CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is a 25-year-old
gentleman with a history of hypercholesterolemia and
hyperlipidemia who was transferred from an outside hospital
with acute pancreatitis.

MEDICAL HISTORY: Hypercholesterolemia.

MEDICATION ON ADMISSION: Lopid as an outpatient.

ALLERGIES: BACTRIM.

PHYSICAL EXAM: 

FAMILY HISTORY: His father had bilateral kidney stones.
Mother has hypothyroidism.  Grandfather had [**Name2 (NI) 499**] cancer.
Another grandfather had liver cancer, but this was secondary
to alcohol abuse.

SOCIAL HISTORY: The patient is married with two children.
He use to drink one drink of alcohol per month.  A
12-pack-year history of tobacco; but he quit four years ago.
He is a Jehovah Witness and is not accepting of any human blood
products. He is a heating-airconditioning technician.
Acute kidney failure, unspecified,Acute pancreatitis,Pneumonia, organism unspecified,Acute respiratory failure,Bacteremia
Acute kidney failure NOS,Acute pancreatitis,Pneumonia, organism NOS,Acute respiratry failure,Bacteremia
Admission Date:  [**2153-9-19**]     Discharge Date:  [**2153-11-1**]

Date of Birth:                  Sex:  M

Service:  [**Hospital Ward Name 332**] MICU

HISTORY OF PRESENT ILLNESS:  The patient is a 25-year-old
gentleman with a history of hypercholesterolemia and
hyperlipidemia who was transferred from an outside hospital
with acute pancreatitis.

The patient reported on admission that four weeks prior to
admission, and again two weeks prior to admission, he hurt
his back when lifting up a heavy object for his job.  After
two weeks he noticed that the pain was not getting better,
and he went to see his primary care physician.  [**Name10 (NameIs) **] pain was
also present in his abdomen where it was a diffuse and dull
but unrelenting.

At his primary care physician's office he was noted to have a
calcium of 16, an elevated amylase, lipase, and low platelets
before he was admitted to a local hospital where he was
diagnosed with hypercalcemia and pancreatitis.  At the local
hospital he was treated with intravenous fluids, Lasix,
calcitonin, and pamidronate with improvement in his calcium
level but with marked worsening of his creatinine to 6.2.  In
addition, during his short stay at the outside hospital, he
had worsening abdominal pain, distention, and developed
shortness of breath with hypoxemia.

He was then transferred to [**Hospital1 188**] for further management.

PAST MEDICAL HISTORY:   Hypercholesterolemia.

MEDICATIONS ON ADMISSION:  Lopid as an outpatient.

ALLERGIES:  BACTRIM.

SOCIAL HISTORY:  The patient is married with two children.
He use to drink one drink of alcohol per month.  A
12-pack-year history of tobacco; but he quit four years ago.
He is a Jehovah Witness and is not accepting of any human blood
products. He is a heating-airconditioning technician.

FAMILY HISTORY:   His father had bilateral kidney stones.
Mother has hypothyroidism.  Grandfather had [**Name2 (NI) 499**] cancer.
Another grandfather had liver cancer, but this was secondary
to alcohol abuse.

PHYSICAL EXAMINATION ON PRESENTATION:  Vital signs on
presentation revealed his temperature was 97 degrees
Fahrenheit, his blood pressure was 114/61, his heart rate was
122, his respiratory rate was 23, and his oxygen saturation
was 92% on 3 liters nasal cannula.  His weight was 110
kilograms.  General appearance revealed he was sitting up in
bed and looked comfortable.  Head, eyes, ears, nose, and
throat examination revealed sclerae were anicteric.  The
mucous membranes were moist.  Pupils were constricted
bilaterally.  Extraocular movements were intact.  The neck
was supple.  No jugular venous distention.  No palpable
lymphadenopathy but tenderness to palpation in the
submandibular space and supraclavicular space.
Cardiovascular examination revealed tachycardia with a
regular rhythm.  The lungs revealed decreased breath sounds
one half of the way bilaterally.  No wheezes, crackles, or
rhonchi.  The abdomen was distended and soft.  Tender in the
right upper quadrant and left lower quadrant and also left
upper quadrant.  There were active bowel sounds; mostly in
the left lower quadrant and left upper quadrant.  There was
marked hepatosplenomegaly on palpation.  No ascites.
Extremity examination revealed no edema.  Dorsalis pedis
pulses were palpable bilaterally.  Neurologic examination
revealed alert and oriented times three.  Cranial nerves II
through XII were intact.

PERTINENT LABORATORY VALUES ON PRESENTATION:   Laboratories
on presentation revealed complete blood count with a white
blood cell count of 26, his hematocrit was 53, and his
platelets were 72.  Chemistry-7 revealed his sodium was 138,
potassium was 4.9, chloride was 102, bicarbonate was 22,
blood urea nitrogen was 69, creatinine was 6.2, and his blood
glucose was 127.  Calcium was 15.3, magnesium was 1.3, and
phosphate was 5.7.  Total triglycerides were 206 and
cholesterol was 180.

PERTINENT RADIOLOGY/IMAGING:  A computerized axial tomography
of the abdomen revealed hepatosplenomegaly with moderate
pancreatitis and a right lobe atelectasis.

CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:  Briefly,
Mr. [**Known lastname 51479**] is a 25-year-old gentleman with a past medical
history only significant for hyperlipidemia and
hypercholesterolemia who presented to his primary care
physician complaining of back pain and abdominal pain and was
found to have acute necrotic pancreatitis complicated by
renal failure and hypercalcemia and thrombocytopenia.

 1.  ACUTE SEVERE NECROTIZING PANCREATITIS ISSUES:  The patient
was initially treated with aggressive fluid resuscitation
and required intubation for respiratory compromise due to
abdominal distention and abdominal pain . His pain
control was addressed after intubation with Fentanyl.  He was
started on meropenem for infection prevention.  His
fingerstick blood glucose levels were monitored and adjusted
with an insulin sliding-scale.

Several computerized axial tomography scans of his abdomen
with intravenous contrast, but not by mouth contrast, were
obtained which revealed necrotic liquefaction of the tail and
body of the pancreas and a interval increase in the size of a
loculated collection along the anterior pancreas with the
lesser sac.  Minimal pancreatic bed enhancement was evident on
most recent CT scan.

Meropenem was stopped as he developed a rash.  He continued
to receive supportive care (as above).  He was also started
on trophic tube feeds at 10 cc per hour which had to be
stopped intermittently during his 6-week course because of
increased abdominal distention and the suggestion of ileus.

 2.  ACUTE RENAL FAILURE ISSUES:  The patient initially
presented with acute renal failure that resolved with
aggressive hydration, with his creatinine dropping to 2.8.
However, five days prior to discharge he was started on Zosyn
and vancomycin which resulted in a second event of acute
renal failure.  At that time, there were no eosinophils in
his urine, and the acute renal failure resolved once again
with aggressive hydration.

 3.  ANEMIA ISSUES:  The patient's entire hospital course was
marked by progressive anemia.  On the day of his arrival,
after aggressive fluid resuscitation, his hematocrit dropped
over 10 points from 52 to 40.  The patient continued to have
a drop in his hematocrit slowly but consistently.

On the last week of his stay at [**Hospital1 188**], he started to ooze from his endotracheal tube and
nasojejunal tube.  He underwent a bronchoscopy on [**2153-10-31**] which revealed some granulation tissue around the
cuff and some oozing in the trachea around the cuff. Epogen had
been started since admission, and at the time of discharge, was
10,000 units three times per day.  He received two courses of
ferrous gluconate eight days each to replete his iron stores.
Blood draws were limited to strictly as necessary in order to
avoid unnecessary blood waste.

 4.  FEVER OF UNKNOWN ORIGIN ISSUES:  Mr. [**Known lastname 51480**]
hospital course was also marked by recurrent fevers up to
102.6 degrees Fahrenheit almost every day or every 48 hours.

He was extensively cultured with consistently negative blood
cultures and urine cultures except for one bottle which grew
Lactobacillus which was considered to be a contaminant.
During his hospital course, he developed two
ventilator-associated pneumonias which were not felt to be
the main cause of his recurrent fevers.  As his blood
cultures, urine cultures remained negative, and his continued
to have high fevers, also when he did not have pneumonia, it
was felt that the main cause of his recurrent high
temperatures was the inflammation and possibly infection
occurring in his abdomen; specifically, around his pancreas.

 5.  VENTILATOR-ASSOCIATED PNEUMONIA ISSUES:  The patient
developed one pneumonia earlier; approximately three weeks
after his admission.  At that time, the pneumonia was in the
right lower lobe.  He was treated with meropenem and
vancomycin; at which point, he developed a maculopapular rash
all over his body.  It was felt that this was most likely an
allergy to meropenem or vancomycin, and both of them were
stopped.  Zosyn was started instead.  While he was taking
Zosyn, his skin rash resolved, and his pneumonia also
resolved.

One week prior to his discharge, he developed a second
ventilator-associated pneumonia in the retrocardiac space;
mostly localized to the left lobe.  He was initially started
on vancomycin and Zosyn, and 24 hours after the initiation of
this therapy he once again developed a rash.  His antibiotics
were immediately stopped, and he was switched to levofloxacin
and clindamycin.  A sputum culture revealed gram-negative
rods, not a fermenter, not pseudomonal; sensitive only to
Bactrim and levofloxacin.  Therefore, he was continued on the
two medications levofloxacin and clindamycin with a good
improvement in the pneumonia (as per subsequent chest
x-rays).  His respiratory status did not require changes in
his ventilatory settings.

Current ventilatory settings at the time of discharge were
assist control with a FIO2 of 50%, tidal volume of 500 to
520, a respiratory rate of 28, a positive end-expiratory
pressure of 15, and a proximal interphalangeal positive
inspiratory pressure of 42 (which has been his baseline given
the massive abdominal distention).

 6.  SKIN RASH ISSUES:  Given the fact that the patient
developed a skin rash twice and that he was on different
antibiotics when this happened (particularly vancomycin,
Zosyn, meropenem, and had incidentally received a dose of
Lasix when he developed the first rash) the Allergy Service
was consulted.  They performed some skin testing which
reported that the patient was not sensitive to penicillin;
however, it was unclear if it was also not sensitive to
histamine.

 7.  THROMBOCYTOPENIA ISSUES:  The patient remained
thrombocytopenic throughout most of his hospital stay with
platelets above 50s only for a few days; scattered throughout
the hospital stay.  This hampered the attempts to perform a
tracheostomy for which the Surgery Service and the
Interventional Pulmonology Service required platelets above
50.  No clear etiology was found for this thrombocytopenia.
Disseminated intravascular coagulation and hemolysis were
ruled out by laboratories.

A bone marrow biopsy was attempted to clarify the etiology of
the patient's thrombocytopenia and anemia but failed and was
not attempted given the risk of bleeding in a patient who
would not be able to be transfused.

 8.  NUTRITION ISSUES:  The patient has been on total
parenteral nutrition which he tolerated well.

 9.  PROPHYLAXIS ISSUES:  The patient had been heparin and
his total parenteral nutrition for many days; which was
recently stopped given his worsening anemia and
thrombocytopenia with some active bleeding.  The patient was
wearing pneumatic boots, and he was on pantoprazole 40 mg by
mouth and intravenously.

10.  CODE STATUS ISSUES:  His code status is full with
directives requiring no transfusions of any blood or blood
products.






                          [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**], M.D.  [**MD Number(1) 2438**]

Dictated By:[**Last Name (NamePattern1) 19227**]

MEDQUIST36

D:  [**2153-11-1**]  15:53
T:  [**2153-11-1**]  16:02
JOB#:  [**Job Number 51481**]
{'Acute kidney failure, unspecified,Acute pancreatitis,Pneumonia, organism unspecified,Acute respiratory failure,Bacteremia'}


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: The patient is a 25-year-old
gentleman with a history of hypercholesterolemia and
hyperlipidemia who was transferred from an outside hospital
with acute pancreatitis.

MEDICAL HISTORY: Hypercholesterolemia.

MEDICATION ON ADMISSION: Lopid as an outpatient.

ALLERGIES: BACTRIM.

PHYSICAL EXAM: 

FAMILY HISTORY: His father had bilateral kidney stones.
Mother has hypothyroidism.  Grandfather had [**Name2 (NI) 499**] cancer.
Another grandfather had liver cancer, but this was secondary
to alcohol abuse.

SOCIAL HISTORY: The patient is married with two children.
He use to drink one drink of alcohol per month.  A
12-pack-year history of tobacco; but he quit four years ago.
He is a Jehovah Witness and is not accepting of any human blood
products. He is a heating-airconditioning technician. 

### Response:
{'Acute kidney failure, unspecified,Acute pancreatitis,Pneumonia, organism unspecified,Acute respiratory failure,Bacteremia'}
