CHIEF COMPLAINT: 

PRESENT ILLNESS: This is a 55-year-old male with
history of coronary artery disease, congestive heart failure,
with an ejection fraction of less than 20 percent, syndrome
of inappropriate antidiuretic hormone, adrenal insufficiency,
diabetes mellitus type 2, history of left ventricular
thrombus in [**4-/2147**] on Coumadin, chronic ulcer status post
vacuum-assisted closure device and ostea, returns from rehab
on [**2148-4-8**] with increased swelling on a cyst in the left
thigh with increased redness and tenderness.

MEDICAL HISTORY: Coronary artery disease status post
right coronary artery and left anterior descending stent in
04/[**2147**].

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Other postoperative infection,Methicillin susceptible Staphylococcus aureus septicemia,Acute kidney failure with lesion of tubular necrosis,Severe sepsis,Septic shock,Acute vascular insufficiency of intestine,Congestive heart failure, unspecified,Cellulitis and abscess of leg, except foot
Other postop infection,Meth susc Staph aur sept,Ac kidny fail, tubr necr,Severe sepsis,Septic shock,Ac vasc insuff intestine,CHF NOS,Cellulitis of leg
Admission Date: [**2148-4-8**]        Discharge Date: [**2148-4-23**]

Date of Birth:  [**2092-8-16**]        Sex:  M

Service:  MICU


CHIEF COMPLAINT/REASON FOR TRANSFER:  Hypotension.

Hypoxic respiratory failure.

HISTORY OF PRESENT ILLNESS:  This is a 55-year-old male with
history of coronary artery disease, congestive heart failure,
with an ejection fraction of less than 20 percent, syndrome
of inappropriate antidiuretic hormone, adrenal insufficiency,
diabetes mellitus type 2, history of left ventricular
thrombus in [**4-/2147**] on Coumadin, chronic ulcer status post
vacuum-assisted closure device and ostea, returns from rehab
on [**2148-4-8**] with increased swelling on a cyst in the left
thigh with increased redness and tenderness.

In the Emergency Room patient was hypotensive at 80/40.
Given intravenous fluids with improvement and admitted to the
Surgical Intensive Care Unit and intubated for hypoxia with a
gas of 7.28, 35, and 54 and broadly treated with vancomycin,
Levofloxacin, and Flagyl, and taken for incision and drainage
with 20 cc of pus removed.  Antibiotics were changed to
meropenem for Methicillin-sensitive Staphylococcus aureus,
posterior pharynges.  Also, briefly on Vasopressin for
question septic shock.  Had a Swan with likely cardiogenic
picture on [**2148-4-11**] with a CVP of 16, a wedge pressure of
41/21, cardiac index of 1.8, and SVR of [**2168**] and started on
Natrecor and Dobutamine drip.  Extubated [**2148-4-12**].  Post
arterial blood gas was 7.24, 40, 91, and given bicarbonate,
Xigris, and diuresed with Lasix on transfer to the congestive
heart failure team.

Patient also with positive abdominal distention relieved with
nasogastric tube and then elevated total bilirubin seen by
the liver team possibly due to congestive heart failure
versus antibiotics versus total parenteral nutrition versus
infection.  Hepatic serologies were sent and pending at the
time and was started on Ursodiol, Lactulose for hepatic
encephalopathy.

On [**2148-4-19**] the patient was out three liters and on
[**2148-4-20**] out four liters then had episodes of desaturations
to 87 percent oxygen on 3 liter nasal cannula.  Chest x-ray
with left lower lobe infiltrate, right pleural effusion.
Natrecor and Lasix drip were discontinued for decreasing SBP
and thought overdiuresis.  An ABG at the time was 7.38, 49,
and 108, and patient was intubated for respiratory distress.

PAST MEDICAL HISTORY:  Coronary artery disease status post
right coronary artery and left anterior descending stent in
04/[**2147**].

Peripheral vascular disease status post left femoral to
popliteal bypass graft.

Status post right femoral to tibial graft status post
metatarsal phalangeal amputation.

Diabetes mellitus type 2.

History of adrenal insufficiency and question syndrome of
inappropriate antidiuretic hormone.

Hypertension.

Congestive heart failure with an ejection fraction less than
20 percent.

Cardiomyopathy.

Acute ischemia.

2 plus mitral regurgitation, 2 plus tricuspid regurgitation
left ventricular thrombus [**4-/2147**] cardiac catheterization on
chronic Coumadin.

Chronic left heel ulcer, probing no bone, status post vacuum-
assisted device for closure.

PHYSICAL EXAMINATION:  At the time of transfer to the unit on
[**2148-4-23**] temperature 100.6, respiratory rate 96, blood
pressure 154/116 to 109/40, respiratory rate 22, satting 95
percent FIO2 of 1.0 on AC, 640 x 22.  Intubated, sedated.
Icteric sclerae.  Mucous membranes dry.  Bronchial breath
sounds bilaterally.  Regular rate and rhythm.  Normal S1, S2
without murmurs, rubs, or gallops on cardiac exam.  Abdomen:
Soft, mildly distended with tympany; decreased bowel sounds
with enlarged and palpable liver.  Extremities:  2 to 3 plus
dependent edema bilaterally lower extremities with vacuum-
assist device.  Left shin with 5 x 4 cm  elliptical
granulating ulcer.  Left heel with erythematous ulcer probing
to bone.  Neuro sedated with pinpoint pupils.

PERTINENT LABORATORY DATA:  EKG:  Normal sinus rhythm, 100,
right axis deviation, T-wave inversions to aVF and V6, [**Street Address(2) 28585**] elevations V1 to V3 with low voltage.

ALT 9, AST 37, LDH 259, total bilirubin 13.5, amylase 40,
albumin 2.4, lipase 43, white count 6.2.  Differential:  9.5
percent eosinophils, 67 percent polys, 16 percent lymphs,
hematocrit is 29.6, creatinine 1.3, potassium 5.1.

HOSPITAL COURSE:  Respiratory failure:  Patient presented to
the Intensive Care Unit with left white-out with ipsilateral
shift, left lower lobe infiltrate, bilateral pleural effusion
status post bronchoscopy with secretions and reinflation,
likely obstructive atelectasis and hypoxia,
Given worsening pleural effusion and infiltrate the patient
had a chest CT to be considered.

Shock:  Patient presented with likely hypovolemia from
overdiuresis.  He initially was maintained on Levophed and
Dobutamine with consider to wean down, possible sepsis from
multiple sources including the osteo ulcer and pneumonia.
The goal CVP was 12 to 14 with the goal to try to wean off
pressors and bolus p.r.n.  After further discussion with a
grim prognosis of this patient, patient was made Do Not
Resuscitate/Do Not Intubate, and after further family meeting
with the wife, the patient was started on comfort measures
only on [**2148-4-23**] given the overall course.  At
approximately 3:15 in the afternoon physician was called to
see the patient for PA arrest.  Patient was nonresponsive.
No breath sounds were noted.  No heartbeat was noted.  The
patient was warm to touch.  No pulse was palpated in four
extremities.  The patient was declared dead at 3:27 p.m. on
[**2148-4-23**].  Family was notified and declined postmortem
examination.

Adrenal insufficiency:  Patient had a random cortisol of 10
empirically treated with dexamethasone, Fludrocortisone, and
Hydrocort.

Abscess:  Patient was initially treated with astrianam.

Pneumonia:  The patient had a bronchoscopy which revealed
collapse due to mucus plugging.  Patient was treated with
vancomycin and dosed by levels of anemia.  Patient was
transfused a hematocrit less than 30, CHF EF less than 20,
goal CVP was 10 to 12, data QCHF on transfer, and patient was
well commutated.  Patient was maintained on Dobutamine to
improve cardiac output.

Hepatitis:  Patient had elevated transaminases likely
infectious versus hepatic congestion.  Hepatic bout
cholangitis.  We needed to follow up with serologies.

Heel ulcer:  Patient had wet-to-dry dressing changes and was
seen by Podiatry.

Left ventricular thrombus:  Discussed with [**Doctor Last Name **] regarding
reversing of flow, who recommended reevaluation versus
organized thrombus since it had been one year since he had
the thrombus in the left ventricle.

Decreased bowel sounds due to IV narcotic effect.  KUB was
unremarkable.

Access:  The patient was maintained with a right IJ, right A-
line.

FEN:  The patient was NPO, awaiting total parenteral
nutrition.


DISPOSITION:  As described above the patient expired on
[**2148-4-23**].



                        [**First Name8 (NamePattern2) **] [**Name8 (MD) **], [**MD Number(1) 6327**]

Dictated By:[**Last Name (NamePattern1) 12481**]
MEDQUIST36
D:  [**2148-7-8**] 18:13:08
T:  [**2148-7-9**] 12:42:05
Job#:  [**Job Number 43875**]
{'Other postoperative infection,Methicillin susceptible Staphylococcus aureus septicemia,Acute kidney failure with lesion of tubular necrosis,Severe sepsis,Septic shock,Acute vascular insufficiency of intestine,Congestive heart failure, unspecified,Cellulitis and abscess of leg, except foot'}


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: This is a 55-year-old male with
history of coronary artery disease, congestive heart failure,
with an ejection fraction of less than 20 percent, syndrome
of inappropriate antidiuretic hormone, adrenal insufficiency,
diabetes mellitus type 2, history of left ventricular
thrombus in [**4-/2147**] on Coumadin, chronic ulcer status post
vacuum-assisted closure device and ostea, returns from rehab
on [**2148-4-8**] with increased swelling on a cyst in the left
thigh with increased redness and tenderness.

MEDICAL HISTORY: Coronary artery disease status post
right coronary artery and left anterior descending stent in
04/[**2147**].

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Other postoperative infection,Methicillin susceptible Staphylococcus aureus septicemia,Acute kidney failure with lesion of tubular necrosis,Severe sepsis,Septic shock,Acute vascular insufficiency of intestine,Congestive heart failure, unspecified,Cellulitis and abscess of leg, except foot'}
