CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is a 60-year-old
African-American female with a history of end-stage renal
disease on hemodialysis, hypertension, peripheral vascular
disease, status post bilateral AKAs, diabetes type 2, CVA,
coronary artery disease, status post CABG and mitral valve
repair, history of DVT and PE, COPD, who presents from
outpatient hemodialysis with increasing lethargy.  At
baseline, the patient is responsive and interactive verbally.
On admission, the patient was only responsive to sternal rub.
At hemodialysis, the temperature was 99.8, pulse 130-140, 02
saturation 85% on room air which went up to 100% on a
nonrebreather; 2 kilograms of fluid were removed at
hemodialysis over two hours and then the patient was sent to
the Emergency Room.

MEDICAL HISTORY: 1.  End-stage renal disease on hemodialysis every Tuesday,
Thursday, and Saturday.
2.  Coronary artery disease, status post CABG.
3.  CVA.
4.  COPD.
5.  Diabetes type 2.
6.  History of PE and DVT.
7.  History of hypertrophic obstructive cardiomyopathy with a
LV outflow tract gradient of 50 mmHg, EF 65-75%.
8.  Peripheral vascular disease, status post bilateral AKA in
[**5-1**].
9.  Breast cancer, status post right mastectomy and XRT in
[**2185**].
10. Status post mitral valve repair.
11. Hypertension, baseline systolic blood pressure in the
160s to 200s.
12. History of pseudoseizures.
13. History of MRSA line infection.
14. Status post appendectomy.
15. Status post TAH/BSO.
16. Status post cataract surgery.

MEDICATION ON ADMISSION: 

ALLERGIES: The patient is allergic to penicillin, aspirin,
Oxycodone, cephalosporins, and benzodiazepines.

PHYSICAL EXAM: 

FAMILY HISTORY: Positive for hypertension and diabetes.

SOCIAL HISTORY: The patient is a Jehovah's witness and does
not accept blood products.  She has a 60 pack year smoking
history.  No history of alcohol.  She lives with her son in a
handicapped apartment.
Other shock without mention of trauma,Unspecified protein-calorie malnutrition,Other septicemia due to gram-negative organisms,Acute vascular insufficiency of intestine,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Pneumonitis due to inhalation of food or vomitus,Chronic airway obstruction, not elsewhere classified,Thrombocytopenia, unspecified
Shock w/o trauma NEC,Protein-cal malnutr NOS,Gram-neg septicemia NEC,Ac vasc insuff intestine,Hyp kid NOS w cr kid V,Food/vomit pneumonitis,Chr airway obstruct NEC,Thrombocytopenia NOS
Admission Date:  [**2196-7-28**]     Discharge Date:  [**2196-8-6**]

Date of Birth:   [**2135-11-11**]     Sex:  F

Service:  MEDICINE

HISTORY OF THE PRESENT ILLNESS:  The patient is a 60-year-old
African-American female with a history of end-stage renal
disease on hemodialysis, hypertension, peripheral vascular
disease, status post bilateral AKAs, diabetes type 2, CVA,
coronary artery disease, status post CABG and mitral valve
repair, history of DVT and PE, COPD, who presents from
outpatient hemodialysis with increasing lethargy.  At
baseline, the patient is responsive and interactive verbally.
On admission, the patient was only responsive to sternal rub.
At hemodialysis, the temperature was 99.8, pulse 130-140, 02
saturation 85% on room air which went up to 100% on a
nonrebreather; 2 kilograms of fluid were removed at
hemodialysis over two hours and then the patient was sent to
the Emergency Room.

The initial vital signs were a temperature of 99.8, blood
pressure 100/53, heart rate 120, respirations 30, saturating
99% on a nonrebreather.  The initial physical examination was
positive for abdominal tenderness.  The patient was sent for
an abdominal CT which showed extensive atherosclerotic
changes involving all of the abdominal vasculature and
possible thickening of the small bowel walls.  Mesenteric
ischemic could be excluded.  No evidence of obstruction.  No
perforation or abscess.

General Surgery were consulted but no operative intervention
was deemed necessary at that time.  The patient continued to
have a blood pressure systolic 80s to 100s, responsive to 2
liters of normal saline.  The patient's chest x-ray also
showed evolving bilateral opacities and the patient was
treated with vancomycin, ceftriaxone, and Flagyl.

The patient was weaned off the nonrebreather to 4 liters
nasal cannula. CTA was done to rule out PE given the
patient's hypoxia, hypertension, and tachycardia.  The study
was negative for PE but did show new ground glass opacities
at the right lung base suspicious for aspiration pneumonitis.
There was also chronic consolidation of the left lung base
and radiation changes of the right hemithorax which were
stable.

The patient was transferred initially to the Medical
Intensive Care Unit for further management.

REVIEW OF SYSTEMS:  The patient had diarrhea for the past
week.  No nausea, vomiting, no change in her chronic
abdominal pain.  No change in her chronic cough.  No fevers,
chills, dysphagia.  The patient is anuric at baseline.

PAST MEDICAL HISTORY:
1.  End-stage renal disease on hemodialysis every Tuesday,
Thursday, and Saturday.
2.  Coronary artery disease, status post CABG.
3.  CVA.
4.  COPD.
5.  Diabetes type 2.
6.  History of PE and DVT.
7.  History of hypertrophic obstructive cardiomyopathy with a
LV outflow tract gradient of 50 mmHg, EF 65-75%.
8.  Peripheral vascular disease, status post bilateral AKA in
[**5-1**].
9.  Breast cancer, status post right mastectomy and XRT in
[**2185**].
10. Status post mitral valve repair.
11. Hypertension, baseline systolic blood pressure in the
160s to 200s.
12. History of pseudoseizures.
13. History of MRSA line infection.
14. Status post appendectomy.
15. Status post TAH/BSO.
16. Status post cataract surgery.

ALLERGIES:  The patient is allergic to penicillin, aspirin,
Oxycodone, cephalosporins, and benzodiazepines.

HOME MEDICATIONS:
1.  Toprol XL 25.
2.  Lactulose 3 mg p.o. q.d.
3.  Lisinopril 80 mg p.o. q.d.
4.  Nephrocaps 1 mg one tablet p.o. q.d.
5.  Colace 100 mg p.o. b.i.d.
6.  Renagel 1,600 mg p.o. t.i.d.
7.  Combivent inhaler.
8.  Celexa 20 mg p.o. q.d.
9.  Prevacid 30 mg p.o. q.d.
10. Senna one tablet p.o. q.d.
11. Diltiazem 180 mg p.o. q.d.
12. Nifedipine 10 mg p.o. on hemodialysis days.

SOCIAL HISTORY:  The patient is a Jehovah's witness and does
not accept blood products.  She has a 60 pack year smoking
history.  No history of alcohol.  She lives with her son in a
handicapped apartment.

FAMILY HISTORY:  Positive for hypertension and diabetes.

PHYSICAL EXAMINATION ON ADMISSION:  Vital signs:  Temperature
99.8, heart rate 88, blood pressure 86/42, respirations 19,
saturating 100% on 4 liters nasal cannula.  General:  The
patient is somnolent and arousable to sternal rub, unable to
follow commands.  More verbal when family is around.  No
clear communication.  HEENT:  The patient is anicteric.  The
oropharynx is dry.  Cardiovascular:  Regular rate and rhythm.
No murmurs.  Lungs:  Diffuse rhonchi bilaterally.  Decreased
breath sounds, left greater than right base.  Abdomen:  Soft,
nontender, nondistended, normoactive bowel sounds, Guaiac
negative.  Extremities:  Status post bilateral AKA right
upper extremity, slightly more edematous than her left upper
extremity, 1+ pitting edema.

LABORATORY/RADIOLOGIC DATA:  Head CT showed multiple old
infarct including occipital infarct bilaterally as well as
lacunar infarct in the right thalamus and left putamen which
appear unchanged compared to [**2196-3-1**].  There is a new
infarct in the left side of the pons, unable to comment on
exact timing.  No mass affect.  No hemorrhage.

CT of the abdomen showed question of possible small bowel
thickening, mesenteric ischemia could not be excluded.  No
obstruction, no perforation, no abscess.

CT angiogram showed no PE, new ground glass patchy opacities
at the right lung base suspicious for aspiration pneumonitis,
chronic left lung base consolidation and radiation treatments
to the right hemithorax.

Right upper quadrant ultrasound showed no intra or
extrahepatic biliary ductal dilatation, small amount of
pericholecystic fluid but no gallbladder wall edema, several
small gallstones.  No biliary obstruction.

Cardiac echocardiogram showed mild left atrial dilation,
symmetric LVH, moderate global LV hypokinesis, moderate
global right ventricular free wall hypokinesis, 1+ MR, 2+ TR,
mild pulmonary artery systolic hypertension, significant
pulmonary regurgitation, trivial pericardial effusions.
Ejection fraction of 30%, TR gradient 34.

HOSPITAL COURSE:  1.  The patient was found to have
gram-negative rod bacteremia with Stenotrophomonas and
Enterobacter, likely from gut translocation from her acute on
chronic mesenteric ischemia.  The patient also had evidence
of an aspiration pneumonia.  The patient was treated with
Levaquin and Flagyl, a total course of 14 days as well as an
initial five day course of gentamicin.  During this time, the
patient's right-sided Hickman was kept in place per renal.
The patient subsequently had 48 hours worth of negative blood
cultures.

2.  HYPOTENSION:  Secondary to sepsis from gram-negative rod
bacteremia, plus/minus pneumonia.  The patient was treated
with normal saline boluses as well as transient use of
dopamine.  The patient's blood pressure eventually stabilized
to the 120s systolic; however, her antihypertensives were
never reintroduced secondary to hypotension after
hemodialysis.  As of discharge, the patient is still not on
home antihypertensive medications.

3.  HYPOXIA:  Secondary to sepsis and aspiration pneumonia.
The patient was treated with antibiotics for the above and
quickly weaned off her 02 requirement.

4.  MIXED ACID BASE DISORDER:  Initially, the patient came in
with nongap metabolic alkalosis as well as respiratory
alkalosis.  These all resolved as the patient's sepsis
improved.

5.  NEUROLOGIC STATUS:  The patient's mental status improved
with treatment of sepsis.

6.  END-STAGE RENAL DISEASE:  The patient continued to
receive dialysis through her right subclavian Hickman.  This
was never removed despite the patient's bacteremia.  The
patient's most recent dialysis before discharge was on
[**2196-8-5**].  She was able to tolerate ultrafiltration; however,
no fluid was able to be removed secondary to hypotension down
to the 80s-90s systolic.

7.  GASTROINTESTINAL:  The patient is known to have bad
diffuse atherosclerosis, likely has chronic mesenteric
ischemia.  MRA of the abdomen was unable to be performed
since the patient did not have any access to receive the MRI
contrast dye.  Given the low likelihood that any surgical or
angioplastic interventions would be likely in this patient
given all of her comorbidities, MRA was deferred at this
time.  The patient's abdominal pain had improved by the time
of discharge and she was tolerating a full cardiac and renal
diet.

8.  HEMATOLOGY:  The patient is a Jehovah's witness and does
not accept any blood transfusion products.  She initially had
a low crit likely from hemodilution which eventually
stabilized.  She also came in with thrombocytopenia.  Workup
was negative for HIT antibody as well as DIC.  The patient
gets Epogen at hemodialysis.

9.  CODE STATUS:  After a family meeting, it was decided that
the patient would be do not intubate (DNI); however, CPR and
resuscitation were still desired.

CONDITION ON DISCHARGE:  Stable.

DISCHARGE STATUS:  Discharge the patient to rehabilitation.

DISCHARGE DIAGNOSIS:
1.  Stenotrophomonas and Enterobacter bacteremia and sepsis.
2.  Acute on chronic mesenteric ischemia.
3.  End-stage renal disease, on hemodialysis.
4.  Peripheral vascular disease, status post bilateral AKAs
and impossible venous access.
5.  Delirium from sepsis.
6.  Aspiration pneumonia.
7.  Anemia of chronic disease.

DISCHARGE MEDICATIONS:
1.  Flagyl 500 mg p.o. b.i.d. until [**2196-8-10**] to complete a 14
day course.
2.  Regular insulin sliding scale.
3.  Levofloxacin 200 mg p.o. q. 48 hours until [**2196-8-10**] to
complete a 14 day course.
4.  Protonix 40 mg p.o. q. 24 hours.
5.  Atrovent two puffs q. six hours.
6.  Albuterol two puffs q. six hours p.r.n.
7.  Tylenol 325 mg p.o. q. four to six hours p.r.n.

FOLLOW-UP:  The patient is to follow-up with PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], in [**9-13**] days.




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

Dictated By:[**Name8 (MD) 7112**]

MEDQUIST36

D:  [**2196-8-6**]  01:12
T:  [**2196-8-6**]  13:52
JOB#:  [**Job Number 14374**]


Name:  [**Known lastname 2251**], [**Known firstname 1647**]                     Unit No:  [**Numeric Identifier 2252**]

Admission Date:  [**2196-7-28**]     Discharge Date:  [**2196-8-11**]

Date of Birth:   [**2135-11-11**]     Sex:  F

Service:  [**Hospital1 **]

ADDENDUM:  This is a discharge Addendum to the Discharge
Summary done on [**2196-8-6**].

HOSPITAL COURSE BY ISSUE/SYSTEM CONTINUED:  (From [**2196-8-6**] until the day of discharge of [**2196-8-11**])

1.  BACTEREMIA ISSUES:  The patient continued to be
asymptomatic during the course of her stay.  The patient also
continued to have negative blood cultures prior to her
discharge.  Cultures from [**8-8**], [**8-9**], and
[**8-10**] were pending.  These blood culture results will
be followed up upon.

2.  HYPOTENSION ISSUES:  The patient continued to have low
blood pressures and abdominal pain while at dialysis
requiring a decrease in the amount of the fluid that could be
removed.  This led to less than optimal dialysis results.
The likely etiology was thought to be due to low-flow
ischemia given her chronic vascular disease as well as past
abdominal computed tomography scans revealing diffuse
atherosclerotic lesions in her abdominal vasculature.

3.  HYPOXIA ISSUES:  The patient's oxygen saturations
remained in the high 90s on room air.  The patient was
asymptomatic without shortness of breath throughout the
course and on through discharge.

4.  END-STAGE RENAL DISEASE ISSUES:  The patient was
continued on dialysis three times per week.  However, the
patient continued to have abdominal pain and hypotension that
led to a decrease in the amount of the fluid that could be
taken off.

Given this chronicity, and the potential to interfere with
dialysis, a magnetic resonance angiography was ordered.
Access was difficult for magnetic resonance angiography;
however, it was eventually done through a hemodialysis line.
The magnetic resonance angiography revealed a mild 40%
stenosis of the mid superior mesenteric artery as well as an
atherosclerotic plaque on the abdominal aorta at the level of
the celiac artery.  Otherwise, the magnetic resonance
angiography was unremarkable with the exception of a
consistent picture of hemosiderosis.  No surgical
intervention or angioplastic intervention was sought after
following these results.  The patient was to continue
dialysis three times per week as an outpatient.

5.  HEMATOLOGIC ISSUES:  A low hematocrit is chronic and
likely attributable to anemia of chronic disease.  The
patient was receiving Epogen during dialysis, and the patient
was to continue to have Epogen during dialysis three times
per week.

6.  CODE STATUS ISSUES:  The patient is do not intubate and
is allowing cardiopulmonary resuscitation and pressor
support.

CONDITION AT DISCHARGE:  Condition on discharge was stable.

DISCHARGE STATUS:  The patient was to be discharged to home
with visiting nurse services.

DISCHARGE DIAGNOSES:
1.  Bacteremia.
2.  Sepsis.
3.  Aspiration pneumonia.
4.  End-stage renal disease (on hemodialysis).
5.  Abdominal pain.

MEDICATIONS ON DISCHARGE:
1.  Ipratropium bromide 2 puffs inhaled q.6h.
2.  Albuterol 2 puffs inhaled q.6h. as needed.
3.  Pantoprazole 40 mg by mouth once per day.
4.  Acetaminophen 325 mg to 650 mg by mouth q.4-6h. as
needed.
5.  Regular insulin sliding-scale.
6.  Nephrocaps 1-mg capsules one capsule by mouth every day.
7.  Colace 100 mg by mouth twice per day.
8.  Celexa 20 mg by mouth once per day.
9.  Timolol 0.25% ophthalmologic drops 1 to 2 drops once per
day in the left eye.

DISCHARGE INSTRUCTIONS/FOLLOWUP:
1.  The patient was instructed to follow up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] (telephone number [**Telephone/Fax (1) 2253**]) in two to four
weeks.
2.  The patient has expressed a willingness and ability to
participate in 24-hour care for the patient.  The patient was
to have maximum assistance at home.
3.  The patient's blood pressure medications were to be held
at this point given her low blood pressure at dialysis;
further decisions to be made by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].





                          [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1385**], M.D.  [**MD Number(1) 2254**]

Dictated By:[**Last Name (NamePattern1) 2255**]

MEDQUIST36

D:  [**2196-8-18**]  17:29
T:  [**2196-8-18**]  18:59
JOB#:  [**Job Number 2256**]
{'Other shock without mention of trauma,Unspecified protein-calorie malnutrition,Other septicemia due to gram-negative organisms,Acute vascular insufficiency of intestine,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Pneumonitis due to inhalation of food or vomitus,Chronic airway obstruction, not elsewhere classified,Thrombocytopenia, unspecified'}


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 60-year-old
African-American female with a history of end-stage renal
disease on hemodialysis, hypertension, peripheral vascular
disease, status post bilateral AKAs, diabetes type 2, CVA,
coronary artery disease, status post CABG and mitral valve
repair, history of DVT and PE, COPD, who presents from
outpatient hemodialysis with increasing lethargy.  At
baseline, the patient is responsive and interactive verbally.
On admission, the patient was only responsive to sternal rub.
At hemodialysis, the temperature was 99.8, pulse 130-140, 02
saturation 85% on room air which went up to 100% on a
nonrebreather; 2 kilograms of fluid were removed at
hemodialysis over two hours and then the patient was sent to
the Emergency Room.

MEDICAL HISTORY: 1.  End-stage renal disease on hemodialysis every Tuesday,
Thursday, and Saturday.
2.  Coronary artery disease, status post CABG.
3.  CVA.
4.  COPD.
5.  Diabetes type 2.
6.  History of PE and DVT.
7.  History of hypertrophic obstructive cardiomyopathy with a
LV outflow tract gradient of 50 mmHg, EF 65-75%.
8.  Peripheral vascular disease, status post bilateral AKA in
[**5-1**].
9.  Breast cancer, status post right mastectomy and XRT in
[**2185**].
10. Status post mitral valve repair.
11. Hypertension, baseline systolic blood pressure in the
160s to 200s.
12. History of pseudoseizures.
13. History of MRSA line infection.
14. Status post appendectomy.
15. Status post TAH/BSO.
16. Status post cataract surgery.

MEDICATION ON ADMISSION: 

ALLERGIES: The patient is allergic to penicillin, aspirin,
Oxycodone, cephalosporins, and benzodiazepines.

PHYSICAL EXAM: 

FAMILY HISTORY: Positive for hypertension and diabetes.

SOCIAL HISTORY: The patient is a Jehovah's witness and does
not accept blood products.  She has a 60 pack year smoking
history.  No history of alcohol.  She lives with her son in a
handicapped apartment. 

### Response:
{'Other shock without mention of trauma,Unspecified protein-calorie malnutrition,Other septicemia due to gram-negative organisms,Acute vascular insufficiency of intestine,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Pneumonitis due to inhalation of food or vomitus,Chronic airway obstruction, not elsewhere classified,Thrombocytopenia, unspecified'}
