CHIEF COMPLAINT: The patient is a 41 year old morbidly obese
gentleman who came to the hospital in the setting of
cellulitis of the left leg with hypotension requiring fluid
resuscitation and desaturation.

PRESENT ILLNESS: The patient is a 41 year old
with a history of diabetes mellitus, morbid obesity, asthma,
obstructive sleep apnea and coronary artery disease.  He was
admitted to the [**Hospital3 4527**] Hospital in [**Location (un) 620**] on
[**2129-9-4**], for cellulitis and sepsis.  He had cut his left leg
with a saw blade on [**2129-9-2**], and subsequently developed
erythema of the leg.

MEDICAL HISTORY: 1.  Morbid obesity.
2.  Type 2 diabetes mellitus with increasing insulin
requirement, diabetic neuropathy.
3.  Chronic pain with possible opioid dependence.
4.  Hypertension since age of 19.
5.  Coronary artery disease.
6.  Obstructive sleep apnea requiring CPAP for more than ten
years.
7.  Asthma.
8.  Osteoarthritis.

MEDICATION ON ADMISSION: 1.  Levofloxacin 500 mg intravenously once a day.
2.  Avandia one q8hours.
3.  Celexa 40 mg twice a day.
4.  Vancomycin two grams twice a day.
5.  Clindamycin 600 mg intravenously q8hours.
6.  Verapamil 480 mg twice a day.
7.  Aspirin 81 mg once a day.
8.  Tylenol 1000 mg p.r.n.
9.  Motrin 800 mg q8hours.
10. Percocet two tablets q6hours.
11. Rhinocort p.r.n.
12. Flovent and Serevent inhalers as required.
13. Neo-Synephrine.
14. [**Doctor First Name **].
15. Oxymetazoline.
16. Remeron 30 mg h.s.
17. Mexiletine 400 mg twice a day.
18. Tegretol 150 mg twice a day.
19. Neurontin 1200 mg q8hours.
20. Heparin 10,000 subcutaneous b.i.d.
21. Zestril 40 mg b.i.d.

ALLERGIES: Cephalosporins and Morphine Sulfate.

PHYSICAL EXAM: 

FAMILY HISTORY: Father has hypertension.  Mother had
emphysema at the age of 63.

SOCIAL HISTORY: The patient lives alone.  He is on
disability.  He smokes a pipe or cigar occasionally.  No
history of ethanol or intravenous drug use.
Acute respiratory failure,Cellulitis and abscess of leg, except foot,Congestive heart failure, unspecified,Atrial fibrillation,Methicillin susceptible pneumonia due to Staphylococcus aureus,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other staphylococcal septicemia,Intestinal infection due to Clostridium difficile,Gastroparesis
Acute respiratry failure,Cellulitis of leg,CHF NOS,Atrial fibrillation,Meth sus pneum d/t Staph,DMII wo cmp nt st uncntr,Staphylcocc septicem NEC,Int inf clstrdium dfcile,Gastroparesis
Admission Date:  [**2129-9-7**]       Discharge Date:  [**2129-10-25**]

Date of Birth:   [**2087-11-5**]       Sex:  M

Service:  MICU

CHIEF COMPLAINT:  The patient is a 41 year old morbidly obese
gentleman who came to the hospital in the setting of
cellulitis of the left leg with hypotension requiring fluid
resuscitation and desaturation.

HISTORY OF PRESENT ILLNESS:  The patient is a 41 year old
with a history of diabetes mellitus, morbid obesity, asthma,
obstructive sleep apnea and coronary artery disease.  He was
admitted to the [**Hospital3 4527**] Hospital in [**Location (un) 620**] on
[**2129-9-4**], for cellulitis and sepsis.  He had cut his left leg
with a saw blade on [**2129-9-2**], and subsequently developed
erythema of the leg.

On [**2129-9-4**], he awoke with fever, chills and rigors and went
to [**Hospital3 4527**] where he was noted to have a temperature
of 104 degrees and also appeared to be uncomfortable and
short of breath.  His saturations were 92% in room air and
improved to 97 to 98% with four liters nasal cannula. His
blood pressure at that time ranged from 120/60 to 150/90.  He
was admitted to the Intensive Care Unit in the [**Hospital3 29718**].

For the left leg cellulitis, he was started on Vancomycin,
Clindamycin and Levofloxacin.  His blood pressure
subsequently dropped to 80 systolic and the patient was
started on Neo-Synephrine infusion and had aggressive fluid
resuscitation.  The left leg cellulitis seemed to improve and
the Neo-Synephrine was weaned off.

On [**2129-9-6**], the patient was noted to have increasing
respiratory distress.  Chest x-ray showed evidence of
pulmonary edema which was treated with Lasix. There was some
response initially but the respiratory distress was not
relieved.  He was placed on CPAP and then a nonrebreathing
mask but the saturations were still in the low 90s with
arterial oxygen tension of 62 to 74 mmHg. At this point, the
patient was transferred to the [**Hospital1 188**].

In the MICU, he was intubated by awake fiberoptic intubation.
Oxygenation seemed to improve with assist control ventilation
and the FIO2 was gradually weaned from 80% to 60% oxygen.

PAST MEDICAL HISTORY:
1.  Morbid obesity.
2.  Type 2 diabetes mellitus with increasing insulin
requirement, diabetic neuropathy.
3.  Chronic pain with possible opioid dependence.
4.  Hypertension since age of 19.
5.  Coronary artery disease.
6.  Obstructive sleep apnea requiring CPAP for more than ten
years.
7.  Asthma.
8.  Osteoarthritis.

PAST SURGICAL HISTORY:
1.  Quadriceps tendon repair in [**2125**].
2.  Carpal tunnel release, bilaterally.
3.  Status post hydrocele repair which was complicated by
postoperative cellulitis.
4.  Status post left ankle surgery.

MEDICATIONS ON ADMISSION:
1.  Levofloxacin 500 mg intravenously once a day.
2.  Avandia one q8hours.
3.  Celexa 40 mg twice a day.
4.  Vancomycin two grams twice a day.
5.  Clindamycin 600 mg intravenously q8hours.
6.  Verapamil 480 mg twice a day.
7.  Aspirin 81 mg once a day.
8.  Tylenol 1000 mg p.r.n.
9.  Motrin 800 mg q8hours.
10. Percocet two tablets q6hours.
11. Rhinocort p.r.n.
12. Flovent and Serevent inhalers as required.
13. Neo-Synephrine.
14. [**Doctor First Name **].
15. Oxymetazoline.
16. Remeron 30 mg h.s.
17. Mexiletine 400 mg twice a day.
18. Tegretol 150 mg twice a day.
19. Neurontin 1200 mg q8hours.
20. Heparin 10,000 subcutaneous b.i.d.
21. Zestril 40 mg b.i.d.

ALLERGIES:  Cephalosporins and Morphine Sulfate.

FAMILY HISTORY:  Father has hypertension.  Mother had
emphysema at the age of 63.

SOCIAL HISTORY:  The patient lives alone.  He is on
disability.  He smokes a pipe or cigar occasionally.  No
history of ethanol or intravenous drug use.

PHYSICAL EXAMINATION:  Temperature is 98.9, heart rate 100
beats per minute, normal sinus rhythm, blood pressure 86/33
and respiratory rate was 30.  After intubation he was
ventilated on pressure support of 20 with a PEEP of 10 and he
was on 100% oxygen.  He was sedated with Propofol and
Lorazepam.  The pupils are equal, reactive to light.
Extraocular movements are intact.  Neck was obese, unable to
see the jugular venous pressure.  Pulmonary - There was no
wheeze.  Distant breath sounds are heard.  Crackles at the
bases.  Cardiac - regular heart sounds, S1 and S2, sounds
distant, no murmur appreciated.  The abdomen is obese, soft,
nontender, bowel sounds heard, abdominal wall was edematous.
Extremities 3+ peripheral edema left leg, torso edematous
with palpable pulses.  Skin - erythema left ankle above the
cut.  Neurologic - alert and appropriate despite the low
oxygen saturation.

LABORATORY DATA:  White cell count was 12.2, hematocrit 36.6,
platelets 211,000.  Sodium 143, potassium 3.9, chloride 99,
bicarbonate 31, blood urea nitrogen 26, creatinine 0.7, blood
sugar 136.  Creatinine kinase was 96 and troponin was
negative.  Arterial blood gases on 100% oxygen pH 7.47, pCO2
47, pO2 90.

Chest x-ray was of poor quality and diffuse alveolar
infiltrate suggestive of pulmonary edema and congestive heart
failure. could not rule out adult respiratory distress
syndrome.

Ultrasound of the lower limbs showed normal compressibility
of the lower limb veins which was negative for deep vein
thrombosis.

Electrocardiogram shows normal sinus rhythm with normal axis,
with no evidence of ischemia.

HOSPITAL COURSE:
1.  Cardiac - Hemodynamic instability requiring inotropics
initially.  He was monitored with a PA catheter.  The
inotropes were gradually weaned.  After the initial course of
hemodynamic instability, there was a face of hypertension
where the blood pressure was difficult to control requiring
increasing the doses of the antihypertensive medications.
There was one episode of fast atrial fibrillation with
hemodynamic instability which required cardioversion.

2.  Pulmonary - The patient required awake fiberoptic
intubation for control of airway.  Initially the oxygen
requirements were very high with FIO2 of 1.

Over a period of time, the oxygenation was weaned from 100%
to 60 to 40%.  During this two to three week period, the
oxygenation was labile and this was treated by intense
physical therapy and nebulizers.  The oxygenation gradually
improved.

Percutaneous tracheostomy was performed on [**2129-9-27**].  The
oxygenation improved gradually and for the past two weeks,
there has been no evidence of respiratory distress.  Adequate
oxygenation was maintained over the tracheostomy mask with
40% oxygen.  The saturations are 100% and the carbon dioxide
levels have been ranging from 35 to 45 mmHg during this time.

3.  Renal - Aggressive diuresis during the MICU stay.  The
patient was treated with Lasix 20 to 80 mg p.r.n. and a
negative balance of one liter to 1.5 liters was maintained to
wean from the ventilator.  There was one episode of prerenal
failure which improved spontaneously and he did not require
dialysis or hemofiltration during his stay in the MICU.

4.  Gastrointestinal - Due to the long-standing diabetes
mellitus, he was prone for recurrent gastroparesis. He
tolerated only forced pyloric feeds. There was one episode of
coffee ground vomitus but the patient had a stable hematocrit
and therefore did not need an endoscopy.

5.  Endocrine - Very large insulin requirements and poorly
controlled diabetes mellitus. The patient had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
consultation and he was started on U-500 regular insulin, now
has a better blood sugar control.

6.  Hematology - The patient's hematocrit has been stable
during his MICU stay and he did not require any transfusions
during the hospital stay.

7.  Infectious disease - Methicillin resistant Staphylococcus
aureus positive and positive blood cultures.   Methicillin
resistant Staphylococcus aureus positive fungal cystitis.  He
was Methicillin resistant Staphylococcus aureus positive in
sputum on [**2129-10-19**].  Clostridium difficile positive on
[**2129-9-10**], and on [**2129-10-6**].  This is being treated with Flagyl
at present. On [**2129-10-17**], the C. difficile toxin assay was
negative.

8.  Musculoskeletal - Back pain which has gradually resolved
and received physical therapy.

9.  Nutrition - The patient required prolonged parenteral
nutrition due to the gastroparesis but now he has a
postpyloric tube and he is on enteral feeds.

10. Prophylaxis - He is on Heparin 5000 units subcutaneous
b.i.d., on Protonix 40 mg intravenously once a day.

MEDICATIONS ON DISCHARGE:
1.  Flagyl 500 mg nasogastric b.i.d., today is day 17 of a 21
day course.
2.  Haldol 2 mg nasogastric b.i.d.
3.  Fentanyl patch 25 mcg per hour.
4.  Aspirin 81 mg nasogastric once a day.
5.  Remeron 30 mg nasogastric h.s.
6.  Heparin 5000 units subcutaneous b.i.d.
7.  Celexa 10 mg nasogastric b.i.d.
8.  Lopressor 100 mg nasogastric three times a day.
9.  Zestril 40 mg nasogastric once a day.
10. PhosLo two tablets nasogastric twice a day.
11. Nystatin swish and spit topical b.i.d.
12. Reglan 20 mg intravenous three times a day.
13. Lorazepam 2 mg p.r.n. h.s.
14. Albuterol and Atrovent nebulizers as required p.r.n.
q.i.d.
15. Lotrimin cream between toes b.i.d.
16. Trapidil to rash in the left lower limb b.i.d.
17. Half strength Respalor plus 80 grams ProMod as tube feeds
with a goal of 70 cc/hour.
18. U-500 regular insulin, 0.12 ccs or 12/100 q8hours
subcutaneous.
19. Sliding scale Humalog as required.

DISCHARGE STATUS:  The patient is ready for transfer to
rehabilitation facility, probably [**Hospital1 **], in the near
future.

CONDITION ON DISCHARGE:  He is alert, awake and afebrile.  He
has stable blood pressure and is in normal sinus rhythm.  The
patient is comfortable with tracheostomy mask with 40%
oxygen.  He needs suction regularly and he has a good cough.
He is awake and oriented, follows simple instructions,
communicates by nodding.  He can move all his limbs.

He had a swallowing study done and trial but he failed this
assessment because of aspiration of colored water and
aphonia.  He also had an ENT consultation in this regard and
the cords are able to move but he is unable to phonates due
to no leak around the tracheostomy tube.  The tracheostomy
tube was not changed for fenestrated tube due to anatomical
difficulty and relatively young tracheostomy tract.

The patient is prone for gastroparesis.  It is very essential
to check the position of the feeding tube tip periodically
and be certain that it is postpyloric.

The patient was assessed for a percutaneous endoscopic
gastrostomy placement or jejunostomy tube placement, but
these procedures could not be performed either by
gastroenterology or interventional radiology because of the
body mass.

The patient's admission weight was 197 kilograms and his
discharge weight as of today is 158 kilograms.

The exact date of discharge and the facility to which the
patient will be discharged is unclear but once this is
finalized, there will be an addendum to this discharge
summary.




                            [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D.  [**MD Number(1) 3795**]

Dictated By:[**Dictator Info **]
MEDQUIST36

D:  [**2129-10-24**]  18:56
T:  [**2129-10-24**]  19:29
JOB#:  [**Job Number 29719**]
{'Acute respiratory failure,Cellulitis and abscess of leg, except foot,Congestive heart failure, unspecified,Atrial fibrillation,Methicillin susceptible pneumonia due to Staphylococcus aureus,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other staphylococcal septicemia,Intestinal infection due to Clostridium difficile,Gastroparesis'}


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: The patient is a 41 year old morbidly obese
gentleman who came to the hospital in the setting of
cellulitis of the left leg with hypotension requiring fluid
resuscitation and desaturation.

PRESENT ILLNESS: The patient is a 41 year old
with a history of diabetes mellitus, morbid obesity, asthma,
obstructive sleep apnea and coronary artery disease.  He was
admitted to the [**Hospital3 4527**] Hospital in [**Location (un) 620**] on
[**2129-9-4**], for cellulitis and sepsis.  He had cut his left leg
with a saw blade on [**2129-9-2**], and subsequently developed
erythema of the leg.

MEDICAL HISTORY: 1.  Morbid obesity.
2.  Type 2 diabetes mellitus with increasing insulin
requirement, diabetic neuropathy.
3.  Chronic pain with possible opioid dependence.
4.  Hypertension since age of 19.
5.  Coronary artery disease.
6.  Obstructive sleep apnea requiring CPAP for more than ten
years.
7.  Asthma.
8.  Osteoarthritis.

MEDICATION ON ADMISSION: 1.  Levofloxacin 500 mg intravenously once a day.
2.  Avandia one q8hours.
3.  Celexa 40 mg twice a day.
4.  Vancomycin two grams twice a day.
5.  Clindamycin 600 mg intravenously q8hours.
6.  Verapamil 480 mg twice a day.
7.  Aspirin 81 mg once a day.
8.  Tylenol 1000 mg p.r.n.
9.  Motrin 800 mg q8hours.
10. Percocet two tablets q6hours.
11. Rhinocort p.r.n.
12. Flovent and Serevent inhalers as required.
13. Neo-Synephrine.
14. [**Doctor First Name **].
15. Oxymetazoline.
16. Remeron 30 mg h.s.
17. Mexiletine 400 mg twice a day.
18. Tegretol 150 mg twice a day.
19. Neurontin 1200 mg q8hours.
20. Heparin 10,000 subcutaneous b.i.d.
21. Zestril 40 mg b.i.d.

ALLERGIES: Cephalosporins and Morphine Sulfate.

PHYSICAL EXAM: 

FAMILY HISTORY: Father has hypertension.  Mother had
emphysema at the age of 63.

SOCIAL HISTORY: The patient lives alone.  He is on
disability.  He smokes a pipe or cigar occasionally.  No
history of ethanol or intravenous drug use. 

### Response:
{'Acute respiratory failure,Cellulitis and abscess of leg, except foot,Congestive heart failure, unspecified,Atrial fibrillation,Methicillin susceptible pneumonia due to Staphylococcus aureus,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other staphylococcal septicemia,Intestinal infection due to Clostridium difficile,Gastroparesis'}
