CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is a 63 year old
Spanish speaking male with a long and complicated medical
history, significant for diabetes mellitus, end-stage renal
disease on hemodialysis, hypertension, coronary artery
disease, and history of multiple lung infections, now
presenting with a left line site pain.  Review of systems is
positive for nausea and vomiting, pain is also significant
along the spine in the back and along the legs, positive
history for malaise, increased shortness of breath, and a
non-productive cough.  The patient denies any abdominal pain,
dysuria, or diarrhea.

MEDICAL HISTORY: 1.  End-stage renal disease, the patient receives
hemodialysis on Monday, Wednesday, and Friday at [**Hospital1 3494**]
where he is also followed by his primary care physician.
2.  History of multiple line infections.  Methicillin
resistant Staphylococcus aureus, vancomycin-resistant
enterococcus, and Klebsiella recently in [**8-16**],
vancomycin-resistant enterococcus in [**7-15**].
3.  Diabetes mellitus.
4.  Coronary artery disease, status post percutaneous
transluminal coronary angioplasty stent in left circ, status
post myocardial infarction.
5.  Osteo-spine with previous line infection.
6.  Chronic obstructive pulmonary disease.
7.  Congestive heart failure.
8.  Right internal jugular thrombosis and right subclavian
thrombosis as well as thrombosis of the superior vena cava
leading to a superior vena cava stenosis-like syndrome.
9.  Peripheral vascular disease.
10. Hypertension.
11. Arteriovenous fistula thrombosis.
12. Atrial fibrillation paroxysmal, an echo in [**11-15**] showed a
normal ejection fraction.

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: Does not use alcohol or smoke cigarettes.
Has been living with one woman for the majority of his life.
They are not married.  At this time, she is his caretaker.
Infection and inflammatory reaction due to other vascular device, implant, and graft,Methicillin susceptible Staphylococcus aureus septicemia,Acute posthemorrhagic anemia,Chronic airway obstruction, not elsewhere classified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Congenital deficiency of other clotting factors,Atrial fibrillation,Hemorrhage, unspecified,Congestive heart failure, unspecified
React-oth vasc dev/graft,Meth susc Staph aur sept,Ac posthemorrhag anemia,Chr airway obstruct NEC,Hyp kid NOS w cr kid V,Cong def clot factor NEC,Atrial fibrillation,Hemorrhage NOS,CHF NOS
Admission Date:  [**2146-7-10**]     Discharge Date:  [**2146-8-7**]

Date of Birth:   [**2082-10-25**]     Sex:  M

Service:  [**Location (un) 259**]

HISTORY OF PRESENT ILLNESS:  The patient is a 63 year old
Spanish speaking male with a long and complicated medical
history, significant for diabetes mellitus, end-stage renal
disease on hemodialysis, hypertension, coronary artery
disease, and history of multiple lung infections, now
presenting with a left line site pain.  Review of systems is
positive for nausea and vomiting, pain is also significant
along the spine in the back and along the legs, positive
history for malaise, increased shortness of breath, and a
non-productive cough.  The patient denies any abdominal pain,
dysuria, or diarrhea.

His previous medical history is very involved.  The patient
was last admitted in [**11-15**] for a superior vena cava syndrome,
occluded superior vena cava secondary to stenosis, and
possible deep vein thrombosis.  The left internal jugular was
removed at that time.  The patient was treated with Coumadin
and received hemodialysis through a femoral line at that
time.  In [**Month (only) **], the arteriovenous fistula was unrepairable
and was removed in [**2146-6-14**].  A magnetic resonance
arteriography showed an occluded right system.  The patient
was receiving dialysis through a left subclavian line which
now appears to be infected.

REVIEW OF SYSTEMS:  Positive for chills.

PAST MEDICAL HISTORY:
1.  End-stage renal disease, the patient receives
hemodialysis on Monday, Wednesday, and Friday at [**Hospital1 3494**]
where he is also followed by his primary care physician.
2.  History of multiple line infections.  Methicillin
resistant Staphylococcus aureus, vancomycin-resistant
enterococcus, and Klebsiella recently in [**8-16**],
vancomycin-resistant enterococcus in [**7-15**].
3.  Diabetes mellitus.
4.  Coronary artery disease, status post percutaneous
transluminal coronary angioplasty stent in left circ, status
post myocardial infarction.
5.  Osteo-spine with previous line infection.
6.  Chronic obstructive pulmonary disease.
7.  Congestive heart failure.
8.  Right internal jugular thrombosis and right subclavian
thrombosis as well as thrombosis of the superior vena cava
leading to a superior vena cava stenosis-like syndrome.
9.  Peripheral vascular disease.
10. Hypertension.
11. Arteriovenous fistula thrombosis.
12. Atrial fibrillation paroxysmal, an echo in [**11-15**] showed a
normal ejection fraction.

HOME MEDICATIONS:
1.  Amlodipine 10.
2.  Aspirin.
3.  Protonix.
4.  Coumadin.
5.  Nephrocaps.
6.  Lactulose.
7.  Morphine.
8.  Atenolol.
9.  Norvasc.
10. Zyprexa.

ALLERGIES:  No known drug allergies.

SOCIAL HISTORY:  Does not use alcohol or smoke cigarettes.
Has been living with one woman for the majority of his life.
They are not married.  At this time, she is his caretaker.

PHYSICAL EXAMINATION ON ADMISSION:  Temperature 101.2; heart
rate 75; blood pressure 150/68; respiratory rate 18; oxygen
saturation rate 95% on room air.  General:  patient is lying
in bed, breathing comfortably.  Head, eyes, ears, nose and
throat:  pupils are equal, round, and reactive to light and
accommodation, anicteric sclera.  Neck:  supple, no
lymphadenopathy.  Chest:  decreased breath sounds to the
bases with rails on deep inspiration.  Cardiovascular:  large
systolic murmur, no rubs, gallops, murmurs, consistent with
previously documented murmur.  Abdomen:  soft, non-tender,
non-distended, bowel sounds are present.  Extremities:  trace
edema, warm, weak pulses in lower extremities bilaterally,
dorsalis pedis pulses.  Neurological:  alert and oriented
times three, no focal deficits to gross confrontation.

LABS:  White count normal 15.1; blood cultures pending.

HOSPITAL COURSE:  The patient had a very long and complicated
hospital course.

1.  Infectious Disease.  The patient had a line infection and
was initially placed on vancomycin and gentamycin.  The
gentamycin was continued for five days.  His doses were
checked with the levels in hemodialysis and dosed
accordingly.  The patient's blood cultures grew out a skin
sensitizing antibody.  The patient was changed to oxacillin
which was started on [**7-13**].  Due to the back pain and the
patient's history of osteo to the spine with prior line
infections, there was concern over a receding of these bones.
It was decided that the patient would need a long course of
intravenous antibiotic therapy secondary to possible osteo as
well as ceding of multiple known blood clots.  Due to his
heart murmur, there was also a question of endocarditis which
was evaluated.  On the 20th, the patient's blood
sedimentation rate was 449, his white count 16.8.  The
patient's back pain was evaluated with a magnetic resonance
scan of the cervical spine initially which showed an early
inflammatory process, though this was greatly resolved from
the last study.  This was thought to be resolving from his
prior episode of osteomyelitis and not representing a new
condition.  The patient also had a magnetic resonance scan of
the lumbar spine much later in his hospital course that
showed no osteo, no discitis which was relevant for possible
abscesses or hematomas in the psoas muscle which will be
discussed in a later section.  The patient had a
transthoracic echocardiography initially to evaluate valvular
changes.  The transthoracic echocardiography showed the left
atrium mildly dilated, a left to right shunt across the
internal atrial septum, consistent with a secundum-type
atrial septal defect, mild symmetric left ventricular
hypertrophy, and ejection fraction greater than 55.  There
was, compared to the prior study, new aortic regurgitation
and the severity of mitral regurgitation was slightly
increased as this was suspicious for endocarditis.  A
transesophageal echocardiography was ordered.  The patient
initially refused the first attempt on [**7-18**].  The patient did
undergo a transesophageal echocardiography on [**2146-7-21**].  No
spontaneous echocontrast or thrombus was seen.  No
vegetations were noted.  The left ventricular ejection
fraction was consistent with greater than 55%.  There were
abnormally thickened aortic valve leaflets with a non-mobile
focal echogenic structure, probable calcifications of the
non-coronary cusp, trace aortic insufficiency, and no aortic
abscess.

2.  Abnormally thickened mitral valve encarditis with trace
mitral regurgitation.  Moderate mitral annular calcification,
no vegetations.  Abnormally thickened tricuspid valve, no
vegetations were seen.  The possibility of endocarditis could
not be excluded.  The patient was treated with intravenous
oxacillin beginning on [**7-13**] which was changed to intravenous
Cephazolin on [**7-27**] as this is dosed during dialysis and did
not require peripheral intravenous access and could be dosed
as an outpatient during dialysis sessions.  The patient
continued to spike from [**7-10**] to [**7-19**].  The patient then
remained afebrile and stable throughout the rest of his
hospital admission.

3.  Access.  The patient had his initial infected line
changed over a wire on [**7-12**] as his INR was 2.1 and
Interventional Radiology felt uncomfortable removing the line
with this level of coagulation.  Anticoagulation was held.
The patient was given Vitamin K as well as fresh frozen
plasma.  The line was removed [**7-13**] and his hematocrit
stabilized.  A PIC was added on [**7-20**] for intravenous
antibiotics as the patient had pulled out most of his
remaining peripheral access.  On day 14 of intravenous
antibiotics, a permanent central dialysis catheter was placed
and his stem dialysis line which had been placed on [**7-12**] was
removed on [**7-28**].  A vascular mapping study was done on the
13th and Transplant will follow-up with these results to
evaluate for further fistula work-up.  The patient
accidentally broke off one line of his PIC on [**8-1**] and then
this line was self discontinued on [**8-3**].  The patient went
home with stable and working dialysis access.

4.  Hematology.  The patient initially presented on Coumadin
for his paroxysmal atrial fibrillation.  This was changed to
heparin to allow adjustments in his lines.  In Interventional
Radiology, the patient had his line changed over a wire on
[**7-12**].  He was noted to have a large bleed at that time.  This
will be discussed under the cardiovascular section.  On [**7-20**]
the patient complained of some pain in his left thigh.  There
was palpable pain over the lower abdomen and thigh area.  The
patient had been on heparin sliding scale and had one dose
that was over 150 PTT.  This was adjusted accordingly.  This
pain began after this high supertherapeutic level.  An
ultrasound was performed on the left thigh which showed no
fluid collection, no abscess.  On the day of [**7-20**], the
patient's hematocrit was noted to drop from 31.5 to 25.6.  He
developed an anion gap of 18.  His CK increased to 263 while
his CKMB remained normal.  The patient was afebrile.  There
was no obvious source of bleed.  The patient had one unit of
blood transfused.  He had DIC labs performed which were
negative.  The patient was taken for a CT of the pelvis with
no doubt a huge retroperitoneal bleed on the left which was 8
x 10 cm.  The heparin was discontinued at that time and
Vascular Surgery was consulted.  The patient was transferred
to the Intensive Care Unit from [**7-21**] to [**7-24**] where he received
8 units of packed red blood cells and 1 unit of fresh frozen
plasma.  All anticoagulation was held.  The patient received
dialysis while in the Intensive Care Unit, but clotted his
femoral dialysis access.  This was changed over a wire while
the patient was in the Intensive Care Unit.  His hematocrit
remained stable and he was transferred back to the floor on
the 10th.  The patient's prior records of Hematology consults
were reviewed in regards to his superior vena cava syndrome
on [**2145-11-29**] which was noted for a questionable decrease in
protein S.  His superior vena cava was secondary to stenosis
and thrombosis.  At that time, he was started on three months
of anticoagulation.  The patient was evaluated by Hematology
for further coagulation difficulties.  The patient developed
anemia and was started on Epogen and hemodialysis.  The
patient was transfused to keep the hematocrit above 30
throughout admission.  On [**7-28**], the patient's PTT was noted
to once again be 150.  This was unusual as he was not on
anticoagulation except heparin during his hemodialysis
sessions.  Renal, Vascular, and Transplant team discussed the
issue of long-term coagulation with the Medical team.  It was
felt that, in light of the patient's need for adequate
dialysis access and his history of clotting his lines and
fistulas, that his risk of re-bleed was well worth his risk
for clotting off all access that was necessary to provide
life saving and sustaining dialysis.  The patient was started
on a light heparin sliding scale with the goal PTT of 50 to
80 and then change to Coumadin.  His PTT was difficult to
control and once again at one point was 132.  His INR
increased to 4.6 and all Coumadin and heparin were held.  The
patient's INR continued to increase off Coumadin and off
sliding scale heparin.  The patient was only receiving
heparin in dialysis.  The patient had a large hematology
workup at that time to evaluate his difficult to control
coagulations.  It was thought that his elevated INR was
secondary to an elevated PTT which was the result of heparin
dosed only during dialysis.  All anticoagulation was held.
The patient was monitored until his INR was within a
therapeutic range.  At 1.4, the patient was started back on
his home dose of Coumadin at that time and discharged home
for close follow-up for monitoring of his INR and coagulation
levels during dialysis.

5.  Renal.  The patient has end-stage renal disease on
hemodialysis.  The patient received dialysis throughout his
hospital course.  His volume status was adjusted multiple
times in dialysis.  He was evaluated for peritoneal dialysis
as he has a history of infections and problems thrombosing
his dialysis lines.  It was felt that he was not a candidate
for peritoneal dialysis at this time.  The patient developed
increased itch, secondary to uremia, and increased phos
absorption after his large retroperitoneal bleed, secondary
to reabsorption of this bleed.  He was started on three days
of Amphojel and improved with the help of the hemodialysis
team.  The patient was also started on [**Doctor First Name **] as Benadryl
caused a change in mental status.  This was followed by
hemodialysis and electrolytes were adjusted accordingly.

6.  Cardiovascular.  The patient had a history of paroxysmal
atrial fibrillation and was in and out of atrial fibrillation
throughout his hospital course.  The patient had the infected
line changed over a wire on [**7-12**].  That evening, a large
amount of blood was noted on his bedsheets, presumably from
the site of line change.  His hematocrit dropped from 31 to
25 over the course of [**7-13**].  He complained of crushing chest
pain and his troponin was 0.1, MB was 2, and CK 126.  His
electrocardiogram showed ST depressions in V4 through V5.
The patient complained of his sharp back pain.  There was a
question for aortic dissection.  His pain resolved with
Nitroglycerin and 2 units of blood, as well as Nitroglycerin
paste.  It was felt that this was likely demand ischemia.
The patient was taken to CT which showed no dissection, but
bilateral pulmonary effusions as well as a consolidation
consistent with infection versus septic emboli.  The patient
was evaluated with a transthoracic echocardiography which has
been described previously.  In the CT, the patient desatted
to an 02 sat in the 50s but was quickly revived and satted at
100% on 2 liters of oxygen.  The patient's electrocardiogram
slowly resolved over time.  The patient did not complain of
any further chest pain until the morning of [**8-1**].  The
patient was refused at dialysis because of this chest pain.
He responded to Nitroglycerin.  Similar electrocardiogram
changes were noted with ST depressions in V5.  The patient
was found on [**8-2**] to be 3 kilos down at hemodialysis.  It was
thought this second episode of chest pain was also likely to
be secondary to demand ischemia.  The patient improved with
fluids.  The patient had frequent electrocardiogram checks
and these changes fully resolved over time.  The patient was
on adequate cardiac therapy with beta-blockers, ace
inhibitors, aspirin, and anticoagulation.  He did develop
some hypotension on Lopressor, but responded to a bolus
during this period of volume depletion.  Volume depletion was
likely secondary to 3 days of nausea and vomiting.

7.  Gastrointestinal.  The patient experienced a 3 to 4 day
period of nausea and vomiting that preceded his 3 kilo volume
loss prior to the incidents described on [**8-1**].  This nausea
and vomiting was self limited.  The patient responded to
boluses as well as increased by mouth intake.

8.  Pulmonary.  Initial CT showed questionable consolidation
at the right lung base.  A repeat CT showed a 13 mm nodule at
the right lung base which was assessed by Pulmonary consult.
They felt this was likely a resulting septic emboli and
recommended a follow-up CT as an outpatient.  A percussion
and postural drainage was also placed which was read as
negative.

9.  Mental status changes.  The patient had noticeable mental
status changes starting [**7-12**] and persisting through the
beginning of [**Month (only) 216**].  Over the weekend of [**7-17**], the patient
required Zyprexa, Risperdal, and restraints.  Apparently, the
patient had tried to bite a staff member and pulled out most
of his peripheral lines.  It was thought the patient was
sundowning as well as having a negative response to Benadryl.
As patient's temperature resolved, the medical condition
stabilized and his mental status changes resolved.

DISCHARGE DIAGNOSIS:
1.  Methicillin-susceptible Staphylococcus aureus line
infection with possible septic emboli to the lung.
2.  Possible endocarditis.
3.  Status post large retroperitoneal bleed
4.  End-stage renal disease on hemodialysis.
5.  Diabetes mellitus type II.
6.  Coronary artery disease with demand ischemia.
7.  Allergy.
8.  Possible coagulopathy.
9. Possible acquired factor 8 deficiency.

RECOMMENDED FOLLOW-UP:
1.  The patient will proceed to dialysis three times a week.
2.  The patient will have his INR, PT, and PTT checked Monday
at dialysis or by his home [**Hospital6 407**]
nursing.
3.  He will contact Dr. [**Last Name (STitle) 34032**] with his coagulations.
4.  Dr. [**Last Name (STitle) 34032**] will contact patient to adjust his Warfarin
dose.
5.  The patient will follow-up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in the
transplant center.
6.  The patient will follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2146-8-9**]
for adjustment of his Warfarin.
7.  The patient will follow-up with Dr. [**First Name (STitle) **] in the next few
weeks, his primary care physician.

DISCHARGE CONDITION:  Fair, tolerating by mouth, minimal
walking, no nausea, vomiting, or diarrhea.  His INR is down
to 1.2 on the day of discharge.

DISCHARGE MEDICATIONS:
1.  Docusate sodium.
2.  Senna.
3.  Folic Acid, Vitamin B.
4.  Pantoprazole 40.
5.  Nitroglycerin sublingual as needed.
6.  Metoprolol 100 three times a day.
7.  Insulin regular sliding scale.  The patient reports he
uses a regular sliding scale at home and is familiar with its
use.
8.  Enalapril 10.
9.  Amlodipine 10 once daily.
10. Fexofenadine 60 once daily as needed for itch.
11. Sarna lotion.
12. Aspirin 325 once daily.
13. Warfarin 7.5 once daily or as instructed by physician.
14. Epogen alpha with hemodialysis.
15. Cephazolin at hemodialysis.




                          [**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**], M.D.  [**MD Number(1) 4521**]

Dictated By:[**Last Name (NamePattern1) 34033**]

MEDQUIST36

D:  [**2146-8-17**]  12:20
T:  [**2146-8-17**]  18:47
JOB#:  [**Job Number 34034**]
{'Infection and inflammatory reaction due to other vascular device, implant, and graft,Methicillin susceptible Staphylococcus aureus septicemia,Acute posthemorrhagic anemia,Chronic airway obstruction, not elsewhere classified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Congenital deficiency of other clotting factors,Atrial fibrillation,Hemorrhage, unspecified,Congestive heart failure, 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 63 year old
Spanish speaking male with a long and complicated medical
history, significant for diabetes mellitus, end-stage renal
disease on hemodialysis, hypertension, coronary artery
disease, and history of multiple lung infections, now
presenting with a left line site pain.  Review of systems is
positive for nausea and vomiting, pain is also significant
along the spine in the back and along the legs, positive
history for malaise, increased shortness of breath, and a
non-productive cough.  The patient denies any abdominal pain,
dysuria, or diarrhea.

MEDICAL HISTORY: 1.  End-stage renal disease, the patient receives
hemodialysis on Monday, Wednesday, and Friday at [**Hospital1 3494**]
where he is also followed by his primary care physician.
2.  History of multiple line infections.  Methicillin
resistant Staphylococcus aureus, vancomycin-resistant
enterococcus, and Klebsiella recently in [**8-16**],
vancomycin-resistant enterococcus in [**7-15**].
3.  Diabetes mellitus.
4.  Coronary artery disease, status post percutaneous
transluminal coronary angioplasty stent in left circ, status
post myocardial infarction.
5.  Osteo-spine with previous line infection.
6.  Chronic obstructive pulmonary disease.
7.  Congestive heart failure.
8.  Right internal jugular thrombosis and right subclavian
thrombosis as well as thrombosis of the superior vena cava
leading to a superior vena cava stenosis-like syndrome.
9.  Peripheral vascular disease.
10. Hypertension.
11. Arteriovenous fistula thrombosis.
12. Atrial fibrillation paroxysmal, an echo in [**11-15**] showed a
normal ejection fraction.

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: Does not use alcohol or smoke cigarettes.
Has been living with one woman for the majority of his life.
They are not married.  At this time, she is his caretaker. 

### Response:
{'Infection and inflammatory reaction due to other vascular device, implant, and graft,Methicillin susceptible Staphylococcus aureus septicemia,Acute posthemorrhagic anemia,Chronic airway obstruction, not elsewhere classified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Congenital deficiency of other clotting factors,Atrial fibrillation,Hemorrhage, unspecified,Congestive heart failure, unspecified'}
