CHIEF COMPLAINT: 

PRESENT ILLNESS: A 41 year-old African-American
female with a history of HIV, dilated cardiomyopathy who
presented to the Emergency Room complaining of left lower
extremity pain.  The patient states that she was unable to
walk today.  She has had left leg particularly in the foot
and shin for about three weeks and had noticed some weakness,
initially unable to walk around her room and developed left
foot pain that resolved with rest.  She did notice some
increased swelling and redness in this area.

MEDICAL HISTORY: 1) HIV:  through sexual transmission
diagnosed in [**2176-1-6**]. Patient was recently restarted
on [**Doctor Last Name **] therapy in [**2185-2-5**] with Adobutadin,
limbividine, avacar, Navaripine.  At that time she had a CD4
count of 334 and a viral load of 12.3 x 103.  However,
patient subsequently self discontinued her [**Doctor Last Name **] therapy about
[**Doctor Last Name **] weeks prior to admission.
2) Multiple pneumococcal pneumonia infections in the past.
3) Thrush.
4) Lymphocytic interstitial pneumonia in [**2182-1-5**].
5) Asthma.
6) Anemia.
7) [**Doctor First Name **] in [**2183**].  Subsequent negative sputum cultures.
8) Positive PPD in [**2184-2-6**] treated with ethambutol for
three months.
9) Status post total abdominal hysterectomy for fibroids and
hemorrhagic.
10) Hepatitis C, undetectable viral load in [**2184-2-6**].
11( Herpes.
12) Congestive heart failure with dilated cardiomyopathy,
with ejection fraction of less than 20 percent by
transthoracic echocardiogram in [**2184-8-5**], 1 to 2+
mitral regurgitation, 2+ tricuspid regurgitation, mild to
moderate pulmonary hypertension, moderately dilated left
atrium, right ventricle dilation, right ventricular systolic
function decreased.
13) Mediastinal lymphadenopathy with negative subcarinal
node.
14) Positive [**Doctor First Name **].
15) Cardiac catheterization in [**2184-8-5**] revealed pulmonary
capillary wedge pressure of 28, no coronary artery disease.
16) History of cocaine abuse.
17) Status post transient ischemic attack in [**2184-8-5**] that
lasted for approximately 30 minutes with an MRA that was
negative.

MEDICATION ON ADMISSION: 

ALLERGIES: Retrovir.

PHYSICAL EXAM: 

FAMILY HISTORY: Significant for a mother with breast cancer.

SOCIAL HISTORY: Patient lives with her daughter and
granddaughter.  She has used cocaine in the past but claims
that her last use was about on week prior to presentation
(this was disproved by urine toxicology screen).  Social
alcohol use.  Smokes one pack a day for the past ten year.
No pets.
Embolism and thrombosis of iliac artery,Subendocardial infarction, initial episode of care,Cerebral embolism with cerebral infarction,Pneumonia, organism unspecified,Congestive heart failure, unspecified,Other primary cardiomyopathies,Cocaine abuse, unspecified,Asymptomatic human immunodeficiency virus [HIV] infection status,Unspecified essential hypertension
Iliac artery embolism,Subendo infarct, initial,Crbl emblsm w infrct,Pneumonia, organism NOS,CHF NOS,Prim cardiomyopathy NEC,Cocaine abuse-unspec,Asymp hiv infectn status,Hypertension NOS
Admission Date:  [**2185-4-10**]       Discharge Date:  [**2185-4-19**]

Date of Birth:   [**2143-7-12**]       Sex:  F

Service:  Medicine-Bloomgart

HISTORY OF PRESENT ILLNESS:  A 41 year-old African-American
female with a history of HIV, dilated cardiomyopathy who
presented to the Emergency Room complaining of left lower
extremity pain.  The patient states that she was unable to
walk today.  She has had left leg particularly in the foot
and shin for about three weeks and had noticed some weakness,
initially unable to walk around her room and developed left
foot pain that resolved with rest.  She did notice some
increased swelling and redness in this area.

On the day of admission the patient noted that the pain
occurred at rest and noted increased pain that was constant
although was worse with pressure and walking.

REVIEW OF SYSTEMS:  Patient denies any chest pain.  However,
she does note some chest pain approximately two days prior to
admission that occurred while she was lying supine.  She also
denies any fevers at home, occasional intermittent shortness
of breath, no cough, no exertional chest pain, positive
dyspnea on exertion approximately one block, two pillow
orthopnea, occasional paroxysmal nocturnal dyspnea.  Patient
also denies any dysuria, diarrhea, nausea, vomiting,
abdominal pain, light headedness or dizziness.

PHYSICAL EXAMINATION:  Temperature 100.4, pulse 120, blood
pressure 110.68, respiratory rate 20, pulse oximetry 97% n
room air.  Head, eyes, ears, nose and throat normocephalic,
atraumatic, moist mucous membranes. Pupils equal, round,
reactive to light.  Neck supple, no lymphadenopathy, jugular
venous pressure elevated approximately 7 cm.  Pulmonary: no
wheezes, left basilar crackles.  Cardiac:  normal S1, S2, no
murmurs, rubs or gallops, regular rate and rhythm.  Abdomen:
normal active bowel sounds, soft, nontender, nondistended.
Surgical scar in midline.  Extremities: no peripheral edema,
tenderness in the left lower extremity from medial shin to
foot, no erythema, cool left foot, dorsalis pedis palpable
only in right foot. Left foot with Dopplerable pulses only,
no cyanosis. Neurologic: alert and oriented times three,
cranial nerves 2 through 12 intact, no focal weakness,
however, decreased mobility in the left lower extremity
secondary to pain.

LABORATORY DATA AT TIME OF ADMISSION:  White blood cell count
6.1, hematocrit 40.4, platelets 255, INR 1.5, PTT 25.8.
Sodium 132, potassium 4.2, chloride 99, bicarb 22, BUN 12,
creatinine 0.9, glucose 95.  The first set of cardiac
enzymes:  CK 168, MB 11, troponin 12.4.
X-ray of left foot shows no significant soft tissue swelling,
no effusion, hallux valgus, no evidence of fracture, no
evidence of osteomyelitis, pes planus.
Chest x-ray:  cardiomegaly, right subclavian line in place,
no effusions.
Electrocardiogram:  Occasional paroxysmal ventricular
contractions, sinus rhythm, left axis deviation, left
ventricular hypertrophy with left atrial enlargement, T wave
inversion 1, 2, V4 through V6, ST depression in 1 and AVL, V4
through V6.  No ST segment elevation or Q wave.  His
electrocardiogram was thought to be similar to prior
electrocardiogram of [**Month (only) 956**] [**Numeric Identifier 13971**].

PAST MEDICAL HISTORY:  1) HIV:  through sexual transmission
diagnosed in [**2176-1-6**]. Patient was recently restarted
on [**Doctor Last Name **] therapy in [**2185-2-5**] with Adobutadin,
limbividine, avacar, Navaripine.  At that time she had a CD4
count of 334 and a viral load of 12.3 x 103.  However,
patient subsequently self discontinued her [**Doctor Last Name **] therapy about
[**Doctor Last Name **] weeks prior to admission.
2) Multiple pneumococcal pneumonia infections in the past.
3) Thrush.
4) Lymphocytic interstitial pneumonia in [**2182-1-5**].
5) Asthma.
6) Anemia.
7) [**Doctor First Name **] in [**2183**].  Subsequent negative sputum cultures.
8) Positive PPD in [**2184-2-6**] treated with ethambutol for
three months.
9) Status post total abdominal hysterectomy for fibroids and
hemorrhagic.
10) Hepatitis C, undetectable viral load in [**2184-2-6**].
11( Herpes.
12) Congestive heart failure with dilated cardiomyopathy,
with ejection fraction of less than 20 percent by
transthoracic echocardiogram in [**2184-8-5**], 1 to 2+
mitral regurgitation, 2+ tricuspid regurgitation, mild to
moderate pulmonary hypertension, moderately dilated left
atrium, right ventricle dilation, right ventricular systolic
function decreased.
13) Mediastinal lymphadenopathy with negative subcarinal
node.
14) Positive [**Doctor First Name **].
15) Cardiac catheterization in [**2184-8-5**] revealed pulmonary
capillary wedge pressure of 28, no coronary artery disease.
16) History of cocaine abuse.
17) Status post transient ischemic attack in [**2184-8-5**] that
lasted for approximately 30 minutes with an MRA that was
negative.

SOCIAL HISTORY:  Patient lives with her daughter and
granddaughter.  She has used cocaine in the past but claims
that her last use was about on week prior to presentation
(this was disproved by urine toxicology screen).  Social
alcohol use.  Smokes one pack a day for the past ten year.
No pets.

FAMILY HISTORY:  Significant for a mother with breast cancer.

ALLERGIES:  Retrovir.

MEDICATIONS:  Was on [**Doctor Last Name **] from [**2185-2-5**] until end of
[**Month (only) 958**] at which time patient stopped secondary to side
effects.  She also states that may have been on Zestril 20 mg
p.o. q day.

HOSPITAL COURSE:  1) Vascular:  The patient with left lower
extremity pain and only Dopplerable left lower extremity
pulses at the time of admission, seemingly ischemic in
nature, initially with movement, now at rest.  Patient was
initially admitted to the vascular service.  However,
subsequent to her positive troponin she was transferred to
the Medicine Service.  She was planned for angiogram of her
leg but given her positive troponin vascular service was
recommending cardiac consultation for potential cardiac
clearance prior to angiogram.  Patient was started on heparin
drip.  Patient was subsequently taken to angiogram at which
time she was found to have an occluded left common iliac
artery, external iliac artery but a reconstituted common
femoral artery.  She also had a small filling defect in the
proximal superficial femoral artery and focal occlusions of
the proximal posterior tibialis and peroneal arteries.
Patient also had focal occlusion of the distal posterior
tibialis with reconstitution of these to plantar branches.
Patient was subsequently started on intra-articular TPA for
thrombolysis.  Subsequently [**Hospital 228**] hospital course was
further complicated by left MCA stroke thought to be embolic
or thrombotic in nature and therefore further treatment with
TPA was held

Subsequently patient was taken back to the interventional
radiology suite and was treated with multiple stents
throughout her left lower extremity arterial system.  Patient
was continued on heparin drip subsequent to this procedure.
Subsequent to stenting patient had good angiographic results
and eventually patient with Dopplerable posterior tibialis
and dorsalis pedis in left lower extremity with good range of
motion and no residual pain.

Patient was followed by the Vascular Service during her
hospital course.

2) Neurologic:  Patient on the night of admission presented
with aphasia and right sided weakness.  Per neurologist
patient was found to be sleepy but arousable with limited
comprehension, preferential left gaze with dense hemiplegia
of affected face and arm and leg on the right side.  Patient
had CT of head without contrast that showed infarct in the
left lenticular nucleus with surrounding cytotoxic edema
involving the anterior limb of the left internal capsule.
Patient was subsequently transferred to the Neurology Service
and was placed on in the Neuro Intensive Care Unit.  She was
continued on heparin drip and initially TPA was held.
Patient throughout the remainder of her hospital course had
gradual improvement in her right lower extremity with ability
to wiggle toe and slightly lift her right lower extremity off
the bed unassisted.  Her right upper extremity remained
without good motor function.  Patient also became less
aphasic and was able to speak and articulate more clearly.
Patient was eventually started on Plavix 75 mg p.o. q. day
for her left middle cerebral artery infarct.  Her goal blood
pressure was around 120 systolic.  However, patient was
unable to maintain an acceptable blood pressure and her blood
pressure during the remainder of her hospital course was
between 90 and 100.  This was in the setting of discontinuing
her beta block and ACE inhibitor as well.

Patient will be discharged to a rehabilitation acute setting
facility.  She was seen by physical therapy who also noted
some improvement in her overall right lower extremity motor
strength.  She was also seen by the occupational therapy
service who in addition recommended rehabilitation.

Patient was also seen by the Speech and Swallow Service who
stated that her diet should be thin liquids, ground solids,
pureed medications.  Aspiration precautions and patient
should be upright at all meals.

3) Cardiovascular:  Initially patient was seen by Cardiology
Service given the history of dilated cardiomyopathy, recent
cocaine use and positive troponin.  The etiology her initial
elevated troponin was thought to be either secondary to
vasospasm induced by her cocaine use versus possible embolic
phenomena with transient occlusion.  Her peak troponin was
12.4 during that event and subsequently trended down to 6.8
on the second hospital day, subsequent to patient's left
middle cerebral artery stroke.  Patient had another peak in
her troponin to 23.1.  However, it was again checked the next
day and was found to be 6.4.  Patient's electrocardiogram was
without evidence of active ischemia.  Initially patient was
stated on ACE inhibitor and beta blocker given her cardiac
risk factors and dilated cardiomyopathy as well as her
positive troponin.  However, given her goal blood pressure
being 110 to 120 and the fact that she was unable to maintain
these blood pressures even being off these medications, these
two medications were discontinued.

For future follow up it will be important to be restarted on
her ACE inhibitor and beta blocker.  In addition, patient had
a persistent tachycardia throughout her hospital courses with
pulse almost consistently greater than 100 from the time of
admission to the time of discharge.

Patient had a transthoracic echocardiogram which showed a
mildly dilated left ventricular cavity with severe global
hypokinesis, a large 3 to 4 cm thrombus seen in the left
ventricular apex with highly mobile component.  The right
ventricular cavity was markedly dilated with severe free wall
hypokinesis.  The patient had 1+ atrial regurgitation, 1 to 2
mitral regurgigation and 2+ tricuspid regurgitation.  She
also had moderate pulmonary artery systolic hypertension but
no effusion.  She was noted to have global biventricular
function and valvular regurgitation which was stable compared
to her prior echocardiogram but with large mobile apical left
ventricular thrombus, new compared to her prior study in
[**2184-8-5**] although that echocardiogram did note a low
flow state and in the past patient had been started on
Coumadin which she self discontinued.

For the thrombus patient was started on Coumadin load while
being on heparin drip.  She received three days of 5 mg of
Coumadin followed by another day of 10 mg of Coumadin. In
addition, her heparin drip was discontinued and Lovenox was
started at 70 mg subcutaneous b.i.d.  Patient's INRs
currently 0.9.  Patient will need to have additional 5 mg to
7.5 mg Coumadin loading with follow up of her INR and goal
INR being 2 to 3.  After goal INR is achieved patient can
discontinue the Lovenox.  This will need to be monitored
closely as patient is also starting antibiotics for
pneumonia.

4)  Infectious Disease:  Patient with a history of HIV
recently being off of [**Doctor Last Name **] therapy for the three weeks prior
to admission.  A question of restarting [**Doctor Last Name **] therapy was
addressed.  However, given patient's other multiple medical
acute problems during this hospitalization although brief
discussion with patient's infectious disease physician, [**Last Name (NamePattern4) **].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], was had regarding question of restarting [**Doctor Last Name **]
therapy.  At this time we will hold off starting therapy
given that patient will be going to an acute rehabilitation/
hospital facility for her current medical problems and the
decision to reininitiate [**Doctor Last Name **] therapy can be made subsequent
to her discharge from rehabilitation facility.  The patient
will also need close monitoring as she is on multiple
anticoagulant medications as well.

Patient had temperature spike during her hospital course.
This was worked up with negative blood cultures, negative
urinalysis.  However, patient did have a right subclavian
line in place which had been in place for approximately six
days at the time of the temperature spike.  This line was
discontinued and replaced with  peripheral intravenous.
Catheter tip was sent for culture and results are still
pending. Also had a Foley catheter that was discontinued.
Chest x-ray revealed a left lower lobe pneumonia for which
patient was started on Levofloxacin 500 mg p.o. q. day.  She
should continue a total of a seven day course.

5) Fluid, electrolytes and nutrition:  Patient should be
maintained on aspiration precautions.  She should be on a
thin liquid, ground solids diet with medication in puree
only.  She is on ranitidine 150 mg p.o. b.i.d. for
prophylaxis.

6) Disposition:  Patient will be transferred to an acute
rehabilitation/hospital facility for rehabilitation and
management of her acute medical issues.

7) FOLLOW UP:
1) Patient will need follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in the
infectious disease clinic after her discharge from the
rehabilitation facility, question of reinitiation of [**Doctor Last Name **]
therapy should be addressed at that time.
2) Patient will need follow up in the cardiology clinic given
her dilated cardiomyopathy of left ventricular thrombus and
recent non-ST elevation myocardial infarction.
3) Patient will need close monitoring of her INR with a goal
INR between 2 to 3.  She is currently on a dose of Coumadin 5
mg p.o. q day and Lovenox 70 mg subcutaneously b.i.d.
Patient should have the Lovenox discontinued after the INR
between 2 and 3 is reached.
3) Patient will need follow up in the neurology clinic for
her left middle cerebral artery stroke. Again this can be
done subsequent to her discharge from the rehabilitation
facility.

DISCHARGE DIAGNOSES:
1.      HIV.
2.      Dilated cardiomyopathy.
3.      Left ventricular thrombus.
4.      Left iliac artery thrombus, status post TPA,
        heparin drip, multiple stents.
5.      Left middle cerebral artery stroke with residual
        right sided motor weakness, aphasia and swallowing
        deficits.
6.      Non-ST elevation myocardial infarction.

MEDICATIONS AT TIME OF DISCHARGE:
1.      Lovenox 70 mg subcutaneous b.i.d.  This should be
        continued until patient's INR is therapeutic between
        2 and 3.
2.      Levofloxacin 500 mg p.o. q day of an additional six
        days.
3.      Ranitidine 150 mg p.o. b.i.d.
4.      Plavix 75 mg p.o. q day.
5.      Tylenol p.r.n.
6.      Patient should be restarted on low dose Captopril at
        6.25 mg p.o. t.i.d. if blood pressure tolerates the
        goal blood pressure being greater than 120.
7.      Beta blocker metoprolol 12.5 mg p.o. t.i.d. only to
        be started if patient with a goal blood pressure
        greater than 120.  Please do not give this medication
        if blood pressure is not at this level.




                            [**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D.  [**MD Number(1) 5712**]

Dictated By:[**Name8 (MD) 231**]
MEDQUIST36

D:  [**2185-4-19**]  13:53
T:  [**2185-4-19**]  15:26
JOB#:  [**Job Number 101122**]

cc:[**Last Name (NamePattern1) 101123**]
{'Embolism and thrombosis of iliac artery,Subendocardial infarction, initial episode of care,Cerebral embolism with cerebral infarction,Pneumonia, organism unspecified,Congestive heart failure, unspecified,Other primary cardiomyopathies,Cocaine abuse, unspecified,Asymptomatic human immunodeficiency virus [HIV] infection status,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: 

PRESENT ILLNESS: A 41 year-old African-American
female with a history of HIV, dilated cardiomyopathy who
presented to the Emergency Room complaining of left lower
extremity pain.  The patient states that she was unable to
walk today.  She has had left leg particularly in the foot
and shin for about three weeks and had noticed some weakness,
initially unable to walk around her room and developed left
foot pain that resolved with rest.  She did notice some
increased swelling and redness in this area.

MEDICAL HISTORY: 1) HIV:  through sexual transmission
diagnosed in [**2176-1-6**]. Patient was recently restarted
on [**Doctor Last Name **] therapy in [**2185-2-5**] with Adobutadin,
limbividine, avacar, Navaripine.  At that time she had a CD4
count of 334 and a viral load of 12.3 x 103.  However,
patient subsequently self discontinued her [**Doctor Last Name **] therapy about
[**Doctor Last Name **] weeks prior to admission.
2) Multiple pneumococcal pneumonia infections in the past.
3) Thrush.
4) Lymphocytic interstitial pneumonia in [**2182-1-5**].
5) Asthma.
6) Anemia.
7) [**Doctor First Name **] in [**2183**].  Subsequent negative sputum cultures.
8) Positive PPD in [**2184-2-6**] treated with ethambutol for
three months.
9) Status post total abdominal hysterectomy for fibroids and
hemorrhagic.
10) Hepatitis C, undetectable viral load in [**2184-2-6**].
11( Herpes.
12) Congestive heart failure with dilated cardiomyopathy,
with ejection fraction of less than 20 percent by
transthoracic echocardiogram in [**2184-8-5**], 1 to 2+
mitral regurgitation, 2+ tricuspid regurgitation, mild to
moderate pulmonary hypertension, moderately dilated left
atrium, right ventricle dilation, right ventricular systolic
function decreased.
13) Mediastinal lymphadenopathy with negative subcarinal
node.
14) Positive [**Doctor First Name **].
15) Cardiac catheterization in [**2184-8-5**] revealed pulmonary
capillary wedge pressure of 28, no coronary artery disease.
16) History of cocaine abuse.
17) Status post transient ischemic attack in [**2184-8-5**] that
lasted for approximately 30 minutes with an MRA that was
negative.

MEDICATION ON ADMISSION: 

ALLERGIES: Retrovir.

PHYSICAL EXAM: 

FAMILY HISTORY: Significant for a mother with breast cancer.

SOCIAL HISTORY: Patient lives with her daughter and
granddaughter.  She has used cocaine in the past but claims
that her last use was about on week prior to presentation
(this was disproved by urine toxicology screen).  Social
alcohol use.  Smokes one pack a day for the past ten year.
No pets. 

### Response:
{'Embolism and thrombosis of iliac artery,Subendocardial infarction, initial episode of care,Cerebral embolism with cerebral infarction,Pneumonia, organism unspecified,Congestive heart failure, unspecified,Other primary cardiomyopathies,Cocaine abuse, unspecified,Asymptomatic human immunodeficiency virus [HIV] infection status,Unspecified essential hypertension'}
