CHIEF COMPLAINT: 

PRESENT ILLNESS: 

MEDICAL HISTORY: 1.   Coronary artery disease, status post inferior myocardial
infarction  [**2114**]  complicated  by  left ventricular thrombus,
status post left circumflex stent in [**2123-4-1**].
2.  Congestive heart failure.
3.    Status post mitral valve and tricuspid valve prosthetic
replacement [**2123-8-10**].
4.  AICD in [**2123-4-1**].
5.    History  of cerebrovascular accident with residual left
finger numbness.
6.  History of Hodgkin lymphoma at the age of 27, status post
radiation and splenectomy.
7.  Hypercholesterolemia.
8.  History of cervical diskectomy.
9.  Tracheostomy in [**2123-8-1**].
10. Gastrostomy tube placed in [**2123-8-1**].
11.   MRSA  diagnosed  in  [**Month (only) **],  [**2123**],  with  witnessed
aspiration with p.o. medications and liquids.
12. Constrictive pericarditis.
13. Iron-deficiency anemia.

MEDICATION ON ADMISSION: 1.  Ceftazidime started [**10-19**].
2.  Epogen.
3.  Amiodarone 400 p.o.q.d.
4.  Aspirin 325 p.o.q.d.
5.  Iron.
6.  Lasix 20 mg p.o.q.d., 20 mg IV.
7.  Spironolactone.
8.  Levothyroxine 200 p.o.q.d.
9.  Enoxaparin 40 subcutaneously b.i.d.
10. Kayexalate.
11. Ativan.
12. Morphine p.r.n.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: The patient's father died from colon cancer.
No  history  of  coronary  artery  disease.    The patient is
married.    He  used  to self employed.  He does not smoke or
drink  alcohol.    He currently lives at [**Hospital **] Rehabilitation
Center.

SOCIAL HISTORY: 
Pneumonia due to Klebsiella pneumoniae,Congestive heart failure, unspecified,Acute kidney failure, unspecified,Acute respiratory failure,Hodgkin's disease, unspecified type, unspecified site, extranodal and solid organ sites,Unspecified septicemia,Drug-induced delirium
K. pneumoniae pneumonia,CHF NOS,Acute kidney failure NOS,Acute respiratry failure,Hdgk dis unsp xtrndl org,Septicemia NOS,Drug-induced delirium
Service:                            Date:  [**2123-11-22**]

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

Surgeon:  [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D.  [**MD Number(1) 3795**]

HISTORY  OF  THE  PRESENT  ILLNESS:    This  is a 54-year-old
gentleman,  who  was  recently  discharged  on  the  13th  of
[**Month (only) **]  to  rehabilitation  with multiple medical problems,
including  coronary  artery disease, status post [**Female First Name (un) 899**] in [**2115**],
congestive  heart  failure with EF of 20% to 30%, status post
pericardial  stripping,  prostatic mitral and tricuspid valve
placement   in   [**Month (only) 205**],   [**2123**]   for   valve  dysfunction  and
constriction  after radiation; ICD placement for nonsustained
VT  and  low  ER  inducible  VT.    The  patient was admitted
recently  with  shortness  of breath and pulmonary edema.  He
had respiratory distress, which was felt to be multifactorial
and  in part, due to MRSA pneumonia and CHF.  Hospital course
then   was  complicated  by  episodic  hypotension  requiring
transient   inotropic   and  pressor  support.    Hemodynamic
monitoring  was  not  possible  secondary  to  the prosthetic
tricuspid   valve.    Hemodynamics  using  showed  physiology
consistent  with  sepsis.   He improved with antibiotics, and
eventually  he  was  diuresed  and  afterload  reduced.   The
etiology  of  the  infection was thought to be pneumonia.  He
was  covered  broadly.    Cultures  were  negative except for
sputum  with  MRSA.    Pleural effusion was tapped and it was
transudative  with  on  evidence  of infection.  He has had a
chronically  low  hematocrit, which is multifactorial.  There
was  no  evidence  for  DIC.  He did have blood loss from the
left  femoral  artery puncture site and required transfusion,
bronchitic support, and blood loss anemia.

On  the  evening  of the 19th, he was found to be hypotensive
with  the  blood  pressures  in the 70s and poor oxygenation.
His chest x-ray showed CHF versus ARDS.  He developed a fever
to  101.2.   He was started on Dopamine.  He was sent to [**Hospital1 98139**] for further care.  He notes
increased sputum production, but no dyspnea or chest pain.

PAST MEDICAL HISTORY:
1.   Coronary artery disease, status post inferior myocardial
infarction  [**2114**]  complicated  by  left ventricular thrombus,
status post left circumflex stent in [**2123-4-1**].
2.  Congestive heart failure.
3.    Status post mitral valve and tricuspid valve prosthetic
replacement [**2123-8-10**].
4.  AICD in [**2123-4-1**].
5.    History  of cerebrovascular accident with residual left
finger numbness.
6.  History of Hodgkin lymphoma at the age of 27, status post
radiation and splenectomy.
7.  Hypercholesterolemia.
8.  History of cervical diskectomy.
9.  Tracheostomy in [**2123-8-1**].
10. Gastrostomy tube placed in [**2123-8-1**].
11.   MRSA  diagnosed  in  [**Month (only) **],  [**2123**],  with  witnessed
aspiration with p.o. medications and liquids.
12. Constrictive pericarditis.
13. Iron-deficiency anemia.

MEDICATIONS ON ADMISSION:
1.  Ceftazidime started [**10-19**].
2.  Epogen.
3.  Amiodarone 400 p.o.q.d.
4.  Aspirin 325 p.o.q.d.
5.  Iron.
6.  Lasix 20 mg p.o.q.d., 20 mg IV.
7.  Spironolactone.
8.  Levothyroxine 200 p.o.q.d.
9.  Enoxaparin 40 subcutaneously b.i.d.
10. Kayexalate.
11. Ativan.
12. Morphine p.r.n.

ALLERGIES:  No known drug allergies.

FAMILY HISTORY:  The patient's father died from colon cancer.
No  history  of  coronary  artery  disease.    The patient is
married.    He  used  to self employed.  He does not smoke or
drink  alcohol.    He currently lives at [**Hospital **] Rehabilitation
Center.

PHYSICAL  EXAMINATION:  The patient is resting comfortably in
bed in no acute distress.  VITAL SIGNS:  Blood pressure 76/43
left  arm; 97/44 right arm.  Pulse 80.  Saturation 94% on 100
FIO2.  HEENT:  Pupils equal, round, and reactive to light and
accommodation.    Extraocular  muscles  are intact; anicteric
sclerae.  Hearing aids are in place.  Moist mucous membranes.
Neck  was  supple  without  lymphadenopathy.   LUNGS:  Coarse
sounds  throughout;  no  wheezes or rhonchi.  CARDIOVASCULAR:
No  jugular  venous  distention.   Carotids normal with brisk
upstrokes, regular rate and rhythm.  Mechanical S1 and normal
S2;   no  rub  or  gallop.    ABDOMEN:    Abdomen  was  soft,
nondistended,    nontender,    normoactive    bowel   sounds.
EXTREMITIES:    Positive  pitting of the lower extremities of
thigh,  pitting  edema  in  the  arm,  markedly improved from
previous  hospitalization.    There was a well healed scar of
the  left arm, PIC in the right arm.  Dressings to both heels
decubitus  ulcers.    Chest:    Well  healed  scar,  muscular
chest-wall  defect  dressed.    Decubitus  on  sacrum  mildly
erythematous without obvious drainage.

LABORATORY DATA:  Laboratory revealed the hematocrit of 23.4;
platelets  453,000,  white  blood  cell  count of 9.8 with no
bands;  sodium  134;  potassium 5.2; chloride 99; bicarbonate
26;  BUN  123;  creatinine  1.5;  glucose  116;  calcium 7.5;
magnesium  3.4; phosphorus 5.6; albumin 2.5; INR 1.3; PTT 32;
arterial  blood  gas  on  90%  with  FIO2  with  5-cm of PEEP
revealed the pO2 of 7.36, pCO2 of 49, pO2 of 56.  Chest x-ray
showed  diffuse  alveolar  filling  with  patchy interstitial
markings.    The  last echocardiogram revealed an EF of 25 to
35%   with   normal   valve   function;  severe  global  left
ventricular hypokinesis; mild right ventricular dilation.

HOSPITAL  COURSE:    Mr. [**Known lastname **] was treated simultaneously
for infectious pneumonic process, as well as congestive heart
failure.  For pneumonia he had initially received Vancomycin,
and  the  Zosyn.    He was extensively evaluated by the Heart
Failure  Team,  Dr.  [**Last Name (STitle) **]  for  management  of  his CHF and
possible  candidacy  for  heart transplant.  He was initially
tried  on  Milrinone,  but  failed secondary to hypertension.
Dopamine  was  tried with limited success in conjunction with
aggressive  bolus  Lasix  regimen.  Dopamine was discontinued
and we started using a combination of afterload reduction and
inotropic  support.  The patient did not successfully diurese
to  this  regimen.    Sputum  eventually showed polys with no
organisms,  but  grew  out  a  fairly  resistant Serratia and
Klebsiella   and  was  started  on  Imipenem.    However,  he
developed  a  rash  from  the  Imipenem and he was started on
Bactrim.     The  Bactrim  was  ultimately  discontinued.  He
remained   on   the  Dopamine  until  [**11-19**].    He  had  been
intermittently  tried on Dopamine, Dobutamine, and Lasix drip
with  again  limited  success in terms of diuresis.  Multiple
blood  transfusions  were given to support hematocrit greater
than  30.    His  renal  function intermittently improved and
worsened  based  on  the  degree  of  diuresis.  There was an
episode  of  acute  renal  failure during the week of [**11-10**],  probably secondary to hypotension after failed attempt
to  wean  Dopamine in conjunction with oncotic support in the
form  of  packed  red  blood cells and Lasix.  Renal function
returned closer to baseline of 2.

Multiple  trials  of  trach-mask were attempted, however, the
patient   did  not  have  the  cardiac  function  to  support
spontaneous  ventilation  and  eventually tired.  He has been
intermittently  using between 10 to 20-cm of pressure support
in conjunction with 5-cm to 10-cm of PEEP and an FIO2 ranging
between .4 and 1.

The Dopamine was eventually weaned to off on [**11-29**] and
21st  with  just  Dobutamine and Lasix.  The patient diuresed
fairly successfully 3-4 liters over a [**3-6**] day period.

Access  had  been  a  difficult  issue secondary to extensive
bleeding  in  the  femoral  region  in  the  past.    A right
subclavian was attempted, but failed.  Right internal jugular
complicated  by  arterial  puncture  and a PICC line had been
placed in the right arm, which is functioning at this point.

Over  the  week  of  [**11-12**] to [**11-19**], the patient was tried on
trach-mask trials.  However, this in conjunction with changes
in  the  Ativan  dosing produced hallucinations and delirium.
The  patient  was  placed back on pressor support ventilation
and improved significantly in terms of his mental status.

ISSUE  #1.    Cardiovascular:    The  patient  is status post
multiple  inotropic  trials  to  improve cardiac function and
diurese both left and right side fluid overload.  He has been
intermittently  tried on milrinone, Dopamine, and dobutamine.
The  most successful of these regimens has been a combination
of  dobutamine  and  Lasix.    The  patient  did not tolerate
Milrinone  secondary  to  hypotension.  On Dopamine, he would
intermittently  diurese,  but not progressively.  Maintaining
the  patient  200 cc to 300 cc negative a day is a reasonable
goal  on  a  moderate  dose  of Dobutamine at 6 mcg per k per
minute using a Lasix drip at 5 to 20 mg an hour.

In  terms  of his tricuspid and mitral valve replacement, the
patient  was  initially  on Coumadin, which had been stopped,
however,  his  INR  continued  to  take  a  long to drip down
secondary  to  poor  nutrition.  He had an INR of 4.2.  There
was  moderate  bleeding from the trach-site.  The patient was
reversed with FFP.  The INR was brought down to 1.9, at which
time  Heparin  was  started.    As  the  patient improved, he
started on Coumadin with a target INR of [**4-4**].

The patient continues to be V-paced at 80.

ISSUE  #2.    Pulmonary:    The  patient  has  a  history  of
pneumonia,  which  in  the  past  grew  MRSA.    During  this
admission  grew Klebsiella and Serratia sensitive to Imipenem
and  Bactrim.    The patient developed a rash to Imipenem and
was  started  on  Bactrim.    The patient developed a rash to
Imipenem.  The patient was started on Bactrim.  However, this
was  stopped  in  the  setting of acute renal failure for the
worry  of  possible  interstitial  nephritis.    However, the
patient  did  not  seem,  from the respiratory standpoint, to
acquire  antibiotics.    Antibiotics were stopped on the 10th
and  12th  of [**Month (only) 359**].  Chest CT was performed on the [**11-19**]  to  help  characterize  the  degree  and  extent  of
pulmonary  disease.  The CT was notable for consolidation and
interstitial disease, which was central sparing the periphery
consistent the primary pulmonary process.  No significant CHF
was seen in the periphery.  It is possible that the amount of
radiation  received  20  years  ago  may  have  resulted in a
primary  interstitial process to whatever cardiogenic process
is  occurring.    With  aggressive  diuresis  in  [**Month (only) 359**]  on
Dobutamine  and  Lasix  the  oxygen requirements decreased to
FIO2  of .41.  Ensuring a steady diuresis of 200-300 cc a day
should  prevent  further oxygen requirements.  However, it is
unlikely secondary to the patient's poor cardiac function and
extent  of  interstitial  disease  that  he  will become vent
independent in the near future.

ISSUE  #3:  Renal.  The patient had sensitive renal function.
Creatinine  ranged  from  1 to 3.  He is clearly sensitive to
renal  perfusion  and systolic blood pressure and keeping the
hematocrit  above  30  to  maintain good oncotic pressure for
renal  perfusion  is necessary for good renal function.   His
renal function was very sensitive to blood pressures below 70
to  80, causing acute renal failure with an ATN type picture.
However,  with  improved  and  aggressive  diuresis  off  the
Dopamine,  his  renal  function has improved to a baseline of
1.1.

A  limit  to his diuresis may be reached in terms of the BUN,
which has risen to the high 90s.

ISSUE  #4:    Endocrinological:    From  an  endocrinological
standpoint  he  has a history of hypothyroidism; TSH has been
relatively  high  and  consistent  with hypothyroidism in the
setting  of  systemic  illness.  His Levothyroxine doses have
been progressively increased.  He is now at 200 mcg a day and
will need a TSH checked in the near future.,

ISSUE  #5:   Gastrointestinal.  The patient was received tube
feeds  through  his  PEG, however, due to increased agitation
and  abdominal distention in the absence of clear obstruction
or  perforation, his tube feeds were stopped in favor or TPN.
As  his fluid balance continues to improve, he should be able
to start enteral feeding.

ISSUE #6:  Psychiatric.  The patient was controlled primarily
with  Remeron and Ativan for sleep at night.  When the Ativan
was  discontinued  in conjunction with trach-mask trials, his
mental   status   acutely   decompensated   in  the  form  of
hallucination  and  delirium.  The mechanical ventilation was
restarted  with  progressive  clearing  of his mental status.
There was no evidence of CO2 narcosis.  However, hypoxia is a
significant  possibility  for  cause of mental status changes
during    independent   ventilation.      The   Remeron   was
discontinued.    The  patient  responds  well  to  Haldol, as
needed.

ISSUE #7.  Electrolytes were followed closely.  Potassium was
repleted  as  needed, as well as magnesium.  Nutrition was as
above.  The patient has a right peripherally inserted central
catheter,  which is functioning.  The patient has been placed
on  a  proton pump inhibitor and had an elevated INR for much
of  his  hospitalization, but recently this has been reversed
as described, and the patient has been Heparinized.

This discharge summary will continued in a DC addendum.

The  patient  is  currently  a  full  code.   Numerous family
discussions with his wife and himself were held.




                          [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D.  [**MD Number(1) 3795**]

Dictated By:[**Name8 (MD) 30528**]

MEDQUIST36

D:  [**2123-11-22**]  14:47
T:  [**2123-11-22**]  15:18
JOB#:  [**Job Number 98140**]


Name:  [**Known lastname 15655**], [**Known firstname 116**]                     Unit No:  [**Numeric Identifier 15656**]

Admission Date:  [**2123-11-19**]     Discharge Date:  [**2123-12-6**]

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

Service:  ICU

ADDENDUM:  Mr. [**Known lastname **] continued to remain hemodynamically
stable and on stable vent settings throughout the remainder
of his hospital stay.  His Lasix was weaned down to 60 mg [**Hospital1 **]
for a rising BUN to 120 and creatinine to 1.3 on the day of
discharge.  At this point his fluid status is felt to be
slightly negative.

DISPOSITION:  He was discharged to rehabilitation in fair
condition.

DISCHARGE INSTRUCTIONS:
1.  He should have strict monitoring of ins and outs and
daily weights.  At this time his fluid status is slightly
negative.  His Lasix should be adjusted for a goal positive
of about 0.5 kg over the next one to two days and then aim
for even fluid status.  Monitor electrolytes, BUN, and
creatinine twice weekly until stable on stable Lasix dose.
2.  Check TSH in two weeks and adjust levothyroxine dose as
needed.
3.  Monitor hematocrit intermittently, especially if he
continues to have intermittent hemoptysis or bleeding
elsewhere.  Transfuse as needed for a goal hematocrit of
greater than 30.

DISCHARGE MEDICATIONS:
1.  Amiodarone 400 mg po q day.
2.  Lansoprazole 30 mg po q day.
3.  Levothyroxine 300 mcg po q day.
4.  Captopril 18.75 mg po tid.
5.  Lasix 60 mg IV bid, titrate to fluid status as above.
6.  Lovenox 40 mg subcutaneous [**Hospital1 **].
7.  Celexa 10 mg po q day.
8.  Combivent eight puffs qid.
9.  Epogen 5,000 units q Monday, Wednesday, and Friday.
10. Reglan 10 mg po tid.
11. Nepro tube feeds 40 cc/hr.

DISCHARGE DIAGNOSES:
1.  Congestive heart failure.
2.  Pneumonia.
3.  Hemoptysis.
4.  Hypothyroidism.
5.  Depression.
6.  Coronary artery disease.
7.  Status post mitral valve replacement and tricuspid valve
replacement.
8.  Status post automatic implantable cardioverter -
defibrillator placement.
9.  Status post tracheostomy.
10. Status post PEG.
11. Methicillin - resistant Staphylococcus aureus
colonization.
12. Status post pericardial stripping for constrictive
pericarditis.



                          [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D.  [**MD Number(1) 3662**]

Dictated By:[**Name8 (MD) 15657**]

MEDQUIST36

D:  [**2123-12-30**]  11:57
T:  [**2123-12-30**]  13:58
JOB#:  [**Job Number 15658**]
{"Pneumonia due to Klebsiella pneumoniae,Congestive heart failure, unspecified,Acute kidney failure, unspecified,Acute respiratory failure,Hodgkin's disease, unspecified type, unspecified site, extranodal and solid organ sites,Unspecified septicemia,Drug-induced delirium"}


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: 

MEDICAL HISTORY: 1.   Coronary artery disease, status post inferior myocardial
infarction  [**2114**]  complicated  by  left ventricular thrombus,
status post left circumflex stent in [**2123-4-1**].
2.  Congestive heart failure.
3.    Status post mitral valve and tricuspid valve prosthetic
replacement [**2123-8-10**].
4.  AICD in [**2123-4-1**].
5.    History  of cerebrovascular accident with residual left
finger numbness.
6.  History of Hodgkin lymphoma at the age of 27, status post
radiation and splenectomy.
7.  Hypercholesterolemia.
8.  History of cervical diskectomy.
9.  Tracheostomy in [**2123-8-1**].
10. Gastrostomy tube placed in [**2123-8-1**].
11.   MRSA  diagnosed  in  [**Month (only) **],  [**2123**],  with  witnessed
aspiration with p.o. medications and liquids.
12. Constrictive pericarditis.
13. Iron-deficiency anemia.

MEDICATION ON ADMISSION: 1.  Ceftazidime started [**10-19**].
2.  Epogen.
3.  Amiodarone 400 p.o.q.d.
4.  Aspirin 325 p.o.q.d.
5.  Iron.
6.  Lasix 20 mg p.o.q.d., 20 mg IV.
7.  Spironolactone.
8.  Levothyroxine 200 p.o.q.d.
9.  Enoxaparin 40 subcutaneously b.i.d.
10. Kayexalate.
11. Ativan.
12. Morphine p.r.n.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: The patient's father died from colon cancer.
No  history  of  coronary  artery  disease.    The patient is
married.    He  used  to self employed.  He does not smoke or
drink  alcohol.    He currently lives at [**Hospital **] Rehabilitation
Center.

SOCIAL HISTORY:  

### Response:
{"Pneumonia due to Klebsiella pneumoniae,Congestive heart failure, unspecified,Acute kidney failure, unspecified,Acute respiratory failure,Hodgkin's disease, unspecified type, unspecified site, extranodal and solid organ sites,Unspecified septicemia,Drug-induced delirium"}
