CHIEF COMPLAINT: Fever

PRESENT ILLNESS: -- per admitting hospitalist --
74 year-old man presents with fatigue, chills, and poor PO
intake over one month. Patient reports that two months ago, he
was able to walk 30 minutes/day with weights, but over the few
weeks prior to admission, he has felt fatigued and is more
easily fatigued.  He has daytime somnolence and night insomnia.
He denies any localizing symptoms. He denies nausea, vomiting,
anorexia, abdominal pain, melena, BRBPR, new lymphadenopathy,
meningismus. Patient denies weight loss, but on review of the
records, patient has lost 10 pounds over one month. He reports
lightheadedness and dizziness with standing for several weeks.

MEDICAL HISTORY: Coronary artery disease s/p cardiac cath in [**2175**]
Hypertension
Chronic renal insufficiency
Hyperlipidemia
Benign prostatic hyperplasia
Insomnia

MEDICATION ON ADMISSION: Atorvastatin 20 mg daily
Nitroglycerin 0.3 SL prn chest pain
Toprol 25 mg XL daily
Zestril 10 mg daily
Zolpidem 10 mg qhs
Aspirin 325 mg daily

ALLERGIES: Zocor

PHYSICAL EXAM: VS: T: 97.9, BP 122/84, RR 15, 98% on 2LNC
GEN: No acute distress
HEENT: EOMI, Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
CHEST: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
SKIN: No rash
EXT: Warm, well perfused, 2+ pulses, trace pedal edema
NEURO: Alert and oriented x3, CN 2-12 intact, strength 5/5
BUE/BLE, sensory intact, fluent speech
PSYCH: Calm, appropriate

FAMILY HISTORY: Mother died at 95 secondary to CAD. Father died at 85 secondary
to pancreatic cancer and had known colon cancer. He is married
with three children.

SOCIAL HISTORY: Patient is a former smoker, quit at age 42. Used to drink beer
or wine twice daily but has not drank for a month due to
fatigue.
Fever, unspecified,Acute kidney failure, unspecified,Pneumonia, organism unspecified,Cerebral artery occlusion, unspecified with cerebral infarction,Acute respiratory failure,Mixed acid-base balance disorder,Bacteremia,Infection and inflammatory reaction due to other vascular device, implant, and graft,Coronary atherosclerosis of native coronary artery,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Other and unspecified hyperlipidemia,Anemia in chronic kidney disease,Unspecified acquired hypothyroidism,Chronic kidney disease, Stage III (moderate),Cardiac arrest,Thrombocytopenia, unspecified,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Cardiogenic shock
Fever NOS,Acute kidney failure NOS,Pneumonia, organism NOS,Crbl art ocl NOS w infrc,Acute respiratry failure,Mixed acid-base bal dis,Bacteremia,React-oth vasc dev/graft,Crnry athrscl natve vssl,Hy kid NOS w cr kid I-IV,BPH w/o urinary obs/LUTS,Hyperlipidemia NEC/NOS,Anemia in chr kidney dis,Hypothyroidism NOS,Chr kidney dis stage III,Cardiac arrest,Thrombocytopenia NOS,Abn react-procedure NEC,Cardiogenic shock
Admission Date:  [**2184-3-6**]              Discharge Date:   [**2184-4-2**]

Date of Birth:  [**2109-9-28**]             Sex:   M

Service: MEDICINE

Allergies:
Zocor

Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Fever

Major Surgical or Invasive Procedure:
Central venous line placement
Endotracheal Intubation
Arterial Line placement

History of Present Illness:
-- per admitting hospitalist --
74 year-old man presents with fatigue, chills, and poor PO
intake over one month. Patient reports that two months ago, he
was able to walk 30 minutes/day with weights, but over the few
weeks prior to admission, he has felt fatigued and is more
easily fatigued.  He has daytime somnolence and night insomnia.
He denies any localizing symptoms. He denies nausea, vomiting,
anorexia, abdominal pain, melena, BRBPR, new lymphadenopathy,
meningismus. Patient denies weight loss, but on review of the
records, patient has lost 10 pounds over one month. He reports
lightheadedness and dizziness with standing for several weeks.

Of note, he presented to his PCP [**Last Name (NamePattern4) **] [**2184-2-12**] with fatigue and
weakness. He was found to have a low normal TSH (0.46) and low
free T4 (0.9). He was referred to endocrinology for evaluation
of central hypothyroidism. He was also found to be anemia to Hct
of 30 with his last checked Hct 41.6 six years prior with anemia
labs consistent with anemia of chronic disease.

In [**Hospital1 18**] ED, his vitals were T 103.5, HR 125, BP 96/ 52, RR 18,
98% on RA. He was found to be markedly dehydrated. A right groin
line was placed and he was given 7L of IVF. He remained
hypotensive at 81/46, so he was started on Levophed 0.2. He was
given Vancomycin, Ceftriaxone, and Decadron as he was initially
alert and oriented x3 but tangential in thought for concern for
meningitis. His mental status improved with hydration therefore
LP was not pursued.

Past Medical History:
Coronary artery disease s/p cardiac cath in [**2175**]
Hypertension
Chronic renal insufficiency
Hyperlipidemia
Benign prostatic hyperplasia
Insomnia

Social History:
Patient is a former smoker, quit at age 42. Used to drink beer
or wine twice daily but has not drank for a month due to
fatigue.

Family History:
Mother died at 95 secondary to CAD. Father died at 85 secondary
to pancreatic cancer and had known colon cancer. He is married
with three children.

Physical Exam:
VS: T: 97.9, BP 122/84, RR 15, 98% on 2LNC
GEN: No acute distress
HEENT: EOMI, Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
CHEST: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
SKIN: No rash
EXT: Warm, well perfused, 2+ pulses, trace pedal edema
NEURO: Alert and oriented x3, CN 2-12 intact, strength 5/5
BUE/BLE, sensory intact, fluent speech
PSYCH: Calm, appropriate

Pertinent Results:
[**2184-3-6**]
WBC-4.3 RBC-2.69* Hgb-7.9* Hct-24.7* MCV-92# Plt Ct-184
Neuts-66 Bands-2 Lymphs-14* Monos-13* Eos-0 Baso-0 Atyps-5*
Metas-0 Myelos-0
PT-15.4* PTT-32.4 INR(PT)-1.3*

Glucose-159* UreaN-46* Creat-2.4* Na-133 K-4.6 Cl-100 HCO3-21*
AnGap-17
ALT-21 AST-36 CK(CPK)-12* AlkPhos-139* TotBili-0.9  ALB 2.2
TotProt-6.3* Calcium-8.5 Phos-4.6* Mg-1.8
Lactate-2.6* K-4.5
Lipase 21

ABG 7.49 / 67 / 35
Serial troponins negative

RHEUM:
[**Doctor First Name **] 1:40
CRP-110.4*  ESR-142*

ENDO:
T4-3.3* Free T4-0.87*
07:45AM BLOOD Cortisol-11.0
02:00PM BLOOD Cortisol-24.2*

HEME:
Iron 15, TIBC 146, HAPTO 263, FERRITIN 1532, TRF 112, RETIC 1.9
VIT B12 767, FOLATE 14.7, Methylmalonic acid 280
SPEP  Elevated IgG

ID:
BLOOD CULTURES all no growth to date
URINE CULTURES negative
SPUTUM CULTURE negative
HIV negative
Monospot negative
Lyme serology negative
MRSA screen negative
RPR Non-reactive

FUNGAL CULTURE [**2184-3-20**] PENDING
EBV IgM Ab PENDING
CMV IgG IgM PENDING
HBsAg PENDING
HBsAb PENDING
HBcAb PENDING
HCV Ab PENDING

CXR [**2184-3-6**] IMPRESSION: No definite pneumonia, but PA/lateral
recommended when clinically feasible given tenting along right
hemidiaphragm.

CT ABD/PEL [**2184-3-9**]:
1. Faint pulmonary ground-glass opacities may represent atypical
infection or small airways inflammation.
2. Splenomegaly.
3. Bilateral adrenal nodules.
4. Severe atherosclerotic disease, with likely high-grade
stenosis of the
left renal artery origin.
5. Small fusiform dilatation of infrarenal aorta.
6. Small hypoattenuating renal lesions, too small to
characterize by CT
criteria.

VQ LUNG SCAN [**2184-3-11**]:
IMPRESSION: Intermediate-level suspicion (30-40%) for PE.

CTA CHEST [**2184-3-12**]:
1. No pulmonary embolism or acute aortic pathology.
2. Mild subpleural inter- and intra-septal thickening with lower
lobe
predominance but without honeycombing, raising suspicion for
interstitial lung disease such as NSIP or early UIP. Recommend
followup in six months with HRCT in prone position.
3. AP-elongation of upper trachea and lunate-shaped lower
trachea,
incompletely assess but suspicious for tracheobronchomalacia.
Recommend
followup with dedicated CT trachea if clinically indicated.
4. Marked coronary artery calcification.
5. Right adrenal nodule, grossly unchanged.

BONE MARROW BX [**2184-3-13**]:
1.  MARKEDLY HYPERCELLULAR (80-90% CELLULAR) MYELOID DOMINANT
BONE MARROW WITH DYSERYTHROPOIESIS AND DYSMEGAKARYOPOIESIS, SEE
NOTE 1.
2.  INCREASED IRON STORES WITH DECREASED SIDEROBLAST SUGGESTIVE
OF ANEMIA OF INFLAMMATORY BLOCK.
3. MILD PLASMACYTOSIS, SEE NOTE 2.

NOTE 1: In a patient with cytopenias, the marrow findings of
hypercellularity and dyspoiesis raise the possibility of
involvement by a myelodysplastic process.  Please correlate with
clinical findings to exclude other secondary causes of marrow
insults which may lead to dyspoietic changes; suggest follow-up
and repeat biopsy, if cytopenia persists in the absence of
identifiable secondary causes. Please correlate with cytogenetic
findings.
NOTE 2. Plasma cells are 3% of aspirate differential and 10-15%
of marrow core biopsy cellularity by CD138 staining. However, by
immunoglobulin light chain staining, plasma cells appear
polytypic with a slight lambda predominance, and morphologic
findings diagnostic of a plasma cell myeloma are not seen in
material evaluated. Please correlate with clinical, other
laboratory (e.g. SPEP, UPEP etc) and radiologic findings.

CT HEAD [**2184-3-13**] IMPRESSION: No hemorrhage, edema, or evidence of
acute process.

ECHOCARDIOGRAM [**2184-3-15**]: The left atrium is normal in size. The
estimated right atrial pressure is 0-10mmHg. Left ventricular
wall thicknesses and cavity size are normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
normal (LVEF>55%). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No masses or
vegetations are seen on the aortic valve, but cannot be fully
excluded due to suboptimal image quality. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. No masses or
vegetations are seen on the mitral valve, but cannot be fully
excluded due to suboptimal image quality. Trivial mitral
regurgitation is seen. No masses or vegetations are seen on the
tricuspid valve, but cannot be fully excluded due to suboptimal
image quality. The pulmonary artery systolic pressure could not
be determined. There is an anterior space which most likely
represents a promient fat pad.

Compared with the report of the prior study (images unavailable
for review) of [**2176-3-18**], posterior wall hypokinesis cannot be
definitively identified. No vegetations identified, but the
images are suboptimal. If clinically indicated, a
transesophageal echocardiographic examination is recommended.

RIGHT TEMPORAL ARTERY BIOPSY [**2184-3-18**]: Temporal artery with
intimal hyperplasia.  No arteritis seen.

MRI Brain and Pituitary [**2184-3-21**] IMPRESSION:
- Multiple punctate bifrontal and left parietal acute embolic
infarcts, without significant mass effect or associated shift of
midline structures.
- No abnormality of the pituitary gland is seen.
- Left mastoid opacification.


Brief Hospital Course:
74 year old man who presented with one month of fatigue and FUO.
 Initially admitted to ICU with hypotension, treated with
pressors and IVF, which then were successfully weaned off.
Patient was called out to floor.  Patient underwent an extensive
fever workup for hematologic, infectious, rheumatologic, and
endocrine sources, none of which revealed a definitive
diagnosis.

The patient developed altered mental status during the
admission; imaging of the head demonstrated multiple acute
embolic infarcts.  A TTE/TEE showed no evidence of vegetations.
No other cause for thromboembolic phenomena was identified.  The
patient's neurological status continued to decline on the floor,
and he became tachypneic / dyspneic but remained stable on
oxygen.

During one night of admission on the floor, the patient became
acutely unresponsive and was found to be asystolic.  A code blue
was called and the patient underwent CPR for PEA/asystole for
approximately 20 minutes, after which the patient was brought
back into NSR with a palpable pulse.

He was re-admitted to the ICU and underwent the Arctic Sun
cooling protocol.  Following rewarming, the patient remained
unresponsive and with a persistent vasopressor requirement.
Additional infectious workup continued to be negative.  Repeat
MRI brain was suggestive of watershed infarcts possibly
sustained during cardiac arrest.

After extensive discussion with the patient's family, including
his wife, it was decided that comfort measures only would be
pursued.  Vasopressors were withdrawn, the patient was extubated
and expired quietly thereafter at 3:05 PM on [**2184-4-2**].

Medications on Admission:
Atorvastatin 20 mg daily
Nitroglycerin 0.3 SL prn chest pain
Toprol 25 mg XL daily
Zestril 10 mg daily
Zolpidem 10 mg qhs
Aspirin 325 mg daily

Discharge Medications:
N/A

Discharge Disposition:
Expired

Discharge Diagnosis:
N/A

Discharge Condition:
N/A

Discharge Instructions:
N/A

Followup Instructions:
N/A

                             [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]

Completed by:[**2184-4-2**]
{'Fever, unspecified,Acute kidney failure, unspecified,Pneumonia, organism unspecified,Cerebral artery occlusion, unspecified with cerebral infarction,Acute respiratory failure,Mixed acid-base balance disorder,Bacteremia,Infection and inflammatory reaction due to other vascular device, implant, and graft,Coronary atherosclerosis of native coronary artery,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Other and unspecified hyperlipidemia,Anemia in chronic kidney disease,Unspecified acquired hypothyroidism,Chronic kidney disease, Stage III (moderate),Cardiac arrest,Thrombocytopenia, unspecified,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Cardiogenic shock'}


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: -- per admitting hospitalist --
74 year-old man presents with fatigue, chills, and poor PO
intake over one month. Patient reports that two months ago, he
was able to walk 30 minutes/day with weights, but over the few
weeks prior to admission, he has felt fatigued and is more
easily fatigued.  He has daytime somnolence and night insomnia.
He denies any localizing symptoms. He denies nausea, vomiting,
anorexia, abdominal pain, melena, BRBPR, new lymphadenopathy,
meningismus. Patient denies weight loss, but on review of the
records, patient has lost 10 pounds over one month. He reports
lightheadedness and dizziness with standing for several weeks.

MEDICAL HISTORY: Coronary artery disease s/p cardiac cath in [**2175**]
Hypertension
Chronic renal insufficiency
Hyperlipidemia
Benign prostatic hyperplasia
Insomnia

MEDICATION ON ADMISSION: Atorvastatin 20 mg daily
Nitroglycerin 0.3 SL prn chest pain
Toprol 25 mg XL daily
Zestril 10 mg daily
Zolpidem 10 mg qhs
Aspirin 325 mg daily

ALLERGIES: Zocor

PHYSICAL EXAM: VS: T: 97.9, BP 122/84, RR 15, 98% on 2LNC
GEN: No acute distress
HEENT: EOMI, Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
CHEST: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
SKIN: No rash
EXT: Warm, well perfused, 2+ pulses, trace pedal edema
NEURO: Alert and oriented x3, CN 2-12 intact, strength 5/5
BUE/BLE, sensory intact, fluent speech
PSYCH: Calm, appropriate

FAMILY HISTORY: Mother died at 95 secondary to CAD. Father died at 85 secondary
to pancreatic cancer and had known colon cancer. He is married
with three children.

SOCIAL HISTORY: Patient is a former smoker, quit at age 42. Used to drink beer
or wine twice daily but has not drank for a month due to
fatigue. 

### Response:
{'Fever, unspecified,Acute kidney failure, unspecified,Pneumonia, organism unspecified,Cerebral artery occlusion, unspecified with cerebral infarction,Acute respiratory failure,Mixed acid-base balance disorder,Bacteremia,Infection and inflammatory reaction due to other vascular device, implant, and graft,Coronary atherosclerosis of native coronary artery,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Other and unspecified hyperlipidemia,Anemia in chronic kidney disease,Unspecified acquired hypothyroidism,Chronic kidney disease, Stage III (moderate),Cardiac arrest,Thrombocytopenia, unspecified,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Cardiogenic shock'}
