CHIEF COMPLAINT: Fever of unknown origin

PRESENT ILLNESS: 43 year old male firefighter who was struck by an auto which
left him with anoxic encephalopathy, seizure disorder, atrial
fibrillation, and multiple extremity wounds.  He returns from
his rehab facility with fevers of unknown origin, which have
persisted despite antibiotic treatment with Vancomycin,
Fluconazole, and Amikacin.  Cultures at the rehab facility were
positive for gram negative staphylococcus bacteremia and
acenitobacter in his sputum.  Urine and stool cultures were
negative.

MEDICAL HISTORY: Polytrauma requiring multiple operative interventions
Anoxic brain injury
Placement of IVC filter, percutaneous gastrostomy, tracheostomy

MEDICATION ON ADMISSION: 1. Keppra [**2141**] QHS, 1500 QAM
2. Folate 1g daily
3. Colace 100 [**Hospital1 **]
4. Metoprolol 50mg TID
5. Diflucan 400mg daily
6. Vancomycin 1.25g Q12h
7. Amikacin 1175mg daily
8. Dilantin 100mg QID
9. Topamax 100mg 5x daily
10. Dilaudid 4mg IV Q4hPRN
11. Sodium bicarbonate 2 tabs TID
12. Magnesium oxide 400 mg daily
13. Senna 2 tabs [**Hospital1 **]
14. Lansoprazole 30 mg [**Hospital1 **]
15. Potassium chloride
16. MVI daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: Temp 100.6, BP 145/68, HR 110, RR 16, O2 sat 100% on 10L
trach mask
GEN: NAD, cachectic, responsive but mildly confused
Lungs: CTA B/L, mild upper airway transmission
Heart: S1S2 RRR, no murmurs, gallops, or rubs.
Abd: Soft, NT/ND, + Bowel sounds.  Gtube in place.
Back: 7x7 cm sacral decubitus ulcer with fibrinous base,
nonpurulent.
Ext: B/L LE with vacs intact.  R arm cast.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Firefighter
Married with children
Pressure ulcer, lower back,Anoxic brain damage,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Chronic osteomyelitis, other specified sites,Atrial fibrillation,Late effect of unspecified injury,Aftercare for healing traumatic fracture of lower leg,Gastrostomy status,Tracheostomy status,Long-term (current) use of aspirin,Unspecified level upper limb amputation status,Late effects of motor vehicle accident
Pressure ulcer, low back,Anoxic brain damage,Pseudomonas infect NOS,Chr osteomyelit NEC,Atrial fibrillation,Late effect injury NOS,Aftrcre traum fx low leg,Gastrostomy status,Tracheostomy status,Long-term use of aspirin,Status amput up lmb NOS,Late eff motor vehic acc
Admission Date:  [**2148-11-5**]              Discharge Date:   [**2148-11-15**]

Date of Birth:  [**2104-12-17**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Fever of unknown origin

Major Surgical or Invasive Procedure:
None


History of Present Illness:
43 year old male firefighter who was struck by an auto which
left him with anoxic encephalopathy, seizure disorder, atrial
fibrillation, and multiple extremity wounds.  He returns from
his rehab facility with fevers of unknown origin, which have
persisted despite antibiotic treatment with Vancomycin,
Fluconazole, and Amikacin.  Cultures at the rehab facility were
positive for gram negative staphylococcus bacteremia and
acenitobacter in his sputum.  Urine and stool cultures were
negative.

Past Medical History:
Polytrauma requiring multiple operative interventions
Anoxic brain injury
Placement of IVC filter, percutaneous gastrostomy, tracheostomy

Social History:
Firefighter
Married with children


Family History:
Noncontributory

Physical Exam:
VS: Temp 100.6, BP 145/68, HR 110, RR 16, O2 sat 100% on 10L
trach mask
GEN: NAD, cachectic, responsive but mildly confused
Lungs: CTA B/L, mild upper airway transmission
Heart: S1S2 RRR, no murmurs, gallops, or rubs.
Abd: Soft, NT/ND, + Bowel sounds.  Gtube in place.
Back: 7x7 cm sacral decubitus ulcer with fibrinous base,
nonpurulent.
Ext: B/L LE with vacs intact.  R arm cast.

Pertinent Results:
[**2148-11-5**] 02:29AM   WBC-16.6* RBC-2.81* HGB-8.9* HCT-26.8* MCV-96
MCH-31.7 MCHC-33.2 RDW-14.2
[**2148-11-5**] 02:29AM   GLUCOSE-118* UREA N-12 CREAT-0.3* SODIUM-133
POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-23 ANION GAP-14
[**2148-11-5**] 02:29AM   ALT(SGPT)-300* AST(SGOT)-73* LD(LDH)-151 ALK
PHOS-262* AMYLASE-41 TOT BILI-0.3
[**2148-11-7**] 09:45PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HAV-NEGATIVE

*****[**11-5**] WOUND CULTURE:
WOUND CULTURE (Final [**2148-11-8**]):
      Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
      workup is performed appropriate to the isolates recovered
from the
      site (including a screen for Pseudomonas aeruginosa,
Staphylococcus
      aureus and beta streptococcus).
      GRAM NEGATIVE ROD(S).    MODERATE GROWTH.
      PROBABLE ENTEROCOCCUS.    MODERATE GROWTH.
      PSEUDOMONAS AERUGINOSA.    MODERATE GROWTH.
      GRAM NEGATIVE ROD #3.    SPARSE GROWTH.

*****[**11-5**] SPUTUM CULTURE:
RESPIRATORY CULTURE (Final [**2148-11-10**]):
      OROPHARYNGEAL FLORA ABSENT.
      ACINETOBACTER BAUMANNII.    >100,000 ORGANISMS/ML..
         "Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
         used, since therapeutic efficacy relies on intrinsic
activity of
         the sulbactam component".
         SULFA X TRIMETH Sensitivity testing per DR [**First Name (STitle) **]
([**Numeric Identifier 1097**]).
         SULFA X TRIMETH PERFORMED BY [**Doctor Last Name **]-[**Doctor Last Name **].
      STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA.
         10,000-100,000 ORGANISMS/ML..

***** [**11-5**] HEAD CT:
FINDINGS: There is no intracranial hemorrhage, shift of normally
midline structures, or evidence of acute major vascular
territorial infarct. No abnormal enhancement is noted. Compared
to [**2148-8-11**], [**Doctor Last Name 352**]-white matter distinction and cerebral edema
has improved. Surrounding osseous structures demonstrate normal
aeration of the paranasal sinuses and mastoid air cells.
Additionally, subcutaneous swelling has improved compared to
[**Month (only) 205**].

IMPRESSION: No intracranial hemorrhage or edema

***** [**11-5**] CT ABDOMEN/PELVIS:
CT ABDOMEN WITH CONTRAST: Opacification within distal bronchi at
the right base likely represent secretions and the lung bases
are otherwise unremarkable. No focal hepatic lesion is
identified and the gallbladder, pancreas, spleen, and adrenal
glands are within normal limits. The kidneys enhance
symmetrically and excrete contrast normally and there is no
evidence of hydronephrosis or hydroureter. Subcentimeter
hypoattenuating bilateral renal lesions measure up to 7 mm in
size and are too small to further characterize. Intra-abdominal
loops of large and small bowel are unremarkable and there is no
free air, free fluid, or pathologically enlarged mesenteric or
retroperitoneal lymph nodes. A G- tube is present within the
stomach and an IVC filter is in place. The abdominal aorta is of
normal caliber throughout.

CT PELVIS WITH CONTRAST: The rectum, sigmoid colon, seminal
vesicles, prostate are unremarkable. A Foley is present within
the bladder which contains nondependent air. No free fluid or
pathologically enlarged lymph nodes are seen within the pelvis.

Bone windows reveal no worrisome lytic or sclerotic lesions. A
few small foci or air within the subcutaneous tissues just
inferior to the coccyx may represent decubitus ulceration, new
since [**Month (only) 205**].

IMPRESSION:
1. New decubitus ulceration just inferior to and approaching the
coccyx bone. Recommend clinical correlation.

2. Opacification of a few right lower lobe bronchi likely
represent secretions.

3. Hypoattenuating renal lesions are too small to characterize

***** [**11-5**] CHEST XRAY:
FINDINGS: Comparison with the study of [**2148-9-21**], the tracheostomy
tube remains in place. The right central catheter has been
removed.

Specifically, there is no evidence of acute pneumonia

***** [**11-5**] RUQ ULTRASOUND:
FINDINGS: The liver demonstrates no focal or textural
abnormality. There is no intra- or extra-hepatic biliary ductal
dilatation. There is a mild amount of sludge within the
gallbladder with a few tiny hyperechoic foci measuring up to 4
mm which may represent [**Doctor Last Name 5691**]/small stones. The common bile duct
measures 3 mm. The main portal vein demonstrates normal
hepatopetal flow. No free fluid is identified in the right upper
quadrant.

IMPRESSION: Gallbladder sludge with tiny [**Doctor Last Name 5691**]/stones. No
evidence of cholecystitis.

*****[**11-6**] TIB/FIB XRAYS:
IMPRESSION: Status post ORIF of comminuted left tibial plateau
fracture and multiple comminuted right tibial fractures.
Evidence of interval fracture healing without hardware
complication.

*****[**11-6**] B/L VENOUS DUPLEX:
IMPRESSION: No evidence of DVT in both legs.

*****[**11-7**] TRANSTHORACIC ECHO:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%) Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.

IMPRESSION: Normal study. No valvular pathology or pathologic
flow identified.
Compared with the prior study (images reviewed) of [**2148-9-21**],
systolic function is now normal.


Brief Hospital Course:
He was admitted to the Trauma ICU on [**2148-11-5**] for expected
ventilator dependency.  He was able to tolerate being off of the
ventilator on trach mask around the clock.  A complete fever
workup was initiated, including cultures of the blood, urine,
sputum, stool, and sacral ulcer.  His left arm midline that was
inserted at the rehab facility was removed and cultured.  His
blood, urine, and stool cultures were negative, and remained
negative on repeat cultures as well.  His wound culture was
positive for Pseudomonas and Enterococcus, and sputum was
positive for Acinetobacter and Strophomonas.  The infectious
disease service was consulted, and as he was hemodynamically
stable, the decision was made to stop all of his antibiotics.
His fever persisted for several days, during which Xrays of the
chest and a CT of the abdomen and pelvis were performed, and
were negative for sources of infection.  Lower extremity
ultrasounds were negative for DVT.  As his liver enzymes were
elevated, a RUQ ultrasound was done, which showed gallbladder
sludge but was negative for cholecystitis.  Hepatitis serologies
were negative as well.  At this time his fever curve began to
trend down, and he was transferred to the surgical floor.  A
transthoracic echo was done, which was negative for
endocarditis.

During his hospital stay the Plastic surgery service was
consulted as well for management of his open wounds.  They
determined that revision of the sacral ulcer would not be
necessary at this time, but that the wounds to the lower
extremities and right elbow were suitable for skin grafting.
Unfortunately he was not able to be scheduled for grafting
during this hospital stay, and will have plastic surgery
followup as an outpatient.  As his fever had resolved and all
workup was negative, the decision was made to discharge him back
to his rehabilitation facility on [**2148-11-15**].

During his hospital stay he was also evaluated by Physical and
Occupational therapy; he will continue to require ongoing
intensive rehabilitation because of his multiple injuries.

Medications on Admission:
1. Keppra [**2141**] QHS, 1500 QAM
2. Folate 1g daily
3. Colace 100 [**Hospital1 **]
4. Metoprolol 50mg TID
5. Diflucan 400mg daily
6. Vancomycin 1.25g Q12h
7. Amikacin 1175mg daily
8. Dilantin 100mg QID
9. Topamax 100mg 5x daily
10. Dilaudid 4mg IV Q4hPRN
11. Sodium bicarbonate 2 tabs TID
12. Magnesium oxide 400 mg daily
13. Senna 2 tabs [**Hospital1 **]
14. Lansoprazole 30 mg [**Hospital1 **]
15. Potassium chloride
16. MVI daily


Discharge Medications:
1. Acetaminophen 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every
6 hours) as needed for fever.
2. Therapeutic Multivitamin     Liquid [**Hospital1 **]: One (1) Cap PO DAILY
(Daily).
3. Senna 8.6 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2 times a
day) as needed.
4. Ferrous Sulfate 325 (65) mg Tablet [**Hospital1 **]: One (1) Tablet PO
DAILY (Daily).
5. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Topiramate 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO 5X/DAY (5
Times a Day).
7. Levetiracetam 100 mg/mL Solution [**Hospital1 **]: 1500 (1500) mg PO QAM
(once a day (in the morning)).
8. Levetiracetam 100 mg/mL Solution [**Hospital1 **]: [**2141**] ([**2141**]) mg PO QHS
(once a day (at bedtime)).
9. Folic Acid 1 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily).

10. Docusate Sodium 50 mg/5 mL Liquid [**Year (4 digits) **]: One Hundred (100) mg
PO BID (2 times a day).
11. Metoprolol Tartrate 25 mg Tablet [**Year (4 digits) **]: Three (3) Tablet PO
TID (3 times a day). Tablet(s)
12. HYDROmorphone (Dilaudid) 1-4 mg IV Q4H:PRN pain
pt stabilized on regimen
13. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN.  Inspect site every shift.
14. Heparin (Porcine) 5,000 unit/mL Solution [**Year (4 digits) **]: One (1) ML
Injection TID (3 times a day).
15. Insulin Regular Human 100 unit/mL Solution [**Year (4 digits) **]: One (1) Dose
Injection four times a day as needed for per sliding scale.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 105**] Northeast - [**Location (un) 38**]

Discharge Diagnosis:
Fever of unknown origin
Grade IV Decubitus Ulcer


Discharge Condition:
Stable


Discharge Instructions:
You were admitted to the hospital with fever of unknown origin.
Your PICC line was thought to be a potential source of infection
and was removed.  Your fever resolved without antibiotic
treament.  You were seen by the plastic surgeons who will
perform skin grafting to your legs and try to repair your elbow
at a future date.  Plastic surgery also evaluated your sacral
ulcer and did not think any intervention was needed at this
time.  You will be called by the plastic surgery service with a
date and time for your surgery. If you are not contact[**Name (NI) **]
regarding a time for your surgery, you should call plastic
surgery clinic.
.
Please call your doctor or return to the hospital for:
* Return of fevers (T > 101)or chills
* Abdominal pain
* Nausea or vomiting
.
Diet: You may resume tube feeds as before.
.
Medication:
Please continue medications as listed:
1. Acetaminophen 500 mg Tablet [**Name (NI) **]: One (1) Tablet PO Q6H (every
6 hours) as needed for fever.
2. Therapeutic Multivitamin     Liquid [**Name (NI) **]: One (1) Cap PO DAILY
(Daily).
3. Senna 8.6 mg Tablet [**Name (NI) **]: Two (2) Tablet PO BID (2 times a
day) as needed.
4. Ferrous Sulfate 325 (65) mg Tablet [**Name (NI) **]: One (1) Tablet PO
DAILY (Daily).
5. Aspirin 81 mg Tablet, Chewable [**Name (NI) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Topiramate 100 mg Tablet [**Name (NI) **]: One (1) Tablet PO 5X/DAY (5
Times a Day).
7. Levetiracetam 100 mg/mL Solution [**Name (NI) **]: 1500 (1500) mg PO QAM
(once a day (in the morning)).
8. Levetiracetam 100 mg/mL Solution [**Name (NI) **]: [**2141**] ([**2141**]) mg PO QHS
(once a day (at bedtime)).
9. Folic Acid 1 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily).

10. Docusate Sodium 50 mg/5 mL Liquid [**Year (4 digits) **]: One Hundred (100) mg
PO BID (2 times a day).
11. Metoprolol 75mg PO TID
12. HYDROmorphone (Dilaudid) 1-4 mg IV Q4H:PRN pain

Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 1005**] ([**Hospital **] Clinic [**Telephone/Fax (1) 1228**]) in
4 weeks.

Please call Plastic Surgery Clinic ([**Telephone/Fax (1) 57665**] if you are not
contact[**Name (NI) **] regarding a date and time for your surgery within the
next week.

Follow up with Dr. [**Last Name (STitle) 519**], Trauma Surgery in 4 weeks or sooner if
necessary, call [**Telephone/Fax (1) 6554**] for an appointment.


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]

Completed by:[**2148-11-19**]
{'Pressure ulcer, lower back,Anoxic brain damage,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Chronic osteomyelitis, other specified sites,Atrial fibrillation,Late effect of unspecified injury,Aftercare for healing traumatic fracture of lower leg,Gastrostomy status,Tracheostomy status,Long-term (current) use of aspirin,Unspecified level upper limb amputation status,Late effects of motor vehicle accident'}


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: Fever of unknown origin

PRESENT ILLNESS: 43 year old male firefighter who was struck by an auto which
left him with anoxic encephalopathy, seizure disorder, atrial
fibrillation, and multiple extremity wounds.  He returns from
his rehab facility with fevers of unknown origin, which have
persisted despite antibiotic treatment with Vancomycin,
Fluconazole, and Amikacin.  Cultures at the rehab facility were
positive for gram negative staphylococcus bacteremia and
acenitobacter in his sputum.  Urine and stool cultures were
negative.

MEDICAL HISTORY: Polytrauma requiring multiple operative interventions
Anoxic brain injury
Placement of IVC filter, percutaneous gastrostomy, tracheostomy

MEDICATION ON ADMISSION: 1. Keppra [**2141**] QHS, 1500 QAM
2. Folate 1g daily
3. Colace 100 [**Hospital1 **]
4. Metoprolol 50mg TID
5. Diflucan 400mg daily
6. Vancomycin 1.25g Q12h
7. Amikacin 1175mg daily
8. Dilantin 100mg QID
9. Topamax 100mg 5x daily
10. Dilaudid 4mg IV Q4hPRN
11. Sodium bicarbonate 2 tabs TID
12. Magnesium oxide 400 mg daily
13. Senna 2 tabs [**Hospital1 **]
14. Lansoprazole 30 mg [**Hospital1 **]
15. Potassium chloride
16. MVI daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: Temp 100.6, BP 145/68, HR 110, RR 16, O2 sat 100% on 10L
trach mask
GEN: NAD, cachectic, responsive but mildly confused
Lungs: CTA B/L, mild upper airway transmission
Heart: S1S2 RRR, no murmurs, gallops, or rubs.
Abd: Soft, NT/ND, + Bowel sounds.  Gtube in place.
Back: 7x7 cm sacral decubitus ulcer with fibrinous base,
nonpurulent.
Ext: B/L LE with vacs intact.  R arm cast.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Firefighter
Married with children 

### Response:
{'Pressure ulcer, lower back,Anoxic brain damage,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Chronic osteomyelitis, other specified sites,Atrial fibrillation,Late effect of unspecified injury,Aftercare for healing traumatic fracture of lower leg,Gastrostomy status,Tracheostomy status,Long-term (current) use of aspirin,Unspecified level upper limb amputation status,Late effects of motor vehicle accident'}
