CHIEF COMPLAINT: 

PRESENT ILLNESS: Mr. [**Known lastname 43972**] is a 36-year-old
male with a past medical history of Hodgkin's lymphoma
treated approximately 15 years ago with staging laparotomy,
splenectomy and nodal sampling followed by x-ray radiation
therapy, the subsequent diagnosis two years ago of ITP with
evidence of splenosis by CT scan, which was treated with
Prednisone IgG, and recently treated with Rituxan with good
effect.  He presented approximately one month ago with severe
abdominal pain and was diagnosed with portal vein thrombosis and
started on coumadin after being heparinized. He presented to the
Emergency Room at [**Hospital1 69**] on
[**2178-5-27**] with 2-3 day history of increasing abdominal pain on
the right side.  At this time he denies nausea, vomiting,
positive flatus and still had a bowel movement at that time.
CT scan was obtained from an outside hospital which
demonstrated a focal area of small bowel wall thickening, portal
vein thrombosis and superior mesenteric vein thrombosis.  It was
felt at that time that patient was experiencing worsening
mesenteric ischemia and was admitted for exploratory
laparotomy to assess the viability of his small bowel.

MEDICAL HISTORY: 1) Hodgkin's lymphoma diagnosed 15
years ago.  2) ITP diagnosed two years ago treated with IgG
and Prednisone, recently treated with Rituxan approximately
one week prior to admission.  3) Portal vein thrombosis
diagnosed approximately one month ago.  4) Hypothyroidism.
5) Restless leg syndrome.  6) Anxiety.

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: A [**3-15**] pack per day smoker times
approximately 15 years, denies current alcohol use.
Acute vascular insufficiency of intestine,Hodgkin's disease, unspecified type, unspecified site, extranodal and solid organ sites
Ac vasc insuff intestine,Hdgk dis unsp xtrndl org
Admission Date:  [**2178-9-26**]     Discharge Date:  [**2178-10-6**]

Date of Birth:   [**2142-5-20**]     Sex:  M

Service:  Blue Surgery
HISTORY OF PRESENT ILLNESS:  Mr. [**Known lastname 43972**] is a 36-year-old
male with a past medical history of Hodgkin's lymphoma
treated approximately 15 years ago with staging laparotomy,
splenectomy and nodal sampling followed by x-ray radiation
therapy, the subsequent diagnosis two years ago of ITP with
evidence of splenosis by CT scan, which was treated with
Prednisone IgG, and recently treated with Rituxan with good
effect.  He presented approximately one month ago with severe
abdominal pain and was diagnosed with portal vein thrombosis and
started on coumadin after being heparinized. He presented to the
Emergency Room at [**Hospital1 69**] on
[**2178-5-27**] with 2-3 day history of increasing abdominal pain on
the right side.  At this time he denies nausea, vomiting,
positive flatus and still had a bowel movement at that time.
CT scan was obtained from an outside hospital which
demonstrated a focal area of small bowel wall thickening, portal
vein thrombosis and superior mesenteric vein thrombosis.  It was
felt at that time that patient was experiencing worsening
mesenteric ischemia and was admitted for exploratory
laparotomy to assess the viability of his small bowel.

PAST MEDICAL HISTORY:  1) Hodgkin's lymphoma diagnosed 15
years ago.  2) ITP diagnosed two years ago treated with IgG
and Prednisone, recently treated with Rituxan approximately
one week prior to admission.  3) Portal vein thrombosis
diagnosed approximately one month ago.  4) Hypothyroidism.
5) Restless leg syndrome.  6) Anxiety.

MEDICATIONS:  Dilaudid 4 mg q 4 hours, Prevacid 30 mg q day,
Levoxyl 250 mcg q day, Mysoline 125 mg q d, Paxil 40 mg q
day, Permax .015 mg q day, Coumadin 5 mg q day.

SOCIAL HISTORY:  A [**3-15**] pack per day smoker times
approximately 15 years, denies current alcohol use.

PHYSICAL EXAMINATION:  Temperature 97, blood pressure 172/91,
respiratory rate 22, oxygen saturation 93% on room air.  He
is an uncomfortable white male in apparent distress.
Respiratory exam was clear to auscultation bilaterally.
Cardiac, regular rate and rhythm, S1 and S2 appreciated.
Abdominal exam showed a firm abdomen with right sided
tenderness, no shake tenderness, no cough tenderness.
Extremities were warm with palpable pulses distally.  His
rectal showed normal tone, and was guaiac negative at that
time.

LABORATORY DATA:  On admission the patient had a white count
of 13.1, hematocrit of 39.1, platelet count 148,000.
Electrolytes, sodium 141, potassium 3.3, BUN and creatinine
14 and 0.9, glucose 112.  At the time of admission
prothrombin time of 23.3 and INR was 2.0.  His liver function
tests were all within normal limits with albumin of 3.2.  The
CAT scan on admission from the outside hospital again showed
small bowel wall thickening, portal vein thrombosis and
superior mesenteric vein thrombosis.

HOSPITAL COURSE:  The patient was admitted on [**2178-9-26**] for
emergent exploratory laparotomy.  He was evaluated by the
general surgery service and the vascular surgery
service.  On admission the patient was begun on a Heparin drip,
IV antibiotics.  The patient was taken for a repeat CT angiogram.
This scan showed new free fluid within the abdomen with the same
focal area of small bowel showing signs of ischemia.  Given the
severe pain and clinical exam as well as CT findings, consent was
obtained to proceed with the exploratory laparotomy.  Exploratory
laparotomy was performed with the preoperative diagnosis of
ischemic bowel.  Approximately a 50 cm segment of small bowel was
found to be thickened/congested in the mid to distal ileum. It
was found that all other small and large bowel was viable .  The
patient was admitted postoperatively from the
operating room to the surgical ICU.  The patient was left
intubated following his operation, given his bowel edema and
otherwise guarded status.  Upon admission to the surgical
Intensive Care Unit the patient was noted to have laboratory
values of white count 16.3, hematocrit 33.1, platelet count
99,000.  [**Name (NI) 2591**], PT 15.5, PTT 29.2, INR 1.7, BUN and
creatinine were stable as were his liver function tests.
Once admitted to the surgical ICU the patient was sedated on
Morphine and Propofol.  Systolic blood pressure was
maintained with fluid boluses and he was left intubated.  He
was admitted with an NG tube, central venous access.  His
coag values were followed q 6 hours and Heparin drip was
begun on the patient.

Overnight in the surgical ICU from [**2178-9-26**] to [**2178-9-27**] the
patient was left intubated on Morphine and Propofol drip.  It
was decided during the morning of [**2178-9-27**] to begin to wean
his sedation.   At that time it was also decided to pursue
extubation of the patient.  The patient's sedation was
weaned.  His ventilator support was weaned as well.  In the
surgical ICU on [**2178-9-27**] values drawn at midnight showed a PT
of 16.1, PTT 29.9, INR 1.8.  On the patient's Heparin drip PT
was found to increase at 4 a.m. to 12.0, PTT was found to be
39.9 and the patient's INR was 2.0.  On [**2178-9-27**] hematology
consult was obtained.  Hematology/Oncology was asked to see
the patient for management of his portal vein and splenic
vein thrombosis and his new diagnosis of superior mesenteric
vein thrombosis given his history of Hodgkin's disease and
ITP.  At that time hematology/oncology service recommended
continuation of the Heparin drip for anticoagulation.  It was
unclear at this time why the patient developed spontaneous
portal vein and splenic vein thrombosis.  At that time they
also decided to obtain the patient's outpatient records from
[**Hospital **] Hospital and spoke with his hematologist, Dr. [**First Name (STitle) **].
At that time the patient's goal PTT should be 55, to maintain
adequate anticoagulation given his venous thrombosis.

Overnight from [**2178-9-27**] to [**2178-9-28**] the patient was extubated
and began to complain of pain at incision.  He was also
transferred from the ICU to the floor overnight between
[**2178-9-27**] to [**2178-9-28**].  On exam the morning of [**2178-9-28**] the
patient was found to be stable, good urine output, we
continued to check hematocrit q 6 hours.  It was decided at
this time to start TPN on the patient to increase his Heparin
to maintain a goal PTT of 55 to 70.  Heparin previously at
1400 units had only elevated his PTT to a value of 45.2.  The
patient was also noted to have a declining platelet count
from 88 to 66.  There is concern at this time that given the
patient's history of prior exposure to Heparin, his current
Heparin drip, the patient might be experiencing Heparin
induced thrombocytopenia.  Complicating this picture was also
the patient's history of ITP.  Hematology/Oncology was again
asked to address this issue.  At this time a Heparin induced
thrombocytopenia panel was obtained.  This was eventually
shown to be negative.  The patient continued to do well the
day of [**2178-9-28**] with continued complaints of incisional pain.
At this time the patient's Dilaudid PCA was increased to
cover his pain.  On exam the patient's abdomen was found to
be markedly distended.  The plan at the time was just to
await return of bowel function with this patient.  We
continued to check his hematocrit q 6 hours which was found
to be fairly stable throughout his hospitalization.  During
the day, however, his platelet count continued to decline to
a value in the 50's.

Overnight from [**2178-9-28**] to [**2178-9-29**] the patient was noted to
have a mild amount of delirium.  The patient spontaneously
pulled his nasogastric tube which was replaced on the floor
without difficulty.  It was felt at the time the delirium was
probably secondary to the Ativan that was being given at that
time and to hold the Ativan.  On [**2178-9-29**] laboratory values
demonstrated a platelet count of 30 with [**Date Range **] demonstrating
an adequate PTT of 55.  Given the concern about the patient's
possible platelet decline being due to Heparin induced
thrombocytopenia, the patient was begun on Lepirudin on
Tuesday, [**2178-9-28**] and was continued to [**2178-9-29**].  At this time
patient's PTT value of 55 was found to be adequate with a
prudent anticoagulation.  On day of [**2178-9-29**] the patient
continued to do well, his pain was better controlled with
increased PCA dose.  Dressing was removed.  The incision was
found to be dry and intact.  The patient continued with good
urine output, had a moderate amount of NG output.  The NG
tube was putting out approximately 640 cc on the 19th, 350 cc
overnight from [**9-28**] to [**2178-9-29**] after the tube was replaced.

Overnight from [**2178-9-29**] to [**2178-9-30**] the patient continued to do
well.  The patient's platelet count, however, was noted to be
declining to a value of 16 from 20 from the previous check.
The patient's PTT was also found to be declining to a value
of 49 and it was decided at this point to increase the
patient's Lepirudin dose.  Also on [**2178-9-30**] the patient's
Heparin induced thrombocytopenia came back negative and it
was decided to restart his Heparin at that time.  The
patient's NG tube continued to have a moderate amount of
output, putting out approximately 1220 cc total overnight
from [**2178-9-29**] to [**2178-9-30**].  The patient was also noted to be
coughing up a small amount of bright red blood on [**9-30**] and it
was felt at this time this was old clot and did not represent
active bleeding in this patient.  The patient's hematocrit
continued to be stable at 26.3.  On [**2178-9-30**] the patient's
negative Heparin induced thrombocytopenia panel was felt that
his platelet drop was most likely due to recurrence of his
ITP and it was decided at that time to give IVIG of 1 gm/kg
in a divided dose over approximately two days.

Overnight from [**2178-9-30**] to [**2178-10-1**] the patient continued to do
well.  He was comfortable, however, his bowel function was
slow to return.  He was still without flatus.  His pain
control continued to be with a Dilaudid PCA.  Half his dose
of IVIG was given on [**2178-9-30**] with the other half given on
[**2178-10-1**].  The patient's platelet count was found to respond
to this IVIG regimen increasing to a value of 53.  The
patient was also restarted on his Heparin drip which was
elevated to 1800 units per hour at which time was found to
have a PTT of 47.9 and it was decided at this point to
increase Heparin dose to [**2176**] units per hour.  On the day of
[**10-1**] the patient continued to do well, however, his bowel
function was again found to be slow to return.  He denied
flatus over the day of [**2178-10-1**].  His NG output was noted to
be moderately decreased over the day and it was decided at
that point to discontinue his Foley catheter and continue to
try and get his Heparin to a therapeutic PTT value.

Overnight from [**2178-10-1**] to [**2178-10-2**] the patient continued to do
well, however, he was still found to be without flatus.  He
was burping with NG tube clamped.  He was having low
residuals from his NG tube, however, his abdomen was still
distended.  His platelets continued to respond well to the
IVIG treatment increasing to a value of 86 from 53 the day
before.  It was felt at that time that his low platelets were
truly consistent with ITP.  On [**2178-10-2**] the patient continued
to do well.  However, complained of increased abdominal
distention during the day.  He was having low residuals from
his clamped NG tube but it was at that time just replaced
back to continue suction.  After replacing the tube to
continuous suction approximately 200 cc of bilious fluid was
obtained.

Overnight from [**2179-10-2**] to [**2178-10-3**] the patient continued to do
well.  He was found to be more comfortable although he was
still without flatus.  The morning of [**2178-10-3**] the patient was
given a Dulcolax suppository which induced good bowel
function.  The patient had a bowel movement shortly after
insertion of the Dulcolax suppository.

Overnight from [**2178-10-3**] to [**2178-10-4**] the patient continued to do
well, continued to have bowel movements, was reporting good
flatus. It was decided on the morning of [**2178-10-4**] to
discontinue the patient's NG tube.  The patient's Heparin
dose was running at a value of 2100 units per hour, PTT was
found to be value of 52.2.  The patient was showing good
signs of bowel function and it was decided at that time to
also start the patient on a clear liquid diet.  The patient
was noted to have elevated white count to a value of 24 on
[**2178-10-4**].  It was decided at that time to change his central
line to check a clostridium difficile toxin assay.  The
patient was also started on Flagyl 500 mg tid.  The patient's
central line was changed on [**2178-10-4**].  Culture of the central
line tip was negative.  Additionally, the patient's
clostridium difficile toxin assay was negative.  Following
changing the patient's central line, chest x-ray was
obtained.  This demonstrated the new central line to be
positioned within the right atrium.  The line was withdrawn 3
cm and was used again.  Following the patient's procedure,
central line was changed.  The patient's Heparin was stopped
for approximately two hours.  Laboratory values after
changing this line demonstrated PTT of 26.3 and the patient
was restarted on his usual dose of Coumadin.  A recheck of
the patient's PTT several hours later demonstrated a value of
46.  It was decided at this time to increase the patient's
Heparin drip to a value of 2400 units per hour, rechecking
the laboratory values on the morning of [**2178-10-5**] demonstrating
PTT of 60.6.  The patient's hematocrit was again noted to be
stable.  The patient was tolerating his clear liquid diet.
On the morning of [**2178-10-5**] it was decided to advance the
patient's diet to a full liquid diet with a regular house
diet to begin that evening.  The patient continued to do
well, continued to pass flatus and bowel function was thought
to be good.  At this time the patient was started on his home
medications of Paxil and Permax.

On the evening of [**2178-10-5**] it was also decided to begin
patient back on his dose of Coumadin for consideration of
long-term anticoagulation.  The patient was given a dose of
7.5 mg of Coumadin this evening.

Overnight from [**2178-10-5**] to [**2178-10-6**] the patient continued to do
well.  He was tolerating a solid diet and it was decided at
this time to discharge the patient home on Lovenox and
Coumadin with follow-up until his Coumadin is therapeutic.
The patient is to continue taking his Lovenox.  The patient
demonstrated good bowel function.  On [**2178-10-6**] the patient's
staples were taken out and the plan was discussed with
Hematology Oncology for long-term anticoagulation in this
otherwise complex patient.

CONDITION ON DISCHARGE:  Good.  He was tolerating full liquid
diet, his pain control is with oral pain medications, he is
therapeutic on a Heparin drip with a PTT value of 84 this
morning.
By review of systems:
1.  From a GI standpoint the patient is status post
exploratory laparotomy with resection of 50 cm of mid to
distal ileum for mesenteric ischemia, most likely induced by
venous congestion.  The patient is currently taking a regular
diet with good bowel function.  Pathology showed no evidence of
recurrent lymphoma.

2.  Hematology:  The patient has ITP.  The patient had a low
platelet count down into the value of the teens.  This was
treated with IVIG with good response.  The patient was to
follow-up with his regular hematology oncologist as an
outpatient for consideration of Rituxan treatment.

3.  From an anticoagulation standpoint the patient was noted
to have PTT value with a slightly elevated stay into the
80's.  It was decided that the patient will need long-term
anticoagulation given his history of a portal venous splenic
vein thrombosis and superior mesenteric vein thrombosis.
This will be accomplished with Coumadin as per the hematology
oncology service who has been in touch with his regular
hematologist, Dr. [**First Name (STitle) **].  Currently the patient has just begun
on his dose of Coumadin.

The patient is to be discharged on a dose of 1 mg/kg,
approximately 120 mg of Lovenox q 12 hours to be injected
subcutaneously.  Until his Coumadin dose is therapeutic with
an INR of 2.5.  The patient is to follow-up at [**Hospital **]
Hospital for laboratory draws tomorrow.  The patient has a
follow-up appointment with his hematologist, Dr. [**First Name (STitle) **] on
Thursday morning at approximately 7:15.

The patient's wife has demonstrated proficiency with
administering the subcutaneous Lovenox in the past.  She has
administered this to both the patient's father and the
patient.  The patient was given his first dose of Lovenox
here in the hospital.  The patient's wife demonstrated that
she was able to give the dose to the patient with the nurse
present.  It was decided at this time the patient will not
need VNA services for administration of Lovenox.  He is to
follow-up with his regular hematologist tomorrow.

DISCHARGE MEDICATIONS:  Percocet 5/325 mg 1-2 tabs po q 4
hours prn pain, Colace 100 mg po bid prn constipation,
Lovenox 120 mg q 12 hours to be administered subcutaneously,
Coumadin 5 mg q day, Protonix 40 mg q day.  Patient's home
medications which he is to begin taking again include Paxil
40 mg q day, Permax .01 mg q day, Levoxyl 250 mcg q day.

FOLLOW-UP:  With Dr. [**First Name (STitle) 2819**] and Dr. [**First Name (STitle) **].




                          [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.  [**MD Number(1) 19318**]

Dictated By:[**Doctor Last Name 43973**]

MEDQUIST36

D:  [**2178-10-6**]  11:56
T:  [**2178-10-12**]  19:57
JOB#:  [**Job Number 43974**]

cc:[**Telephone/Fax (1) 43975**]
{"Acute vascular insufficiency of intestine,Hodgkin's disease, unspecified type, unspecified site, extranodal and solid organ sites"}


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 43972**] is a 36-year-old
male with a past medical history of Hodgkin's lymphoma
treated approximately 15 years ago with staging laparotomy,
splenectomy and nodal sampling followed by x-ray radiation
therapy, the subsequent diagnosis two years ago of ITP with
evidence of splenosis by CT scan, which was treated with
Prednisone IgG, and recently treated with Rituxan with good
effect.  He presented approximately one month ago with severe
abdominal pain and was diagnosed with portal vein thrombosis and
started on coumadin after being heparinized. He presented to the
Emergency Room at [**Hospital1 69**] on
[**2178-5-27**] with 2-3 day history of increasing abdominal pain on
the right side.  At this time he denies nausea, vomiting,
positive flatus and still had a bowel movement at that time.
CT scan was obtained from an outside hospital which
demonstrated a focal area of small bowel wall thickening, portal
vein thrombosis and superior mesenteric vein thrombosis.  It was
felt at that time that patient was experiencing worsening
mesenteric ischemia and was admitted for exploratory
laparotomy to assess the viability of his small bowel.

MEDICAL HISTORY: 1) Hodgkin's lymphoma diagnosed 15
years ago.  2) ITP diagnosed two years ago treated with IgG
and Prednisone, recently treated with Rituxan approximately
one week prior to admission.  3) Portal vein thrombosis
diagnosed approximately one month ago.  4) Hypothyroidism.
5) Restless leg syndrome.  6) Anxiety.

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: A [**3-15**] pack per day smoker times
approximately 15 years, denies current alcohol use. 

### Response:
{"Acute vascular insufficiency of intestine,Hodgkin's disease, unspecified type, unspecified site, extranodal and solid organ sites"}
