CHIEF COMPLAINT: 

PRESENT ILLNESS: Mr. [**Known lastname 25800**] is a 23-year-old
male with a past medical history significant for admission to
[**Hospital1 69**] from [**2141-12-18**] to
[**2141-12-23**] for bilateral pulmonary emboli status post TPA
administration.  During this admission, he was also found to
have a patent foramen ovale on echocardiography.  The patient
was discharged to home on Lovenox and Coumadin.  Patient
received a hypercoagulable state work up during this
admission which was notable for an anticardiolipin antibodies
and a heterozygosity for a prothrombin gene mutation.
Patient presents to the [**Hospital3 **] Emergency Department with
hemoptysis.

MEDICAL HISTORY: 1.  Significant for right upper extremity basilar vein
superficial thrombophlebitis.
2.  Chronic lower extremity swelling which was diagnosed as
chronic compartment syndrome.
3.  Patent foramen ovale, prothrombin gene mutation.
4.  Anticardiolipin antibodies.

MEDICATION ON ADMISSION: 

ALLERGIES: Patient denies any known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: No history of hypercoagulable or bleeding
states.

SOCIAL HISTORY: Patient is a [**University/College 5130**] [**Location (un) **]
student, lacrosse player.  Denies tobacco.  Occasional ETOH.
Denies any IVDA.  Patient denies risk factors for
tuberculosis.
Arteriovenous fistula of pulmonary vessels,Other pulmonary embolism and infarction,Ostium secundum type atrial septal defect,Rupture of artery
Arterioven fistu pul ves,Pulm embol/infarct NEC,Secundum atrial sept def,Rupture of artery
Admission Date:  [**2141-12-31**]     Discharge Date:  [**2142-1-10**]

Date of Birth:   [**2118-11-17**]     Sex:  M

Service:

HISTORY OF PRESENT ILLNESS:  Mr. [**Known lastname 25800**] is a 23-year-old
male with a past medical history significant for admission to
[**Hospital1 69**] from [**2141-12-18**] to
[**2141-12-23**] for bilateral pulmonary emboli status post TPA
administration.  During this admission, he was also found to
have a patent foramen ovale on echocardiography.  The patient
was discharged to home on Lovenox and Coumadin.  Patient
received a hypercoagulable state work up during this
admission which was notable for an anticardiolipin antibodies
and a heterozygosity for a prothrombin gene mutation.
Patient presents to the [**Hospital3 **] Emergency Department with
hemoptysis.

After discharge from first hospital admission, the patient
continued to improve until one day prior to admission when he
noted cough productive of mild amounts, he estimated a half a
cup of bright red blood with some accompanying dark clots.
Patient denies any feeling of lightheadedness, dizziness or
weakness.  Patient denies any fever, chills, cough or
shortness of breath.  Has occasional cough.  Denies runny
nose, sore throat.  Denies melena, edema, bright red blood
per rectum.  Patient was admitted for observation.

PAST MEDICAL HISTORY:
1.  Significant for right upper extremity basilar vein
superficial thrombophlebitis.
2.  Chronic lower extremity swelling which was diagnosed as
chronic compartment syndrome.
3.  Patent foramen ovale, prothrombin gene mutation.
4.  Anticardiolipin antibodies.

ALLERGIES:  Patient denies any known drug allergies.

MEDICATIONS:
1.  Tylenol p.r.n.
2.  Coumadin 10 mg q. day.
3.  Lovenox 100 mg b.i.d. subcutaneous.

FAMILY HISTORY:  No history of hypercoagulable or bleeding
states.

SOCIAL HISTORY:  Patient is a [**University/College 5130**] [**Location (un) **]
student, lacrosse player.  Denies tobacco.  Occasional ETOH.
Denies any IVDA.  Patient denies risk factors for
tuberculosis.

PHYSICAL EXAMINATION:  On admission temperature of 98.4 F,
pulse 77, blood pressure 138/80, respirations 20 and
saturating at 95% on room air.  In general this was a thin
Caucasian male sitting at the foot of the bed in no apparent
distress.  Head, eyes, ears, nose and throat:  Pupils equal,
round and reactive to light.  Extraocular movements intact.
Anicteric sclerae.  Moist mucous membranes.  No oropharyngeal
lesions were appreciated.  Patient's nares were only
significant for a small spot of old blood on the right nares.
Lungs were clear to auscultation bilaterally.  Heart was
regular rate and rhythm, S1, S2, no murmurs, rubs, or
gallops.  Abdomen was soft, nontender, nondistended without
masses.  Normoactive bowel sounds.  Extremities:  No clubbing
or cyanosis.  Left lower extremity was slightly larger than
right lower extremity.

LABORATORY:  White count of 5.2, hematocrit of 40.7,
platelets of 302.  Sodium of 140, potassium of 4, chloride of
100, bicarbonate of 23, BUN of 19, creatinine of 0.9, glucose
of 103, calcium 9.7, magnesium 1.8, phosphate 4.0.  PT 16.3,
PTT 41.9, INR of 1.8.

Patient received a chest x-ray which was normal without focal
consolidation or pleural effusion.

HOSPITAL COURSE:  Secondary concern that the origin of
bleeding was from patient's nares with questionable
epistaxis.  Patient's nose was packed in the Emergency
Department.  ENT consult was obtained and found no evidence
on fiberoptic examination of any recent bleeding in patient's
nose.  Consult was able to induce bloody sputum on prompting
without any evidence of nasal bleeding thus suggesting
pulmonary source.

Shortly after admission, the patient experienced recurrently
hemoptysis, approximately 500 cc.  Intervention Pulmonary
consult was obtained and patient was transferred to Medical
ICU for closure observation.  CT Scan of the patient's chest
was obtained to evaluate for possible recurrent pulmonary
emboli.  CT Scan showed interval stable 2 mm nodule left lung
apex, notable for interval appearance of patchy areas of
ground-glass opacifications in the right lower lobe and
additional patches of ground-glass opacification in the right
middle lobe.  No pleural effusions.  These abnormalities were
concerning for pulmonary hemorrhage in addition to pneumonia,
filling defects within the bronchi of the right middle and
right lower lobe were also appreciated.

The patient continued to have episodes of hemoptysis.  CT
Scan with contrast was repeated.  The scan showed significant
recanalization of the left pulmonary arterial system with
extensive retraction revascularization of previously noted
pulmonary emboli.  The residual filling defects within the
segmental branches of the left lower and left middle lobe
vessels were appreciated.  Consolidation was on the right low
and right middle, no lobe was appreciated.  No
lymphadenopathy, no effusion.  Scan again concerning for
pneumonic consolidation versus area of infarct secondary to
difficulty of reversal Lovenox at which time patient was
started on heparin.

On [**2142-1-4**], patient underwent flexible and rigid
bronchoscopy which showed a large blood clot obstruction
right lower lobe bronchus which after suctioning revealed a
small polypoid lesion at the take off the right lower lobe
bronchus with a stream of pulsatile blood emanating from it.
Intervention Pulmonary Team used argon plasma coagulation to
coagulate the lesion which was successful without further
bleeding.  The patient tolerated the procedure well.

The patient also received bronchial arteriogram which showed
take off at the right bronchial artery at the level of T4, T5
which showed a bronchial artery to lower right pulmonary
artery shunt.  Concern was raised given patient's history of
the right lower lobe pulmonary embolus, embolization of this
right bronchial artery to right pulmonary artery fistula
could possible result in infarction of the patient's right
lower lobe.

Thoracic Surgery consult was then obtained.  Discussion with
Medical Team, Thoracic Surgery Team and family was then held
discussing options of:  1) Coil embolization with possible
consequence of right lower lobe infarction, 2) a right lower
lobe lobectomy or 3) a conservative approach of gentle
anticoagulation with the hopes of continuing and low dose
thrombolysis would promote natural closure of fistula.

In the setting of elevated right sided pressures in the
setting of patient's pulmonary emboli, embolization and
lobectomy were felt to possibly impose significant risk to
patient at this time.  Thus in consultation with Thoracic
Surgery and family, a conservative approach was decided upon,
though CT Surgery had initially recommended right lower lobe
lobectomy with subsequent anticoagulation for the patient.
Both patient and family did not want to pursue this option so
consensus was made for low dose anticoagulation.

The patient was then started on Lovenox with Protamine at bed
side. The patient continued to do well on Lovenox.  Serial
hematocrits showed no drop in patient's hematocrit status
post argon beam therapy.  The patient was transferred to the
floor where he continued to improve.  Hematocrit remained
stable.  Consultation with Hematology and Interventional
Pulmonary Service felt that the patient would benefit from
three weeks of Lovenox prior to transition to Coumadin
secondary to greater ease of reversal of Lovenox than
Coumadin.

At the time of discharge, the patient was given a Lovenox
injection instructions.  The patient was clearly instructed
to lay on right side in the event of any bleeding and to
present to the Emergency Department immediately.  The patient
is instructed to follow a diet low in vitamin K.  The patient
is scheduled for a follow up appointment with Hematology /
Oncology on [**2142-1-12**] with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].  The patient is
instructed to follow up with primary care physician within
two weeks.

CONDITION ON DISCHARGE:  At the time of discharge, the
patient is stable and improved.

DISCHARGE MEDICATIONS:  Lovenox 100 b.i.d. subcutaneous.



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

Dictated By:[**Last Name (NamePattern1) 5924**]

MEDQUIST36

D:  [**2142-1-13**]  17:26
T:  [**2142-1-15**]  12:40
JOB#:  [**Job Number 25801**]
{'Arteriovenous fistula of pulmonary vessels,Other pulmonary embolism and infarction,Ostium secundum type atrial septal defect,Rupture of artery'}


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: Mr. [**Known lastname 25800**] is a 23-year-old
male with a past medical history significant for admission to
[**Hospital1 69**] from [**2141-12-18**] to
[**2141-12-23**] for bilateral pulmonary emboli status post TPA
administration.  During this admission, he was also found to
have a patent foramen ovale on echocardiography.  The patient
was discharged to home on Lovenox and Coumadin.  Patient
received a hypercoagulable state work up during this
admission which was notable for an anticardiolipin antibodies
and a heterozygosity for a prothrombin gene mutation.
Patient presents to the [**Hospital3 **] Emergency Department with
hemoptysis.

MEDICAL HISTORY: 1.  Significant for right upper extremity basilar vein
superficial thrombophlebitis.
2.  Chronic lower extremity swelling which was diagnosed as
chronic compartment syndrome.
3.  Patent foramen ovale, prothrombin gene mutation.
4.  Anticardiolipin antibodies.

MEDICATION ON ADMISSION: 

ALLERGIES: Patient denies any known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: No history of hypercoagulable or bleeding
states.

SOCIAL HISTORY: Patient is a [**University/College 5130**] [**Location (un) **]
student, lacrosse player.  Denies tobacco.  Occasional ETOH.
Denies any IVDA.  Patient denies risk factors for
tuberculosis. 

### Response:
{'Arteriovenous fistula of pulmonary vessels,Other pulmonary embolism and infarction,Ostium secundum type atrial septal defect,Rupture of artery'}
