CHIEF COMPLAINT: Fever, hypotension and back and chest pain.

PRESENT ILLNESS: This is a 62 year old with a
history significant for sarcoidosis complicated by cirrhosis
who presents with fever, noted to have many prior admissions
bowel obstructions, cholelithiasis, and spontaneous bacterial
peritonitis that was assumed (no paracentesis performed) and
placed on Ciprofloxacin.  Also recent mechanical fall causing
chest and back pain and recent urinary tract infection that
was not treated due to not filling her prescription.  She
presents with recurrent chest and back pain with fevers to
101.  Noted to have abdominal tenderness with rebound and
the 80s despite six liters of crystalloid.  She was given
Vancomycin, Gentamicin and Flagyl in the Emergency Department
with stress dose steroids and was transferred to the
Intensive Care Unit for management.

MEDICAL HISTORY: 1.  Cirrhosis secondary to sarcoidosis complicated by portal
hypertension, esophageal varices, ascites, splenomegaly and
thrombocytopenia.
2.  Sarcoidosis.
3.  Osteoporosis.
4.  Hypercholesterolemia.
5.  Hypertension.
6.  Anemia.
7.  PPD positive.
8.  Echocardiogram in [**2144-6-29**], with an ejection fraction of
55%, trace aortic regurgitation, 1+ mitral regurgitation.
9.  Status post total abdominal hysterectomy, bilateral
salpingo-oophorectomy.
10. Status post right knee replacement [**10/2142**], complicated by
Staphylococcus infection.
11. Status post right total hip replacement.
12. Cholelithiasis.
13. Spontaneous bacterial peritonitis.
14. Small bowel obstruction secondary to hernia.
15. Clostridium difficile colitis.
16. Status post pelvic fracture.
17. Urinary tract infection, proteus [**2144-8-30**].

MEDICATION ON ADMISSION: 1.  Ursodiol 300 mg p.o. three times a day.
2.  Hydromorphone 2 mg p.o. q4-6hours p.r.n.
3.  Evista 60 mg p.o. once daily.
4.  Propranolol 10 mg p.o. three times a day.
5.  Protonix 40 mg p.o. once daily.
6.  Folate 1 mg p.o. once daily.
7.  Prednisone 9 mg p.o. once daily.
8.  Multivitamin.
9.  Aldactone 100 mg p.o. once daily.
10. Tylenol p.r.n.

ALLERGIES: The patient has allergies to Penicillin which
causes rash and nausea, Keflex which causes rash and iodine.

PHYSICAL EXAM: 

FAMILY HISTORY: Significant for coronary artery disease,
cancer and diabetes mellitus.

SOCIAL HISTORY: The patient has eight children and lives
with her family.  She denies any smoking or alcohol abuse.
Urinary tract infection, site not specified,Cirrhosis of liver without mention of alcohol,Sarcoidosis,Pathologic fracture of vertebrae,Pure hypercholesterolemia,Unspecified essential hypertension
Urin tract infection NOS,Cirrhosis of liver NOS,Sarcoidosis,Path fx vertebrae,Pure hypercholesterolem,Hypertension NOS
Admission Date:  [**2144-11-4**]     Discharge Date:  [**2144-11-13**]

Date of Birth:   [**2082-1-26**]     Sex:  F

Service:  [**Company 191**]-EAST
CHIEF COMPLAINT:  Fever, hypotension and back and chest pain.

HISTORY OF PRESENT ILLNESS:  This is a 62 year old with a
history significant for sarcoidosis complicated by cirrhosis
who presents with fever, noted to have many prior admissions
bowel obstructions, cholelithiasis, and spontaneous bacterial
peritonitis that was assumed (no paracentesis performed) and
placed on Ciprofloxacin.  Also recent mechanical fall causing
chest and back pain and recent urinary tract infection that
was not treated due to not filling her prescription.  She
presents with recurrent chest and back pain with fevers to
101.  Noted to have abdominal tenderness with rebound and
the 80s despite six liters of crystalloid.  She was given
Vancomycin, Gentamicin and Flagyl in the Emergency Department
with stress dose steroids and was transferred to the
Intensive Care Unit for management.

PAST MEDICAL HISTORY:
1.  Cirrhosis secondary to sarcoidosis complicated by portal
hypertension, esophageal varices, ascites, splenomegaly and
thrombocytopenia.
2.  Sarcoidosis.
3.  Osteoporosis.
4.  Hypercholesterolemia.
5.  Hypertension.
6.  Anemia.
7.  PPD positive.
8.  Echocardiogram in [**2144-6-29**], with an ejection fraction of
55%, trace aortic regurgitation, 1+ mitral regurgitation.
9.  Status post total abdominal hysterectomy, bilateral
salpingo-oophorectomy.
10. Status post right knee replacement [**10/2142**], complicated by
Staphylococcus infection.
11. Status post right total hip replacement.
12. Cholelithiasis.
13. Spontaneous bacterial peritonitis.
14. Small bowel obstruction secondary to hernia.
15. Clostridium difficile colitis.
16. Status post pelvic fracture.
17. Urinary tract infection, proteus [**2144-8-30**].

ALLERGIES:  The patient has allergies to Penicillin which
causes rash and nausea, Keflex which causes rash and iodine.

MEDICATIONS ON ADMISSION:
1.  Ursodiol 300 mg p.o. three times a day.
2.  Hydromorphone 2 mg p.o. q4-6hours p.r.n.
3.  Evista 60 mg p.o. once daily.
4.  Propranolol 10 mg p.o. three times a day.
5.  Protonix 40 mg p.o. once daily.
6.  Folate 1 mg p.o. once daily.
7.  Prednisone 9 mg p.o. once daily.
8.  Multivitamin.
9.  Aldactone 100 mg p.o. once daily.
10. Tylenol p.r.n.

FAMILY HISTORY:  Significant for coronary artery disease,
cancer and diabetes mellitus.

SOCIAL HISTORY:  The patient has eight children and lives
with her family.  She denies any smoking or alcohol abuse.

PHYSICAL EXAMINATION:  On admission, temperature is 97.9,
temperature maximum of 101, heart rate of 75, blood pressure
108/68, respiratory rate 14, oxygen saturation 97% in room
air.  In general, this is an elderly female who appears much
older than stated age.  Head, eyes, ears, nose and throat -
Sclera nonicteric.  Extraocular movements are intact.  Mucous
membranes are dry.  No jugular venous distention.
Cardiovascular examination - systolic ejection murmur at the
upper sternal border to the carotids, IV/VI and at apex to
axilla  IV/VI.  The lungs are clear to auscultation
anterolaterally.  Abdominal examination is distended,
positive ascites, positive tenderness to palpation with
rebound and guarding.  Extremities - 2 to 3+
pitting edema, left lower extremity in brace, no splinter
hemorrhages or [**Last Name (un) 1003**] or Osler nodes.  Rectal per the
Emergency Department was guaiac negative, however, subsequent
stools had flecks of blood in them.

LABORATORY DATA:  White blood cell count was 8.3, 86%
neutrophils, 8% lymphocytes, 3% monocytes, hematocrit 32.9,
platelet count 129,000.  Prothrombin time 16, partial
thromboplastin time 34, INR 1.7.  Fibrinogen 188, D-dimer
1000 to [**2141**]. Sodium 140, potassium 5.1 and hemolyzed,
chloride 106, CO2 24, blood urea nitrogen 22, creatinine 1.1,
glucose 91, ALT 19, AST 34, CPK 56, troponin I less than 0.3.
Alkaline phosphatase 355, total bilirubin 4.0, amylase 355,
lipase 8.  Ascitic fluid results were albumin 2.8, white
blood cell count [**Pager number **], red blood cells 4,333, 60% polys, 6%
lymphocytes, 31% monocytes, 2% enucleated red blood cells, 1%
mesothelial cells.  Urinalysis revealed nitrite positive,
white blood cell count greater than 50, few bacteria and a
few yeast.

Chest x-ray on admission revealed no new infiltrates,
persistent widened mediastinum thought secondary to
adenopathy which is old.  CT of the abdomen resulted in a
sclerotic liver with massive ascites, cholelithiasis,
reticulonodular pattern at the lung bases.  Electrocardiogram
revealed sinus tachycardia at 120, Q waves in II, III and
aVF.  Compared to previous tracing, resolution of ST segment
elevation.

HOSPITAL COURSE:
1.  Hypotension - The patient was given seven liters of
normal saline in the Emergency Department and transferred to
the Intensive Care Unit with stable blood pressure for treatment
of hypotension and incipient sepsis syndrome.   Her Propranolol
was held and her blood pressure remained stable throughout her
hospital course.

2.  Infectious disease - The patient was empirically started
on Vancomycin, Gentamicin and Flagyl per the Emergency
Department.  The gastroenterology service was consulted for
possible endoscopic retrograde cholangiopancreatography to
examine the biliary tree for possible cholangitis, but this was
deferred as etiology of her pain became clear.  Her antibiotic
regimen was changed to Vancomycin, Levofloxacin, Flagyl and
the infectious disease service was also consulted and
recommended Levofloxacin for empiric coverage for suspected
spontaneous bacterial peritonitis and Flagyl for prophylaxis
against Clostridium difficile.  Ascites culture empirically
grew out gram negative rods and was identified as
Citrobacter.  She will be continued on a ten day course of
Levofloxacin, Flagyl. She was also treated with Diflucan to treat
her Candiduria. Her Foley catheter was also changed at this time.

3.  Oliguria - On transfer to the Intensive Care Unit, it was
noted that the patient was having suboptimal urine output
most likely from hypotension and hypovolemia. Her Lasix and
Aldactone were subsequently held and attempts to volume replete
were performed with albumin infusion and gentle intravenous fluid
hydration.  Her oliguria had improved throughout her hospital
admission and her Lasix and Aldactone were subsequently
restarted when her blood pressure stabilized.  The albumin
infusion was stopped and she continued to produce adequate
amounts of urine.

4.  Liver transplant - The gastroenterology service also
commented on possibility for liver transplant, however, given
the extent of her aortic valve disease and her restrictive
lung disease, she was thought unlikely to be a favorable
candidate. An arterial blood gases was performed in room air
revealing no a/A gradient.  Attempts were made to clarify the
status of her aortic valve given her prior echocardiographic
reports but was unsuccessful.  She will need pulmonary follow-up
with Dr. [**Last Name (STitle) 575**] in approximately two weeks as well as an
appointment with cardiology to further assess her possible
liver transplant.

5.  Anemia, thrombocytopenia - The patient was noted to have
a drop in hematocrit and platelet count throughout the first
three days of her hospital course.  DIC laboratories were not
conclusive.  She was transfused two units of packed red blood
cells and her platelet counts were followed and eventually
started increasing without intervention.

6.  Back pain, chest pain - The patient ruled out for
myocardial infarction by cardiac enzymes.  Spine films showed
compression fractures of T wave and L3 of uncertain age.  Rib
films were also obtained which showed a left number two rib
fracture of unknown age.  A magnetic resonance scan of the
spine was performed to rule out osteomyelitis and tumor which
revealed a T11 chronic wedge fracture of C4 to C6,
spondylosis, no abnormal spine abnormality.  Her pain was
well controlled with Hydromorphone p.r.n. and was gradually
improving at the time of discharge.

7.  Sarcoidosis - The patient was given stress dose steroids
for acute process and was subsequently weaned back to her
baseline of Prednisone 9 mg p.o. once daily.

8.  Osteoporosis - The patient continued her Evista treatment
as planned.  She states that Alendronate is not tolerated
because she cannot sit up fully to properly take this
medication.

CONDITION ON DISCHARGE: Stable.

DISCHARGE STATUS:  The patient will be discharged to acute
rehabilitation facility, [**Last Name (un) 14482**].  She will
require follow-up appointments with her primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], Dr. [**Last Name (STitle) 575**] in approximately two
weeks as well as a cardiology clinic appointment to follow-up
her aortic valve status.

MEDICATIONS ON DISCHARGE:
1.  Ursodiol 300 mg p.o. three times a day.
2.  Hydromorphone 2 mg p.o. q4-6hours p.r.n.
3.  Evista 60 mg p.o. once daily.
4.  Levofloxacin 500 mg p.o. once daily times two days.
5.  Protonix 40 mg p.o. once daily.
6.  Folate 1 mg p.o. once daily.
7.  Prednisone 9 mg p.o. once daily.
8.  Multivitamin.
9.  Aldactone 100 mg p.o. once daily.
10. Tylenol p.r.n.
11. Flagyl 500 mg p.o. three times a day times two days.
12. Lasix 40 mg p.o. once daily.
13. Vitamin K 10 mg subcutaneous times one day.
14. Calcitonin two sprays in each nostril twice a day for 2-4
weeks to treat compression fracture.

DISCHARGE DIAGNOSES:
1.  Spontaneous bacterial peritonitis.
2.  Urinary tract infection.
3.  Anemia requiring packed red blood cell transfusion.
4.  Cirrhosis.
5.  Sarcoidosis.
6.  Osteoporosis.
7.  Hypercholesterolemia.
8.  Hypertension.




                          [**First Name11 (Name Pattern1) 4283**] [**Last Name (NamePattern4) 4284**], M.D.  [**MD Number(1) 7551**]

Dictated By:[**Name8 (MD) 5406**]

MEDQUIST36

D:  [**2144-11-15**]  21:06
T:  [**2144-11-16**]  18:37
JOB#:  [**Job Number 14483**]
{'Urinary tract infection, site not specified,Cirrhosis of liver without mention of alcohol,Sarcoidosis,Pathologic fracture of vertebrae,Pure hypercholesterolemia,Unspecified essential hypertension'}


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, hypotension and back and chest pain.

PRESENT ILLNESS: This is a 62 year old with a
history significant for sarcoidosis complicated by cirrhosis
who presents with fever, noted to have many prior admissions
bowel obstructions, cholelithiasis, and spontaneous bacterial
peritonitis that was assumed (no paracentesis performed) and
placed on Ciprofloxacin.  Also recent mechanical fall causing
chest and back pain and recent urinary tract infection that
was not treated due to not filling her prescription.  She
presents with recurrent chest and back pain with fevers to
101.  Noted to have abdominal tenderness with rebound and
the 80s despite six liters of crystalloid.  She was given
Vancomycin, Gentamicin and Flagyl in the Emergency Department
with stress dose steroids and was transferred to the
Intensive Care Unit for management.

MEDICAL HISTORY: 1.  Cirrhosis secondary to sarcoidosis complicated by portal
hypertension, esophageal varices, ascites, splenomegaly and
thrombocytopenia.
2.  Sarcoidosis.
3.  Osteoporosis.
4.  Hypercholesterolemia.
5.  Hypertension.
6.  Anemia.
7.  PPD positive.
8.  Echocardiogram in [**2144-6-29**], with an ejection fraction of
55%, trace aortic regurgitation, 1+ mitral regurgitation.
9.  Status post total abdominal hysterectomy, bilateral
salpingo-oophorectomy.
10. Status post right knee replacement [**10/2142**], complicated by
Staphylococcus infection.
11. Status post right total hip replacement.
12. Cholelithiasis.
13. Spontaneous bacterial peritonitis.
14. Small bowel obstruction secondary to hernia.
15. Clostridium difficile colitis.
16. Status post pelvic fracture.
17. Urinary tract infection, proteus [**2144-8-30**].

MEDICATION ON ADMISSION: 1.  Ursodiol 300 mg p.o. three times a day.
2.  Hydromorphone 2 mg p.o. q4-6hours p.r.n.
3.  Evista 60 mg p.o. once daily.
4.  Propranolol 10 mg p.o. three times a day.
5.  Protonix 40 mg p.o. once daily.
6.  Folate 1 mg p.o. once daily.
7.  Prednisone 9 mg p.o. once daily.
8.  Multivitamin.
9.  Aldactone 100 mg p.o. once daily.
10. Tylenol p.r.n.

ALLERGIES: The patient has allergies to Penicillin which
causes rash and nausea, Keflex which causes rash and iodine.

PHYSICAL EXAM: 

FAMILY HISTORY: Significant for coronary artery disease,
cancer and diabetes mellitus.

SOCIAL HISTORY: The patient has eight children and lives
with her family.  She denies any smoking or alcohol abuse. 

### Response:
{'Urinary tract infection, site not specified,Cirrhosis of liver without mention of alcohol,Sarcoidosis,Pathologic fracture of vertebrae,Pure hypercholesterolemia,Unspecified essential hypertension'}
