CHIEF COMPLAINT: Abdominal and back pain, fever

PRESENT ILLNESS: 39 M with history of MEN I and multiple procedures including
parathyroidectomy, unilateral adrenalectomy, partial
pancreatectomy and segment III liver resection ([**2184-3-18**]) with
recent gastrinoma metastisis to liver presented to [**Hospital1 18**] with
fevers to 103 and shoulder/back/abdominal pain. He was in his
usual state of health. On [**2184-11-17**] he underwent radiofrequency
ablation of his liver lesion. He did well until [**11-25**] when he
noted worsening pain and fevres. He presented to [**Hospital3 **]
Hospital where he received antibiotics and was transferred to
the [**Hospital1 18**] for further care.

MEDICAL HISTORY: 1. Gastrinoma and Zollinger-[**Doctor Last Name 9480**] syndrome
2. MEN 1 syndrome: medical records indicate genetic testing
confirmed MEN1 syndrome. Per hx, pt had GERD symptoms in [**2172**],
Abd U/S showed rt adrenal mass.
- s/p 3 parathyroid surgeries ([**2172**]-[**2176**]) with eventual total
parathyroidectomy & reimplant in arm
- Unilateral rt adrenalectomy ([**11/2174**]) at MD [**Last Name (Titles) 4223**]: pathology
demonstrated 7 x 6.5 x 4 cm pheo, adrenocortical hyperplasia, &
mult adrenal cortical adenomas. Pt noted to have nl left adrenal
at this time. Pre-op urinary mets were 5000, nl urinary
catecholamines.
- 80% partial pancreatectomy ([**11/2174**]) at MD [**Last Name (Titles) 4223**]: for masses
in body & tail of pancreas; pre-op gastrin level was 895. Path
demonstrated islet cell tumors, immunostaining results not
available
3. Type 1 DM: dx'd at age 16 (presenting sx fatigue, polyuria);
has h/o DKA; complications include nephropathy.
4. CKD stage II (diabetic nephropathy), baseline creatine
1.4-1.6
5. s/p splenectomy ([**11/2174**]): done at same time as adrenalectomy
and partial pancreatectomy.
6. Gastritis
7. GERD
8. Completion pancreatectomy, segement 3 liver resection [**2184-3-18**]

MEDICATION ON ADMISSION: Lantus 15 qam, humalog SS, protonix 40mg daily, HCTZ 25mg [**Hospital1 **],
Creon with meals

ALLERGIES: Levaquin

PHYSICAL EXAM: On admission:
VS: Temp 99.3, HR 109, BP 124/77, RR 20, O2 sat 100% on room air
Gen: alert and oriented, stable, tired appearing
HEENT: No icterus, no LAD
CV: RRR
Pulm: clear bilaterally
Abd: soft, NT, ND, +BS well healed sub-costal scar
Ext: left ankle with 1+non-pitting edema, [**3-19**] DP/PT pulses

FAMILY HISTORY: Father with MEN-->presumably type 1 though this is not stated
explicitly in records; medical records indicate he had high
gastrin level pre-op and high glucagon s/p Whipple procedure.
Mother & sibling are healthy.
Cousin w/brain tumor, unknown type.
Grandfather died of colon cancer.

SOCIAL HISTORY: He quit smoking in [**2182**].  He admits to occasional marijuana use.
 He denies alcohol use.
Other postoperative infection,Other septicemia due to gram-negative organisms,Acute posthemorrhagic anemia,Acute kidney failure with lesion of tubular necrosis,Septic shock,Unspecified pleural effusion,Severe sepsis,Aneurysm of other visceral artery,Urinary complications, not elsewhere classified,Multiple endocrine neoplasia [MEN] type I,Diabetes with renal manifestations, type I [juvenile type], not stated as uncontrolled,Chronic kidney disease, Stage II (mild),Pain in joint, shoulder region
Other postop infection,Gram-neg septicemia NEC,Ac posthemorrhag anemia,Ac kidny fail, tubr necr,Septic shock,Pleural effusion NOS,Severe sepsis,Visceral aneurysm NEC,Surg compl-urinary tract,Mult endo neoplas type I,DMI renl nt st uncntrld,Chro kidney dis stage II,Joint pain-shlder
Admission Date:  [**2184-11-25**]              Discharge Date:   [**2184-12-22**]

Date of Birth:  [**2144-12-16**]             Sex:   M

Service: SURGERY

Allergies:
Levaquin

Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Abdominal and back pain, fever

Major Surgical or Invasive Procedure:
coil embolization x2 for pseudo-aneurysm of right intrahepatic
artery


History of Present Illness:
39 M with history of MEN I and multiple procedures including
parathyroidectomy, unilateral adrenalectomy, partial
pancreatectomy and segment III liver resection ([**2184-3-18**]) with
recent gastrinoma metastisis to liver presented to [**Hospital1 18**] with
fevers to 103 and shoulder/back/abdominal pain. He was in his
usual state of health. On [**2184-11-17**] he underwent radiofrequency
ablation of his liver lesion. He did well until [**11-25**] when he
noted worsening pain and fevres. He presented to [**Hospital3 **]
Hospital where he received antibiotics and was transferred to
the [**Hospital1 18**] for further care.

Past Medical History:
1. Gastrinoma and Zollinger-[**Doctor Last Name 9480**] syndrome
2. MEN 1 syndrome: medical records indicate genetic testing
confirmed MEN1 syndrome. Per hx, pt had GERD symptoms in [**2172**],
Abd U/S showed rt adrenal mass.
- s/p 3 parathyroid surgeries ([**2172**]-[**2176**]) with eventual total
parathyroidectomy & reimplant in arm
- Unilateral rt adrenalectomy ([**11/2174**]) at MD [**Last Name (Titles) 4223**]: pathology
demonstrated 7 x 6.5 x 4 cm pheo, adrenocortical hyperplasia, &
mult adrenal cortical adenomas. Pt noted to have nl left adrenal
at this time. Pre-op urinary mets were 5000, nl urinary
catecholamines.
- 80% partial pancreatectomy ([**11/2174**]) at MD [**Last Name (Titles) 4223**]: for masses
in body & tail of pancreas; pre-op gastrin level was 895. Path
demonstrated islet cell tumors, immunostaining results not
available
3. Type 1 DM: dx'd at age 16 (presenting sx fatigue, polyuria);
has h/o DKA; complications include nephropathy.
4. CKD stage II (diabetic nephropathy), baseline creatine
1.4-1.6
5. s/p splenectomy ([**11/2174**]): done at same time as adrenalectomy
and partial pancreatectomy.
6. Gastritis
7. GERD
8. Completion pancreatectomy, segement 3 liver resection [**2184-3-18**]


Social History:
He quit smoking in [**2182**].  He admits to occasional marijuana use.
 He denies alcohol use.


Family History:
Father with MEN-->presumably type 1 though this is not stated
explicitly in records; medical records indicate he had high
gastrin level pre-op and high glucagon s/p Whipple procedure.
Mother & sibling are healthy.
Cousin w/brain tumor, unknown type.
Grandfather died of colon cancer.


Physical Exam:
On admission:
VS: Temp 99.3, HR 109, BP 124/77, RR 20, O2 sat 100% on room air
Gen: alert and oriented, stable, tired appearing
HEENT: No icterus, no LAD
CV: RRR
Pulm: clear bilaterally
Abd: soft, NT, ND, +BS well healed sub-costal scar
Ext: left ankle with 1+non-pitting edema, [**3-19**] DP/PT pulses

On discharge:
VS: Temp 101.1, HR 102, BP 117/80, RR 26, O2 sat 94% on room air
Gen: alert and oriented, no acute distress, more energetic
HEENT: anicteric sclera, no lymphadenopathy
CV: RRR, no murmurs, gallops, rubs
Pulm: clear bilaterally
Abd: soft, nontender, nondistended, palpable hepatomegaly
Ext: 1+ edema bilaterally up to knees, 2+ distal pulses


Pertinent Results:
Discharge labs:
[**2184-12-22**] 04:47AM BLOOD WBC-15.7* RBC-3.29* Hgb-9.0* Hct-29.2*
MCV-89 MCH-27.4 MCHC-30.9* RDW-18.5* Plt Ct-863*
[**2184-12-22**] 04:47AM BLOOD Glucose-85 UreaN-16 Creat-1.4* Na-141
K-4.0 Cl-103 HCO3-30 AnGap-12
[**2184-12-22**] 04:47AM BLOOD ALT-23 AST-28 AlkPhos-331* TotBili-0.8
[**2184-12-17**] 04:38AM BLOOD Lipase-6
[**2184-12-22**] 04:47AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.0
[**2184-12-19**] 05:19AM BLOOD TSH-1.2

CT abdomen/pelvis prior to discharge ([**2184-12-21**]):
1. No interval change to known subcapsular and intraparenchymal
hematomas without CT findings to suggest superinfection. No new
fluid collections identified.
2. Resolution of small left pleural effusion with probably
stable right pleural effusion, which displaced posterior and
medial components. Moderate amount of interstitial septal
thickening involving the visualized aerated right lower lobe may
reflect interstitial pulmonary edema, however, in conjunction
with metastatic left lower lobe pulmonary nodules, lymphangitic
carcinomatosis cannot be excluded.
3. Stable left adrenal lesions and post-surgical changes without
evidence of bowel obstruction.

Brief Hospital Course:
Patient was admitted to the [**Hospital1 18**] on [**11-25**].  Vancomycin and
Zosyn were started. A non-contrast CT abdomen/pelvis was
obtained given the patient's renal disease and showed a limited
evaluation of the liver parenchyma due to lack of intravenous
contrast. Expected post-radiofrequency ablation findings in the
right lobe of the liver, a small, nonobstructing left anterior
abdominal wall hernia, enlarged, nodular left adrenal gland
unchanged since [**2184-1-16**], multiple enlarged mesenteric
lymph nodes unchanged since the prior study, prior
pancreatectomy, splenectomy, partial gastrectomy, partial
hepatectomy and right adrenalectomy.
Overnight on hospital day 1 he was febrile to 103.1 with a
significant leukocytosis. He was continued on antibiotics and
cultures were sent. On [**11-28**] RUQ ultrasound was obtained and
demonstrated a 6.4 cm heterogeneously echoic lesion within the
right lobe of the liver, likely segment VIII, consistent with
prior radiofrequency ablation site, a rounded, 1.3 cm vascular
area within the radiofrequency ablation site which is suggestive
of a pseudoaneurysm. The pseudoaneurysm appeared to arise from
an intrahepatic branch of the right hepatic artery. The portal
vein was patent.
ID service was consulted and patient was switched to meropenem.
On [**11-28**] patient developed worsening abdominal/back pain and
became diaphoretic. He was hypotensive with BP 82/70 and
relative hypoxia with oxygen saturation of 90 %.  He received
bolus of NS with good response and was transferred to the ICU
for closer monitoring. Patient also had a 4% drop in HCT and was
transfused 1 unit of PRBCs without appropriate rise in
hematocrit. Central line was placed. 2 more units of PRBCs were
administered. Given ultrasound findings, patient was
administered bicarb and Mucomyst in preparation for angiography
and coil embolization of pseudoaneurysm which he underwent on
[**2184-11-29**]. At the time of the procedure, the pseudoaneurysm
appeared to be successfully obliterated with coiling.  Post
procedure patient developed oliguric renal failure with
creatinine peaking around 7. Nephrology service was consulted
and he was managed conservatively. He did not require dialysis.
Renal failure subsequently resolved with a concomitant fall in
creatinine and marked increase in urine output.  During this
time he continued to have a leukocytosis between 25-38,000 and
continued to periodically spike temps.
A non-contrast CT scan of the abdomen was obtained on [**12-2**] and
showed increasing size of hyperdensity in the right liver lobe
adjacent to the RF ablation and pseudoaneurism embolization
site, likely represents presence of a hematoma. Large
subcapsular hematoma, compressing the hepatic parenchyma. Since
he continued to spike fevers in presence of leukocytosis, there
was concern for superinfected hematoma. However, because of the
extent of liver damage and size of hematoma, it was deemed
unsafe to tap fluid as this could potentially negate the
tamponade effect of the capsule and may result in
exsanguination.  He was managed conservatively and seemed to be
stable.
Overnight on [**12-5**] into [**12-6**] patient developed an acute drop in
hematocrit with relative hypotension. [**Name2 (NI) **] was transfused 2 units
of PRBCs.  An urgent RUQ u/s was obtained and showed that the
pseudoaneurysm has decreased from [**2184-11-29**], and there is
now a small thrombus. The vessel remained patent, however. Given
these findings, patient was once again administered bicarbonate
and Mucomyst in preparation for angiography. He underwent repeat
coil embolization of pseudoaneurysm on [**12-7**]. Once again patient
developed oliguric ATN approximately 36 hours post procedure.
Although fluid intake was minimized he progressively developed
respiratory problems with desaturation when supine.  CXR
revealed a large right sided pleural effusion. This was tapped
and drained on [**12-9**] with successful drainage of 1300 cc of
dark, blood-tinged exudative fluid.  Initial Gram stain showed
4+ PMNs, but no bacteria and subsequent cultures were negative.
ATN subsequently resolved and he started auto-diuresing with
improvement in respiratory status.
Follow-up U/S on [**12-10**] showed complete obliteration of
pseudoaneurysm. His hematocrits were stable. Leukocytosis
persisted as did his fevers. Antibiotics were continued.
Superinfection of liver hematoma continued to be of high concern
but collection was not drained given high risk of the procedure.

He was transferred out of the SICU on [**12-14**]. TPN was stopped.
Kcals were done showing a daily kcal count of ~1300. Nutritional
supplements were given. Meropenum was continued for Klebsiella
bacteremia (at referring hospital) and subcapsular hematoma.
Klebsiella was pan-sensitive. ID recommended at least 3 weeks of
treatment using Ertapenum until [**1-5**].  A picc line was placed
on [**12-15**].  [**Last Name (un) **] followed for management of diabetes. He
received iv lasix for significant lower extremity edema. On
[**12-15**] a non-contrast CT was repeated showing stable large
subcapsular and intraparenchymal hematomas, without evidence of
active extravasation.  Follow chest x-rays revealed a stable
right sided pleural effusion.

Psychiatry was consulted to evaluate for depressed mood,
tearfullness, and problems with sleep. It was felt that he was
dysphoric and recommendations included avoidance of ambien.
Ativan was recommended prn at HS. Outpatient psychiatry follow
up was discussed with the patient who agreed to think about it.

On [**12-19**], he continued to spike temperatures of 101 to 101.9. A
repeat U/A was negative. Blood and urine cultures are negative
to date. The possibility of a feeding tube was discussed but he
declined this and agreed to eat more and over the last 3 days of
his hospital stay he has steadily increased his po intake.  He
continues to have low grade fevers.  A CT scan obtained on
[**2184-12-21**] revealed a stable subcapsular hematoma.  He is
tolerating a diabetic diet and ambulating regularly.  He is
discharged home in good condition with VNA to administer IV
antibiotics for 2 more weeks.  He has appropriate follow up
appointments scheduled.

Medications on Admission:
Lantus 15 qam, humalog SS, protonix 40mg daily, HCTZ 25mg [**Hospital1 **],
Creon with meals

Discharge Medications:
1. PICC Line Care
Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
Heparin Flush: dispense # 30 (Thirty) Refills 1 (One)
Normal Saline Flush: Dispense #100 (one hundred) Refill 1 (One)
box
2. PICC Line Care
PICC Line Dressing Kit
Change dressing q three days and PRN
Dispense # 7 (seven) Refill 1 (One)
3. Ertapenem 1 gram Recon Soln Sig: One (1)  Intravenous once a
day for 14 doses.
Disp:*14 units* Refills:*1*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule,
Delayed Release(E.C.) Sig: [**5-21**] Caps PO QIDWMHS (4 times a day
(with meals and at bedtime)).
Disp:*540 Cap(s)* Refills:*2*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15) units
Subcutaneous once a day.
Disp:*1 bottle* Refills:*2*
10. Insulin Glargine 100 unit/mL Solution Sig: Three (3) units
Subcutaneous at bedtime.
11. Insulin Lispro 100 unit/mL Solution Sig: follow sliding
scale  Subcutaneous four times a day.
Disp:*1 * Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Last Name (un) 6438**]

Discharge Diagnosis:
MEN I
Metastatic gastrinoma
Klebsiella bacteremia (at referring hospital)
Subcapsular liver hematoma s/p RFA with pseudoaneurysm
s/p Pseudoaneurysm coil embolization x 2
Acute renal failure
Anemia


Discharge Condition:
good


Discharge Instructions:
Please call Dr.[**Name (NI) 670**] office at [**Telephone/Fax (1) 673**] if you
experience:
- fever >101.5
- chills
- persistent nausea or vomiting
- dizziness
- abdominal pain not relieved by your medication
- inability to eat or drink
- any other concerns you may have

You will have weekly labs drawn by the visiting nurse [**First Name (Titles) **] [**Last Name (Titles) 58870**]
(cbc, bun, creatinine, ast, alt, alk phos, t.bili).  The results
should be faxed to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**] in the [**Hospital **] clinic at
[**Telephone/Fax (1) 432**].

Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2184-12-31**]
8:45
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2184-12-31**] 1:10
{'Other postoperative infection,Other septicemia due to gram-negative organisms,Acute posthemorrhagic anemia,Acute kidney failure with lesion of tubular necrosis,Septic shock,Unspecified pleural effusion,Severe sepsis,Aneurysm of other visceral artery,Urinary complications, not elsewhere classified,Multiple endocrine neoplasia [MEN] type I,Diabetes with renal manifestations, type I [juvenile type], not stated as uncontrolled,Chronic kidney disease, Stage II (mild),Pain in joint, shoulder region'}


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: Abdominal and back pain, fever

PRESENT ILLNESS: 39 M with history of MEN I and multiple procedures including
parathyroidectomy, unilateral adrenalectomy, partial
pancreatectomy and segment III liver resection ([**2184-3-18**]) with
recent gastrinoma metastisis to liver presented to [**Hospital1 18**] with
fevers to 103 and shoulder/back/abdominal pain. He was in his
usual state of health. On [**2184-11-17**] he underwent radiofrequency
ablation of his liver lesion. He did well until [**11-25**] when he
noted worsening pain and fevres. He presented to [**Hospital3 **]
Hospital where he received antibiotics and was transferred to
the [**Hospital1 18**] for further care.

MEDICAL HISTORY: 1. Gastrinoma and Zollinger-[**Doctor Last Name 9480**] syndrome
2. MEN 1 syndrome: medical records indicate genetic testing
confirmed MEN1 syndrome. Per hx, pt had GERD symptoms in [**2172**],
Abd U/S showed rt adrenal mass.
- s/p 3 parathyroid surgeries ([**2172**]-[**2176**]) with eventual total
parathyroidectomy & reimplant in arm
- Unilateral rt adrenalectomy ([**11/2174**]) at MD [**Last Name (Titles) 4223**]: pathology
demonstrated 7 x 6.5 x 4 cm pheo, adrenocortical hyperplasia, &
mult adrenal cortical adenomas. Pt noted to have nl left adrenal
at this time. Pre-op urinary mets were 5000, nl urinary
catecholamines.
- 80% partial pancreatectomy ([**11/2174**]) at MD [**Last Name (Titles) 4223**]: for masses
in body & tail of pancreas; pre-op gastrin level was 895. Path
demonstrated islet cell tumors, immunostaining results not
available
3. Type 1 DM: dx'd at age 16 (presenting sx fatigue, polyuria);
has h/o DKA; complications include nephropathy.
4. CKD stage II (diabetic nephropathy), baseline creatine
1.4-1.6
5. s/p splenectomy ([**11/2174**]): done at same time as adrenalectomy
and partial pancreatectomy.
6. Gastritis
7. GERD
8. Completion pancreatectomy, segement 3 liver resection [**2184-3-18**]

MEDICATION ON ADMISSION: Lantus 15 qam, humalog SS, protonix 40mg daily, HCTZ 25mg [**Hospital1 **],
Creon with meals

ALLERGIES: Levaquin

PHYSICAL EXAM: On admission:
VS: Temp 99.3, HR 109, BP 124/77, RR 20, O2 sat 100% on room air
Gen: alert and oriented, stable, tired appearing
HEENT: No icterus, no LAD
CV: RRR
Pulm: clear bilaterally
Abd: soft, NT, ND, +BS well healed sub-costal scar
Ext: left ankle with 1+non-pitting edema, [**3-19**] DP/PT pulses

FAMILY HISTORY: Father with MEN-->presumably type 1 though this is not stated
explicitly in records; medical records indicate he had high
gastrin level pre-op and high glucagon s/p Whipple procedure.
Mother & sibling are healthy.
Cousin w/brain tumor, unknown type.
Grandfather died of colon cancer.

SOCIAL HISTORY: He quit smoking in [**2182**].  He admits to occasional marijuana use.
 He denies alcohol use. 

### Response:
{'Other postoperative infection,Other septicemia due to gram-negative organisms,Acute posthemorrhagic anemia,Acute kidney failure with lesion of tubular necrosis,Septic shock,Unspecified pleural effusion,Severe sepsis,Aneurysm of other visceral artery,Urinary complications, not elsewhere classified,Multiple endocrine neoplasia [MEN] type I,Diabetes with renal manifestations, type I [juvenile type], not stated as uncontrolled,Chronic kidney disease, Stage II (mild),Pain in joint, shoulder region'}
