CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is a 54 year old
male with multiple medical problems transferred from [**Hospital1 33995**] for management of left ventricular
dysfunction and worsening renal failure.  The patient's
history is notable for Hodgkin's disease at age 27, at which
time he underwent mantel radiation and splenectomy.

MEDICAL HISTORY: 1.  Hodgkin's disease at age 27, status post mantel radiation
therapy and splenectomy.
2.  Coronary artery disease history, status post inferior
myocardial infarction in [**2115**], complicated by left
ventricular thrombus and cerebrovascular accident. History of
left circumflex stent in 03/00.  History of nonsustained
ventricular tachycardia and inducible ventricular
tachycardia, status post ICD in 03/00.  History of
constrictive pericarditis and valvular dysfunction secondary
to mantel radiation therapy, status post mitral valve
replacement, tricuspid valve replacement, both St. [**Male First Name (un) 1525**],
pericardial stripping [**2123-8-10**].  The patient not
anticoagulated because of consistent bleeding risk.  He is
not anticoagulation candidate.
3.  History of congestive heart failure, ejection fraction 20
to 30%.
4.  History of Methicillin resistant Staphylococcus aureus
pneumonia.
5.  History of aspiration pneumonia, status post tracheostomy
and status post percutaneous endoscopic gastrostomy
placement.
6.  Hypercholesterolemia.
7.  Status post cervical discectomy.
8.  History of hypothyroidism.
9.  History of iron deficiency anemia.

MEDICATION ON ADMISSION: 1.  Epogen 5000 units Monday, Wednesday and Friday.
2.  Lasix 40 mg q.d.
3.  Ceptaz 2.25 q8hours.
4.  Amiodarone 400 mg q.d.
5.  Captopril 18.75 mg t.i.d.
6.  Celexa 10 mg q.d.
7.  Benadryl 25 mg q.i.d.
8.  Lactulose 15 b.i.d.
9.  Lansoprazole 30 q.d.
10. Levothyroxine 30 mcg q.d.
11. L-Thyroxine 5 mcg b.i.d.
12. Reglan 10 intravenous t.i.d.
13. Albuterol two puffs q4hours.
14. Tylenol 650 mg q4hours p.r.n.
15. Ativan 0.5 mg q6hours p.r.n.
16. Fleets q.d. p.r.n.

ALLERGIES: The patient prior to this admission was listed as
allergic to Imipenem causing a rash.

PHYSICAL EXAM: 

FAMILY HISTORY: Colon cancer in his father who ultimately
died of that ailment.

SOCIAL HISTORY: The patient was married, lived at [**Hospital1 5593**] Rehabilitation.  No alcohol and no tobacco and
no intravenous drug abuse.
Acute kidney failure with lesion of tubular necrosis,Congestive heart failure, unspecified,Hodgkin's disease, unspecified type, unspecified site, extranodal and solid organ sites,Unspecified osteomyelitis, other specified sites,Acute respiratory failure,Hyposmolality and/or hyponatremia,Tracheostomy status,Automatic implantable cardiac defibrillator in situ
Ac kidny fail, tubr necr,CHF NOS,Hdgk dis unsp xtrndl org,Osteomyelit NOS-oth site,Acute respiratry failure,Hyposmolality,Tracheostomy status,Status autm crd dfbrltr
Admission Date:  [**2124-1-26**]     Discharge Date:

Date of Birth:   [**2069-5-9**]     Sex:  M

Service:

HISTORY OF PRESENT ILLNESS:  The patient is a 54 year old
male with multiple medical problems transferred from [**Hospital1 33995**] for management of left ventricular
dysfunction and worsening renal failure.  The patient's
history is notable for Hodgkin's disease at age 27, at which
time he underwent mantel radiation and splenectomy.

Complications of radiation therapy included early coronary
artery disease in [**2115**], with an inferior myocardial
infarction complicated by a left ventricular thrombus,
history of left circumflex stent placed in 03/00, ICD implant
as well for nonsustained ventricular tachycardia and
inducible ventricular tachycardia in Electrophysiology
Laboratory.

The patient presented in [**Month (only) 205**] with pulmonary edema, acute
renal failure, evaluated by catheterization revealing
ejection fraction of 30%, restrictive hemodynamics.  He
ultimately underwent pericardial stripping and received at
St. [**Male First Name (un) 1525**] prosthetic mitral and tricuspid valve.  He
underwent a tracheostomy and percutaneous endoscopic
gastrostomy placement after failing to wean off the
ventilator in the same month.

He had two admissions since then requiring Intensive Care
Unit care.  His most recent prior to this admission that I am
dictating was [**12-2**], and it was notable for congestive heart
failure/renal failure.  He had trials of multiple regimens to
improve left ventricular dysfunction and increase renal
perfusion.  Milrinone was attempted at that time because
hypotension, Dopamine and Lasix were unsuccessful.  Dopamine
and Lasix were successful for a short amount of time,
improved left ventricular function and end organ perfusion
temporarily.

His hospital course was also notable for Methicillin
resistant Staphylococcus aureus positive sputum and excessive
bleeding on Coumadin, thus making him not an anticoagulation
candidate. Ultimately he was discharged to [**Hospital1 **]
Rehabilitation for further management and returned to [**Hospital1 1444**] after four to five days of
worsening renal function with a creatinine that was 3.4, up
from his discharge creatinine of 1.2 and his baseline at [**Hospital1 5593**] of 1.5 and also elevated blood urea nitrogen at
186.

PAST MEDICAL HISTORY:
1.  Hodgkin's disease at age 27, status post mantel radiation
therapy and splenectomy.
2.  Coronary artery disease history, status post inferior
myocardial infarction in [**2115**], complicated by left
ventricular thrombus and cerebrovascular accident. History of
left circumflex stent in 03/00.  History of nonsustained
ventricular tachycardia and inducible ventricular
tachycardia, status post ICD in 03/00.  History of
constrictive pericarditis and valvular dysfunction secondary
to mantel radiation therapy, status post mitral valve
replacement, tricuspid valve replacement, both St. [**Male First Name (un) 1525**],
pericardial stripping [**2123-8-10**].  The patient not
anticoagulated because of consistent bleeding risk.  He is
not anticoagulation candidate.
3.  History of congestive heart failure, ejection fraction 20
to 30%.
4.  History of Methicillin resistant Staphylococcus aureus
pneumonia.
5.  History of aspiration pneumonia, status post tracheostomy
and status post percutaneous endoscopic gastrostomy
placement.
6.  Hypercholesterolemia.
7.  Status post cervical discectomy.
8.  History of hypothyroidism.
9.  History of iron deficiency anemia.

ALLERGIES:  The patient prior to this admission was listed as
allergic to Imipenem causing a rash.

SOCIAL HISTORY:  The patient was married, lived at [**Hospital1 5593**] Rehabilitation.  No alcohol and no tobacco and
no intravenous drug abuse.

FAMILY HISTORY:   Colon cancer in his father who ultimately
died of that ailment.

MEDICATIONS ON ADMISSION:
1.  Epogen 5000 units Monday, Wednesday and Friday.
2.  Lasix 40 mg q.d.
3.  Ceptaz 2.25 q8hours.
4.  Amiodarone 400 mg q.d.
5.  Captopril 18.75 mg t.i.d.
6.  Celexa 10 mg q.d.
7.  Benadryl 25 mg q.i.d.
8.  Lactulose 15 b.i.d.
9.  Lansoprazole 30 q.d.
10. Levothyroxine 30 mcg q.d.
11. L-Thyroxine 5 mcg b.i.d.
12. Reglan 10 intravenous t.i.d.
13. Albuterol two puffs q4hours.
14. Tylenol 650 mg q4hours p.r.n.
15. Ativan 0.5 mg q6hours p.r.n.
16. Fleets q.d. p.r.n.

PHYSICAL EXAMINATION:  On admission, the patient is 75
kilograms, temperature 97.9, blood pressure 105/43, pulse 80
paced, respiratory rate 28, 100% on 50% FIO2 on assist
control.  Inputs and outputs not recorded at the time of
admission.  Ventilatory was assist control at 500/16 50%,
PEEP of 5, PIP 36, plateau not recorded.  Generally speaking,
the patient was in no apparent distress.  Head, eyes, ears,
nose and throat - tracheostomy site clean, dry and intact.
Neck - unable to assess jugular venous distention.
Cardiovascular regular rate and rhythm, S1 and S2, no
murmurs, mechanical valve sounds auscultated for S1.
Respiratory - ventilated breath sounds, rhonchi bilaterally,
no rales.  The abdomen is soft, distended, normoactive bowel
sounds.  Back - 3.0 by 4.0 centimeter times 5.0 centimeter
deep sacral decubitus.  Extremities - cachectic, no edema,
bilateral heel ulcers.  Lines - Left hand PICC.  Skin -
bilateral left upper and lower extremity warm and well
perfused.

LABORATORY DATA:  On admission, white count 11.7, hematocrit
28.8, platelets 295,000.  Sodium 131, potassium 5.0, chloride
97, bicarbonate 21, blood urea nitrogen 186, creatinine 3.4.
The patient had a differential of 81 neutrophils, 1 bands, 12
eosinophils, 3 lymphocytes with positive toxic granulation.

HOSPITAL COURSE:  The patient was admitted for possible
Dobutamine or Dopamine trial.  Ultimately, the decision was
made not to try that and the patient was dry so he initially
received fluid boluses for the goal of improving his urinary
output.  Initially, his urinary output was on the low side
making 500 ccs in his first twelve hours in the Intensive
Care Unit ultimately with the creatinine that stayed stable
or elevated to 3.4 on [**2124-1-27**].

We continued to give the patient fluid boluses, checked the
fractional excretion of urea given the fact that he was on a
diuretic prior to admission that revealed that he was
prerenal.  On deciding this, we gave him fluid and the
patient started to have a slightly increased urinary output
with a total of 796 on his second hospital day although his
creatinine remained stable.

The patient had a blood pressure that continued to be on the
low side even for him though there have been frequent issues
in the past of him being hypotensive while still perfusing
his brain and also having good renal function.  He has had a
history of multiple A lines, all of which have been
complicated resulting in the decision to no longer place A
lines.  Also because of peripheral vascular disease, his
blood pressure tends to run about 30 to 40 points lower than
his A line tracing when he was on the [**Hospital Ward Name 517**] on a prior
admission.

On [**2124-1-29**], the patient's TSH returned at 40 so a full set
of thyroid function laboratories were ordered, ultimately
revealing that he was profoundly hypothyroid.  We continued
to give the patient fluids with mildly improved renal
function with a creatinine that went down to 2.8 on [**2124-1-31**].
He, however, continued to have a blood urea nitrogen elevated
to 148.  He received a unit of packed red blood cells during
this hospitalization to improve his hematocrit to 35.0.  He
continued his dose.

It was felt that he had a large decubitus on his back.
Plastic surgery was consulted and they felt that he was not a
surgical candidate and that they could not probe down to bone
on [**2124-1-31**].  He also was noted to have a heel ulcer that was
evaluated by podiatry.  Ultimately, he had noninvasive
arterial studies that revealed iliac disease bilaterally.  We
are still awaiting the podiatry plan regarding his heel ulcer
given that it is down to his bone and does qualify as an
osteomyelitis.

Throughout the hospital course, the patient also was weaned
off his ventilator, ultimately being on a tracheostomy mask
for ten to twelve hours a day.  He was started on Bicitra.
Ultimately his Captopril was discontinued and on renal
consultation it was noted that the patient had high
eosinophils peripherally, eosinophils in his urine, prompting
them to discontinue his Zosyn and his Celexa for fear that
those were causes interstitial nephritis.

Endocrine was also asked to see the patient because of his
profound hypothyroidism with both reduced T3 and T4 and very
elevated TSH, ultimately recommending intravenous repletion
of his thyroid hormone.  The patient was started
simultaneously on intravenous thyroid replacement as well as
on steroids on [**2124-2-4**].  His blood pressure was slightly
improved after that and his creatinine began to improve
rapidly within a day after initiation of those two
interventions.  Ultimately, the patient at the time of this
dictation had a creatinine that returned to the 2.2 range
with urine outputs greater than one liter a day, not on
diuretic.  Based on the interstitial nephritis, there is a
plan to continue his steroids and ultimately to shoot for
tapering after two weeks to off.  There is no plan for
discontinuing his Levothyroxine intravenous.

Also another issue that came up are his multiple infectious
issues in the hospital.  He was started on Levofloxacin,
Flagyl and Vancomycin, the Vancomycin dosed for levels
because of his osteomyelitis in his heel and because of his
sacral decubitus.  The patient's white count remained stable
and he has been afebrile throughout his entire course.  He
has several swabs that are growing Methicillin resistant
Staphylococcus aureus from his heel.  He has a sputum culture
that is growing Klebsiella sensitive to Ceftazidime only in
his sputum and a pseudomonas growing from his sacral
decubitus that is highly resistant with sensitivity to
Gentamicin.  The patient ultimately does not appear infected
at the moment but because he is on steroids, also started
Diflucan.




                          [**Name6 (MD) **] [**Name8 (MD) **], M.D.  [**MD Number(1) 968**]

Dictated By:[**Name8 (MD) 24764**]

MEDQUIST36

D:  [**2124-2-8**]  16:32
T:  [**2124-2-8**]  17:02
JOB#:  [**Job Number **]


Admission Date:  [**2124-1-26**]       Discharge Date:  [**2124-2-11**]

Date of Birth:   [**2069-5-9**]       Sex:  M

Service:

ADDENDED MEDICINE LIST:
1.  Reglan 10 mg by gastrostomy tube q8hours.
2.  Epogen 5000 units subcutaneous every Sunday, Tuesday,
Thursday.
3.  Amiodarone 400 mg by gastrostomy tube q.d.
4.  Albuterol four puffs MDI q.i.d.
5.  Vitamin C 500 mg by gastrostomy tube q.d.
6.  Zinc Sulfate 220 meq by gastrostomy tube q.d.
7.  Digoxin 0.125 mg by gastrostomy tube every other day.
8.  TUMS two tablets by gastrostomy tube three times a day.
9.  Prevacid 30 mg by gastrostomy tube every day.
10. Levofloxacin 250 mg by gastrostomy tube q.d., date
started [**2124-2-4**], duration six weeks.
11. Flagyl 500 mg p.o. b.i.d., date initiated [**2124-2-4**],
continue for six weeks.
12. Vancomycin dosed for levels less than 12.0.  Continue for
six weeks, start date [**2124-2-4**].
13. Prednisone current dose 40 mg which is continued through
[**2124-2-12**], then should be dose reduced to 35 which would
continue through [**2124-2-16**], then reduced to 30 and continued
through [**2124-2-20**], then reduced to 25 and continued through
[**2124-2-24**], then reduced to 20 and continued through [**2124-2-28**],
then reduced to 15 and continued through [**2124-3-4**], then
reduced to 10 and continued to [**2124-3-8**], then reduced to 5
and continued until [**2124-3-12**], ultimately to discontinue on
[**2124-3-13**].
13. Diflucan 200 mg by gastrostomy tube q.d. while on
steroids.
14. Levothyroxine 75 mcg intravenous q.d.
15. Free water boluses 350 ccs by gastrostomy tube q.i.d.
16. Tube feeds are currently 3/4 strength Nepro with 45 grams
ProMod powder at 45 cc/hour.
17. Ativan 0.5 mg intravenous q6hours p.r.n. and q.h.s.
18. Benadryl 25 mg by gastrostomy tube q6hours p.r.n. and
q.h.s.
19. Tylenol 650 mg by gastrostomy tube q4-6hours p.r.n.
20. Lactulose 15 ccs by gastrostomy tube b.i.d. p.r.n.
21. Hystatin cream topical p.r.n.
22. Sarna cream topically p.r.n.
23. Atarax 10 mg by gastrostomy tube q.i.d. p.r.n. for
pruritus.




                            [**Name6 (MD) **] [**Name8 (MD) **], M.D.  [**MD Number(1) 968**]

Dictated By:[**Name8 (MD) 24764**]
MEDQUIST36

D:  [**2124-2-9**]  17:55
T:  [**2124-2-9**]  18:23
JOB#:  [**Job Number **]
{"Acute kidney failure with lesion of tubular necrosis,Congestive heart failure, unspecified,Hodgkin's disease, unspecified type, unspecified site, extranodal and solid organ sites,Unspecified osteomyelitis, other specified sites,Acute respiratory failure,Hyposmolality and/or hyponatremia,Tracheostomy status,Automatic implantable cardiac defibrillator in situ"}


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: The patient is a 54 year old
male with multiple medical problems transferred from [**Hospital1 33995**] for management of left ventricular
dysfunction and worsening renal failure.  The patient's
history is notable for Hodgkin's disease at age 27, at which
time he underwent mantel radiation and splenectomy.

MEDICAL HISTORY: 1.  Hodgkin's disease at age 27, status post mantel radiation
therapy and splenectomy.
2.  Coronary artery disease history, status post inferior
myocardial infarction in [**2115**], complicated by left
ventricular thrombus and cerebrovascular accident. History of
left circumflex stent in 03/00.  History of nonsustained
ventricular tachycardia and inducible ventricular
tachycardia, status post ICD in 03/00.  History of
constrictive pericarditis and valvular dysfunction secondary
to mantel radiation therapy, status post mitral valve
replacement, tricuspid valve replacement, both St. [**Male First Name (un) 1525**],
pericardial stripping [**2123-8-10**].  The patient not
anticoagulated because of consistent bleeding risk.  He is
not anticoagulation candidate.
3.  History of congestive heart failure, ejection fraction 20
to 30%.
4.  History of Methicillin resistant Staphylococcus aureus
pneumonia.
5.  History of aspiration pneumonia, status post tracheostomy
and status post percutaneous endoscopic gastrostomy
placement.
6.  Hypercholesterolemia.
7.  Status post cervical discectomy.
8.  History of hypothyroidism.
9.  History of iron deficiency anemia.

MEDICATION ON ADMISSION: 1.  Epogen 5000 units Monday, Wednesday and Friday.
2.  Lasix 40 mg q.d.
3.  Ceptaz 2.25 q8hours.
4.  Amiodarone 400 mg q.d.
5.  Captopril 18.75 mg t.i.d.
6.  Celexa 10 mg q.d.
7.  Benadryl 25 mg q.i.d.
8.  Lactulose 15 b.i.d.
9.  Lansoprazole 30 q.d.
10. Levothyroxine 30 mcg q.d.
11. L-Thyroxine 5 mcg b.i.d.
12. Reglan 10 intravenous t.i.d.
13. Albuterol two puffs q4hours.
14. Tylenol 650 mg q4hours p.r.n.
15. Ativan 0.5 mg q6hours p.r.n.
16. Fleets q.d. p.r.n.

ALLERGIES: The patient prior to this admission was listed as
allergic to Imipenem causing a rash.

PHYSICAL EXAM: 

FAMILY HISTORY: Colon cancer in his father who ultimately
died of that ailment.

SOCIAL HISTORY: The patient was married, lived at [**Hospital1 5593**] Rehabilitation.  No alcohol and no tobacco and
no intravenous drug abuse. 

### Response:
{"Acute kidney failure with lesion of tubular necrosis,Congestive heart failure, unspecified,Hodgkin's disease, unspecified type, unspecified site, extranodal and solid organ sites,Unspecified osteomyelitis, other specified sites,Acute respiratory failure,Hyposmolality and/or hyponatremia,Tracheostomy status,Automatic implantable cardiac defibrillator in situ"}
