36

D:  [**2132-12-10**]  17:13
T:  [**2132-12-10**]  17:13
JOB#:  [**Job Number 13250**]

cc:[**Numeric Identifier 13251**]
{'Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia],Pneumococcal septicemia [Streptococcus pneumoniae septicemia],Acute respiratory failure,Iatrogenic pulmonary embolism and infarction,Other convulsions,Other specified cardiac dysrhythmias,Acute bronchitis,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Unspecified acquired hypothyroidism'}


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: Mr. [**Known lastname **] is a 54 year old
gentleman with a history of supraventricular tachycardia,
hypothyroidism, hypercholesterolemia who was transferred from
[**Hospital 1263**] Hospital to [**Hospital6 256**]
[**2132-11-20**] for failure to wean from ventilator and
persistent fevers.  Please see [**Hospital 1263**] Hospital discharge
summary for further details of his initial presentation and
hospital course there.

MEDICAL HISTORY: 1.  History of supraventricular tachycardia
2.  Hypothyroidism, status post thyroidectomy in [**2120**]
3.  Hypercholesterolemia
4.  Neuralgia

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies on admission.  During
admission Haldol was noted to cause seizures.

PHYSICAL EXAM: 

FAMILY HISTORY: Mother has diabetes mellitus and coronary
artery disease.

SOCIAL HISTORY: Mr. [**Known lastname **] works as a history professor at a
nearby community college.  He smokes two packs per day.  He
drinks occasional alcohol.  He has a wife and two children. 

### Response:
{'Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia],Pneumococcal septicemia [Streptococcus pneumoniae septicemia],Acute respiratory failure,Iatrogenic pulmonary embolism and infarction,Other convulsions,Other specified cardiac dysrhythmias,Acute bronchitis,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Unspecified acquired hypothyroidism'}
