CHIEF COMPLAINT: 1.  Shortness of breath.
2.  Painless jaundice.

PRESENT ILLNESS: This is an 82-year-old male with
a past medical history of hypothyroidism, type 2 diabetes,
and alcoholic cirrhosis who was referred to the Emergency
Department by his primary care physician after he visited the
office for increasing jaundice and shortness of breath, and
primary care physician found the hematocrit to be 21.  The
patient had noticed one to two weeks of worsening painless
jaundice as well as about one-month history of weight loss
and tea-colored dark urine.  He was also beginning to feel
worsening shortness of breath/dyspnea on exertion and
fatigue/weakness over the past one to two weeks.  He denies
hematemesis, BR/PPR, melena, hematuria, nausea, vomiting,
abdominal pain, cough, chest pain, pruritus, rash, fever,
chills, sweats, or upper respiratory infection symptoms.  He
also denies any new medications, including herbal remedies,
aside from taking a Metformin, which he stopped one month ago
when PCP informed him his sugars were normal.  No recent
alcohol use.

MEDICAL HISTORY: 1.  Alcoholic cirrhosis with history of alcohol abuse;
patient quit in [**2083**].
2.  History of gastrointestinal bleed on aspirin.
3.  Diabetes type 2 which is diet controlled.
4.  Hypothyroidism.
5.  Vertigo.
6.  Questionable history of TIA.
7.  History of undescended testes status post surgery.

MEDICATION ON ADMISSION: 1.  Clopidogrel 75 mg p.o. q.d.
2.  Levothyroxine 75 mcg p.o. q.d.
3.  Meclizine p.r.n.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: One brother with lymphoma who passed away;
two brothers with alcoholism, also have passed away, one
brother with pernicious anemia.

SOCIAL HISTORY: A 50-pack-year history of tobacco; quit in
[**2103**].  Prior alcohol abuse; quit in [**2083**].  No illicit drug
use.  Lives alone.  Possible remote history of asbestos
exposure as a youth.  Patient has no children.
Autoimmune hemolytic anemias,Paroxysmal ventricular tachycardia,Alcoholic cirrhosis of liver,Acidosis,Other diseases of lung, not elsewhere classified,Enlargement of lymph nodes,Unspecified acquired hypothyroidism
Autoimmun hemolytic anem,Parox ventric tachycard,Alcohol cirrhosis liver,Acidosis,Other lung disease NEC,Enlargement lymph nodes,Hypothyroidism NOS
Admission Date:  [**2109-11-6**]     Discharge Date:  [**2109-11-14**]


Service:  MEDICINE

CHIEF COMPLAINT:
1.  Shortness of breath.
2.  Painless jaundice.

HISTORY OF PRESENT ILLNESS:  This is an 82-year-old male with
a past medical history of hypothyroidism, type 2 diabetes,
and alcoholic cirrhosis who was referred to the Emergency
Department by his primary care physician after he visited the
office for increasing jaundice and shortness of breath, and
primary care physician found the hematocrit to be 21.  The
patient had noticed one to two weeks of worsening painless
jaundice as well as about one-month history of weight loss
and tea-colored dark urine.  He was also beginning to feel
worsening shortness of breath/dyspnea on exertion and
fatigue/weakness over the past one to two weeks.  He denies
hematemesis, BR/PPR, melena, hematuria, nausea, vomiting,
abdominal pain, cough, chest pain, pruritus, rash, fever,
chills, sweats, or upper respiratory infection symptoms.  He
also denies any new medications, including herbal remedies,
aside from taking a Metformin, which he stopped one month ago
when PCP informed him his sugars were normal.  No recent
alcohol use.

In the Emergency Department the patient was noted to have a
hemoglobin of 16, and hemolysis labs showed a greatly
elevated bilirubin, LDH with a haptoglobin less than 20.  In
the ED he also reportedly had a 10 to 15 beat run of
ventricular tachycardia which was nonsustained.

The patient was initially admitted to the [**Hospital Unit Name 153**] for monitoring
during transfusion of incompatible past red cells given that
the patient was very hard to cross match.  Incidentally, the
patient denies eating faba beans.

PAST MEDICAL HISTORY:
1.  Alcoholic cirrhosis with history of alcohol abuse;
patient quit in [**2083**].
2.  History of gastrointestinal bleed on aspirin.
3.  Diabetes type 2 which is diet controlled.
4.  Hypothyroidism.
5.  Vertigo.
6.  Questionable history of TIA.
7.  History of undescended testes status post surgery.

MEDICATIONS ON ADMISSION:
1.  Clopidogrel 75 mg p.o. q.d.
2.  Levothyroxine 75 mcg p.o. q.d.
3.  Meclizine p.r.n.

ALLERGIES:

No known drug allergies.

SOCIAL HISTORY:  A 50-pack-year history of tobacco; quit in
[**2103**].  Prior alcohol abuse; quit in [**2083**].  No illicit drug
use.  Lives alone.  Possible remote history of asbestos
exposure as a youth.  Patient has no children.

FAMILY HISTORY:  One brother with lymphoma who passed away;
two brothers with alcoholism, also have passed away, one
brother with pernicious anemia.

PHYSICAL EXAMINATION ON ADMISSION:  Temperature 97.2, pulse
79, blood pressure 118/59, respirations 20, oxygen saturation
96% on room air.  In general, a pleasant, interactive, very
talkative, jaundiced male in no acute distress.  HEENT:  No
sinus tenderness; pupils equal, round, reactive to light;
sublingual/conjunctival icterus.  Cardiovascular:  Regular
rate; normal S1, S2; II/VI holosystolic murmur throughout the
precordium; no rubs or gallops.  Neck:  No lymphadenopathy;
soft, supple.  Pulmonary:  Clear to auscultation bilaterally.
Abdomen:  Soft, nontender, nondistended; no organomegaly.
Rectal:  Guaiac negative per ED resident.  Back:  No
CVA/paraspinal tenderness.  Neuro:  Alert, oriented;
appropriately conversant.  Skin:  Jaundiced.

DATA ON ADMISSION:  CBC remarkable for a white count 15.9
with 69% neutrophils, 0 bands, 24 lymphs, 4 monos, hematocrit
21.5, MCV 106, platelets 371.  A repeat hematocrit drawn
showing hematocrit dropped to 17.5 with 26.4% reticulocytes,
electrolytes remarkable for a creatinine of 1.2 to 1.3.
Urinalysis:  Small blood, 4+ urobilinogen, small bilirubin,
trace protein, 0 RBC, ALT 19, AST 64, alkaline phosphatase
65, total bilirubin 8.0, LVH 719, total protein 7.0, albumin
3.9, haptoglobin less than 20.

Chest x-ray showing bilateral upper lobe opacities, right
greater than left.

CT of the abdomen and pelvis:  Small right pleural effusion
at 6 mm right middle lobe nodule.  Nodular liver with
regeneration consistent with cirrhosis.  No ascites,
gallstones.  4 mm focus of calcification in the right lobe of
the liver.  8 mm region of hypoattenuation of inferior
spleen, bilateral simple renal cyst, atrophic pancreas with
multiple calcifications of the tail/head, irregular
pancreatic head, findings consistent with chronic
pancreatitis.  No pancreatic mass, no biliary ductal
dilatation.

CT of chest:  Several mediastinal lymph nodes, enlarged
bilateral, faint multifocal opacities predominant in upper
lobe with thickening of interlobular septa with differential
including lymphoma infection, vasculitis, sarcoidosis, and
very asymmetric pulmonary edema.

TTE from [**12/2106**] showed a normal chamber size and wall
motion, a moderately dilated aortic root, a mildly dilated
ascending aorta, a mildly thickened AV leaflets.

HOSPITAL COURSE:
1.  Hemolytic anemia:  The patient had a negative direct
Coombs' test which suggested against a warm or cold
autoimmune hemolytic anemia.  However, on further evaluation
by the blood bank/transfusion team he was noted to have the
presence of warm autoantibodies which were easily washed off
during the Coomb's which explained the negative finding.
Thus, the test results were consistent with AIHA, the
etiology for which could possibly including autoimmune
diseases or malignancies such as CLL or a lymphoma.  The team
felt that a malignancy was likely as an etiology given his
abnormal chest x-ray and chest CT findings.  However, given
his tenuous hemodynamic status a workup of this will be
deferred until the patient is an outpatient.

Hematology/Oncology followed the patient during his entire
admission, and he was placed on Prednisone 60 mg a day.  The
patient was transfused three units of packed red cells with
his hematocrit rising into the mid 20s.  His hematocrit was
followed initially every eight hours and then tapered to
twice daily, with all his laboratory results showing
stabilization of his hematocrit requiring no further
transfusions.

A follow up of his hemolysis labs showed that his total
bilirubin slowly came down to 3.9, though his indirect
bilirubin was still elevated above normal.  His lab results
on discharge show that he was still hemolyzing at a slow
rate.  However, given that his hematocrit remained stable, he
will be continued for now on Prednisone 60 a day until follow
up with Hematology/Oncology, at which time they may choose to
pursue a different medication route such as including
cytotoxic agents in his regimen.

2.  Pulmonary opacities/mediastinal lymphadenopathy:  A
tissue diagnosis is needed for the diagnosis of lymphoma
versus sarcoid, but given that the patient must be stabilized
on his steroids, he will follow up with Pulmonary as an
outpatient for possible bronchoscopy/mediastinoscopy for
tissue biopsy.  Sarcoidosis seems to be less likely given the
patient's demographics and the absence of hilar adenopathy.
His dyspnea on exertion was thought to be mostly due to his
anemia rather than the pulmonary opacities, though his weight
loss was worrisome for possible malignancy.

3.  History of ventricular tachycardia:  The patient was
monitored on telemetry for the first three days of his
hospitalization which showed no recurrence of the
nonsustained ventricular tachycardia that he had had in the
Emergency Room which was likely secondary to the stress of
severe anemia.

4.  Possible B12/folate deficiency:  He had B12 and folate
levels checked, which were both within normal limits.
However, Hematology/Oncology recommended starting folate and
B12 supplements based on being hypersegmented neutrophils on
his peripheral blood smear.

5.  Remote history of transient ischemic attack:  Patient is
to continue Plavix.

6.  Glycemic control:  As the patient was started on
high-dose steroids, his blood glucose became quite high into
the high 200s, low 300s, which was not well controlled on the
500 b.i.d. of Metformin.  Thus, on discharge he will be
taking 1000 mg p.o. b.i.d. of Metformin with instructions to
follow up for this at his primary care physician's office.

7.  Hypothyroidism:  His TSH was checked on admission and was
within normal, and he will be continued on his current home
dose of Levothyroxine.

8.  History of GI bleed on aspirin:  Patient was not put on
aspirin during this admission and was put on Protonix daily.

9.  Congestion/rhinorrhea:  The patient complained of these
symptoms during his admission, however, had no other
associated upper respiratory infection symptoms or fever.  He
reported relief with started pseudoephedrine and [**Doctor First Name **] and
will take Claritin when he gets home.

DISCHARGE CONDITION:  Stable.

DISCHARGE STATUS:  To home.

DISCHARGE DIAGNOSES:
1.  Warm autoantibody hemolytic anemia.
2.  Hypothyroidism.
3.  Pulmonary nodules.
4.  Type 2 diabetes.
5.  Alcoholic cirrhosis.
6.  History of nonsustained ventricular tachycardia.

DISCHARGE MEDICATIONS:
1.  Plavix 75 mg p.o. q.d.
2.  Synthroid 75 mcg p.o. q.d.
3.  Folate 1 mg p.o. q.d.
4.  Protonix 40 mg p.o. q.d.
5.  Colace 100 mg p.o. q.d.
6.  Pseudoephedrine 30 mg, two 60 mg p.o. q. six hours p.r.n.
congestion.
7.  Senna one tablet p.o. b.i.d. p.r.n. constipation.
8.  Meclizine 12.5 mg p.o. q. eight hours p.r.n. vertigo.
9.  Metformin 1000 mg p.o. b.i.d.
10. Prednisone 60 mg p.o. q.d.
11. Fexofenadine 60 mg p.o. b.i.d. p.r.n.

DISCHARGE INSTRUCTIONS:
1.  Hematology office will call the patient to schedule a
follow up as per Hematology/Oncology fellow.
2.  Primary care appointment with Dr. [**Last Name (STitle) 58**] on Tuesday,
[**2109-11-19**], at 11:30 to follow up patient's condition and
check a repeat hematocrit.




                          [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D.  [**MD Number(1) 1212**]

Dictated By:[**Last Name (NamePattern1) 1606**]

MEDQUIST36

D:  [**2109-11-14**]  17:50
T:  [**2109-11-15**]  10:51
JOB#:  [**Job Number 103408**]
{'Autoimmune hemolytic anemias,Paroxysmal ventricular tachycardia,Alcoholic cirrhosis of liver,Acidosis,Other diseases of lung, not elsewhere classified,Enlargement of lymph nodes,Unspecified acquired hypothyroidism'}


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: 1.  Shortness of breath.
2.  Painless jaundice.

PRESENT ILLNESS: This is an 82-year-old male with
a past medical history of hypothyroidism, type 2 diabetes,
and alcoholic cirrhosis who was referred to the Emergency
Department by his primary care physician after he visited the
office for increasing jaundice and shortness of breath, and
primary care physician found the hematocrit to be 21.  The
patient had noticed one to two weeks of worsening painless
jaundice as well as about one-month history of weight loss
and tea-colored dark urine.  He was also beginning to feel
worsening shortness of breath/dyspnea on exertion and
fatigue/weakness over the past one to two weeks.  He denies
hematemesis, BR/PPR, melena, hematuria, nausea, vomiting,
abdominal pain, cough, chest pain, pruritus, rash, fever,
chills, sweats, or upper respiratory infection symptoms.  He
also denies any new medications, including herbal remedies,
aside from taking a Metformin, which he stopped one month ago
when PCP informed him his sugars were normal.  No recent
alcohol use.

MEDICAL HISTORY: 1.  Alcoholic cirrhosis with history of alcohol abuse;
patient quit in [**2083**].
2.  History of gastrointestinal bleed on aspirin.
3.  Diabetes type 2 which is diet controlled.
4.  Hypothyroidism.
5.  Vertigo.
6.  Questionable history of TIA.
7.  History of undescended testes status post surgery.

MEDICATION ON ADMISSION: 1.  Clopidogrel 75 mg p.o. q.d.
2.  Levothyroxine 75 mcg p.o. q.d.
3.  Meclizine p.r.n.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: One brother with lymphoma who passed away;
two brothers with alcoholism, also have passed away, one
brother with pernicious anemia.

SOCIAL HISTORY: A 50-pack-year history of tobacco; quit in
[**2103**].  Prior alcohol abuse; quit in [**2083**].  No illicit drug
use.  Lives alone.  Possible remote history of asbestos
exposure as a youth.  Patient has no children. 

### Response:
{'Autoimmune hemolytic anemias,Paroxysmal ventricular tachycardia,Alcoholic cirrhosis of liver,Acidosis,Other diseases of lung, not elsewhere classified,Enlargement of lymph nodes,Unspecified acquired hypothyroidism'}
