CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is a 67-year-old man
with a past medical history significant for coronary artery
disease, Wegener's granulomatosis and myelodysplasia (please
see past medical history below) who presented with chest pain
over the prior three days, as well as fevers and chills.

MEDICAL HISTORY: 1.  Coronary artery disease
    A.  Status post multiple interventions: Coronary artery
bypass graft in [**2105**] with left internal mammary artery to the
LAD, saphenous vein graft to the PL and saphenous vein graft
to the PDA.
    B.  Multiple catheter procedures:  Stent x2 to the left
circumflex, stent to the LAD, distal to the left internal
mammary artery touchdown.  Most recent catheter procedure:
[**2114-6-4**], normal hemodynamics.  Angiography
significant for occlusion of the LAD mid segment with a
patent left internal mammary artery and a patent distal LAD
stent.  Old RCA occlusion.  Saphenous vein graft to the PL
was found to be widely patent.  Saphenous vein graft to the
PDA was found to have 70% mid vessel stenosis.  The patient
underwent stenting of the saphenous vein graft to the PDA
with 0% residual stenosis.
   C.  Last echocardiogram prior to current admission
(performed [**2114-1-29**]):  The study was of relatively
poor quality and revealed a left ventricular ejection
fraction of 35% to 40%.  Mild concentric left ventricular
hypertrophy was seen with moderate depression of LV systolic
function.  Dyskinesis of the basal inferior and mid inferior
segments was noted, as was hypokinesis of the basal
inferolateral and mid inferolateral portions.  Right
ventricular size and function was normal.  The patient was
found to have moderate mitral regurgitation.
2.  Wegener's granulomatosis was initially diagnosed as RA,
later felt to be Wegener's in [**2111**].  The patient had been
treated with prednisone and Cytoxan.  Cytoxan was started in
[**2113-10-18**] and discontinued in [**2113-12-18**].
3.  Myelodysplasia, receives transfusions every one to two
weeks.
4.  Hypertension
5.  Hyperlipidemia

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.  REPORTS
GASTROINTESTINAL UPSET WITH CODEINE.

PHYSICAL EXAM: 

FAMILY HISTORY: The patient's brother has coronary artery
disease.  The patient's mother was diagnosed with [**Name (NI) 2481**]
disease.

SOCIAL HISTORY: The patient is married and lives at home
with his wife.  [**Name (NI) **] smoked one pack per day x20 years, quit
about 17 years ago.  The patient reports alcohol use of
approximately one to two drinks per week.
Subendocardial infarction, initial episode of care,Other vascular complications of medical care, not elsewhere classified,Wegener's granulomatosis,Coronary atherosclerosis of native coronary artery,Aortocoronary bypass status
Subendo infarct, initial,Vasc comp med care NEC,Wegener's granulomatosis,Crnry athrscl natve vssl,Aortocoronary bypass
Admission Date:  [**2114-8-20**]       Discharge Date:  [**2114-9-4**]

Date of Birth:   [**2047-1-30**]       Sex:  M

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

HISTORY OF PRESENT ILLNESS:  The patient is a 67-year-old man
with a past medical history significant for coronary artery
disease, Wegener's granulomatosis and myelodysplasia (please
see past medical history below) who presented with chest pain
over the prior three days, as well as fevers and chills.

Regarding fevers, the patient has a history of Wegener's
granulomatosis with treatment with prednisone (still on 5 mg
q day) and Cytoxan (discontinued in [**2113-12-18**]) and
several admissions for fever and neutropenia in the past.  On
presentation for this admission, the patient reported having
had low grade temperatures and odynophagia for approximately
three days prior to admission, as well as mild cough and
fatigue.  He was started on levofloxacin two days prior to
admission without significant improvement in symptoms.  Then,
on the morning of admission, he reported having fevers to
104??????, as well as shaking chills, for which he presented to
the [**Hospital6 256**] Emergency
Department.  There, he received a dose of vancomycin,
gentamicin, ceftazidime and Flagyl in the Emergency
Department.  While in the Emergency Department, the patient's
systolic blood pressure dropped to the 80s and this was
accompanied by lightheadedness and left sided chest pain.
The patient's blood pressure improved with hydration.

Regarding the patient's chest pain, the patient has an
extensive history of coronary artery disease and is followed
for this by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (see below for more detail).  The
patient reported substernal chest pain with swallowing that
he was felt was dissimilar to past anginal pain.  The pain
did not radiate, was not associated with dyspnea,
palpitations, nausea or vomiting.  However, in the Emergency
Department, in the setting of hypertension, the patient's
reported onset of his left sided chest tightness that was
indeed similar to his prior anginal pain.  An
electrocardiogram in the Emergency Department showed ST
depressions in V2 through V5, as well as T-wave inversions in
leads 1, AVL and V1 through V6.  The patient was given
aspirin and sublingual nitroglycerin with improvement in his
left sided chest pain from 6 out of 10 in severity to 1 out
of 10 in severity in the Emergency Department.  His pain
resolved by the time he arrived in the Medical Intensive Care
Unit.  Electrocardiogram findings also resolved with repeat
electrocardiogram taken in the Intensive Care Unit.

PAST MEDICAL HISTORY:
1.  Coronary artery disease
    A.  Status post multiple interventions: Coronary artery
bypass graft in [**2105**] with left internal mammary artery to the
LAD, saphenous vein graft to the PL and saphenous vein graft
to the PDA.
    B.  Multiple catheter procedures:  Stent x2 to the left
circumflex, stent to the LAD, distal to the left internal
mammary artery touchdown.  Most recent catheter procedure:
[**2114-6-4**], normal hemodynamics.  Angiography
significant for occlusion of the LAD mid segment with a
patent left internal mammary artery and a patent distal LAD
stent.  Old RCA occlusion.  Saphenous vein graft to the PL
was found to be widely patent.  Saphenous vein graft to the
PDA was found to have 70% mid vessel stenosis.  The patient
underwent stenting of the saphenous vein graft to the PDA
with 0% residual stenosis.
   C.  Last echocardiogram prior to current admission
(performed [**2114-1-29**]):  The study was of relatively
poor quality and revealed a left ventricular ejection
fraction of 35% to 40%.  Mild concentric left ventricular
hypertrophy was seen with moderate depression of LV systolic
function.  Dyskinesis of the basal inferior and mid inferior
segments was noted, as was hypokinesis of the basal
inferolateral and mid inferolateral portions.  Right
ventricular size and function was normal.  The patient was
found to have moderate mitral regurgitation.
2.  Wegener's granulomatosis was initially diagnosed as RA,
later felt to be Wegener's in [**2111**].  The patient had been
treated with prednisone and Cytoxan.  Cytoxan was started in
[**2113-10-18**] and discontinued in [**2113-12-18**].
3.  Myelodysplasia, receives transfusions every one to two
weeks.
4.  Hypertension
5.  Hyperlipidemia

OUTPATIENT MEDICATIONS:
1.  Epogen 40,000 units q week
2.  Carafate 1 gm q day
3.  Captopril 25 mg t.i.d.
4.  Prednisone 5 mg q.d.
5.  Amiodarone 200 mg q.d.
6.  Lopressor 100 mg t.i.d.
7.  Lasix 40 mg prn
8.  Vitamin E

ALLERGIES:  No known drug allergies.  REPORTS
GASTROINTESTINAL UPSET WITH CODEINE.

SOCIAL HISTORY:  The patient is married and lives at home
with his wife.  [**Name (NI) **] smoked one pack per day x20 years, quit
about 17 years ago.  The patient reports alcohol use of
approximately one to two drinks per week.

FAMILY HISTORY:  The patient's brother has coronary artery
disease.  The patient's mother was diagnosed with [**Name (NI) 2481**]
disease.

LABORATORY DATA ON PRESENTATION:  A CBC revealed a white
count of 1.0 with the following differential:  40 segs, 4
bands, 50 lymphocytes, 6 monocytes.  Granulocyte count was
590.  The patient's hemoglobin was 12.5 and his hematocrit
was 36.2.  His platelet count was 43.  A chem-7 revealed
sodium of 137, potassium of 4.0, chloride of 99, bicarbonate
of 22. BUN of 32 and creatinine of 1.2 with a glucose of 118.
The patient's initial CK was 33 with a troponin of 3.
Subsequent CKs were 82 and then 67.  Subsequent troponins
were 2.7 and 6.4.  The patient's last ANCA prior to this
current admission was 1.3.  A urinalysis revealed no red
blood cells, no white blood cells, no bacteria and no
epithelials.

IMAGING:  An AP and lateral chest x-ray obtained on [**8-20**] revealed heart size stable.  Pulmonary vasculature was
within normal limits.  Bibasilar interstitial coarse
reticular opacities were seen.  These were stable compared
with prior studies.  No acute processes were appreciated.
Electrocardiogram in the Emergency Department:  Sinus
tachycardia at 100 beats per minute, axis 0, intervals normal
with T-wave inversions in leads 1, AVL, V2 through V6.  ST
depressions were seen in leads V2 through V5.  An old Q wave
was seen in lead 3.  Compared with prior study from [**2114-6-30**], T-wave inversions and ST depressions are new.
Electrocardiogram in the MICU:  Sinus tachycardia at 100
beats per minute, axis 0, intervals normal.  Resolution as
above, no change compared with prior electrocardiogram from
[**2114-6-30**].

OTHER LABS AND IMAGING OF NOTE FOR THIS CURRENT ADMISSION:
Transthoracic echocardiogram:  As will be discussed below,
the patient received a TTE on [**2114-8-24**] for
evaluation of his heart function following non Q-wave
myocardial infarction as well as for evaluation of possible
endocarditis in the setting of fevers and neutropenia.  This
echocardiogram was felt to be of adequate quality (versus
poor quality of above noted echocardiogram).  There was no
evidence of endocarditis found; left ventricular ejection
fraction was estimated at 55%.  Left ventricular hypertrophy
was noted.  Wall motion abnormalities were noted as
hypokinesis at the basal inferoseptal and mid inferoseptal
portions.  Right ventricular function and wall thickness were
normal; 3+ mitral regurgitation was noted.
Esophagogastroduodenoscopy:  As will also be noted below, the
patient underwent esophagogastroduodenoscopy on or about
[**8-24**] for evaluation of possible esophagitis, again
in the setting of neutropenia and fevers, as well as a
history of odynophagia.  The esophagogastroduodenoscopy was
negative for esophagitis.  CT scan of the sinuses, [**2114-8-27**], revealed no evidence of acute sinus disease.

BRIEF HOSPITAL COURSE:  The patient was initially admitted to
the Medical Intensive Care Unit on [**2114-8-20**] with
neutropenia, fevers, odynophagia and hypotension.  As noted
above, during a hypotensive episode, the patient developed
chest pain.  What follows is a brief hospital course by
problem list:

1.  CARDIAC:  The patient ruled in for a non Q-wave
myocardial infarction by troponin levels.  He was continued
on captopril, Lopressor and Aspirin; subsequently, the
aspirin was discontinued for very low platelet levels.  In
terms of the patient's rate and rhythm status, the patient
has a history of AT and NST; initially his amiodarone was
discontinued upon admission for the possible risk of bone
marrow suppression.  However, following cardiology consult,
his amiodarone was restarted on [**2114-8-23**].
Cardiology felt that the overall chronology of the patient's
onset of neutropenia was not compatible with his starting
amiodarone and that furthermore, his history of atrial
tachycardia and NST warranted restarting amiodarone.  The
patient's overall post myocardial infarction cardiac function
was assessed with the transthoracic echocardiogram.  Results
from the [**8-24**] study are noted above.  The patient's
hemodynamic status was stabilized over the first day or so of
his admission, such that he was no longer hypertensive, nor
did he exhibit any chest pain or electrocardiogram changes
following his above mentioned course.  Thus, on [**2114-8-22**], he was called out of the MICU to the medicine
floor.

2.  INFECTIOUS DISEASE:  Shortly after transfer from the MICU
to the medicine floor on [**2114-8-22**], the patient
spiked  temperature to 103.4?????? and exhibited rigors and
chills.  The infectious disease service was consulted and an
exhaustive work up for the fever source ensued.  The patient
initially received the above mentioned antibiotics in the
Emergency Department.  His subsequent antibiotic regimen was
tailored over the course of his hospitalization.  The patient
received a course of ceftazidime, as well as a 14 day course
of acyclovir.  The latter was prescribed for HSV like lesions
that appeared shortly after admission on the patient's upper
lip and which subsequently subsided completely following the
administration of acyclovir.  As noted above, the patient
underwent a transthoracic echocardiogram for evaluation of
endocarditis; this study was negative for endocarditis.  The
patient also underwent esophagogastroduodenoscopy for
evaluation of possible esophagitis in the setting of
neutropenia and odynophagia; this study was likewise
negative.

Furthermore, cultures were taken of the patient's blood,
urine and stools.  These were negative, as was a buffy coat
test for HSV.  The patient continued to have intermittent
fevers with a T-max on [**8-25**] of 102.0??????; subsequently,
his temperature curve dwindled such that his T-max on
[**8-27**] was 100.0??????.  Thereafter, the patient remained
afebrile for a time until, on [**8-30**], he was noted to
have a temperature of 100.9??????.  At this point, as with the
remainder of the patient's hospitalization, no clear source
for a fever was found, however it was felt on [**8-30**]
that his resurgence of temperature was most likely due to
possible cellulitis and/or intravenous site infection.  Thus,
the patient was restarted on ceftazidime and started on
vancomycin.  Subsequent blood cultures were negative and the
ceftazidime was discontinued.  However, the patient continued
intravenous vancomycin through the remainder of his
hospitalization for treatment of the possible intravenous
site infection.  The patient's right forearm intravenous site
exhibited some tenderness, erythema and a palpable cord.
These signs and symptoms slowly diminished over the ensuing
days up to the patient's discharge from the hospital.

From this point on, the patient did not exhibit frank fever
spikes and his intravenous sites as noted above slowly
improved.  The patient, as will be noted below, was
discharged home on four doses of p.o. Linezolid to finish
covering what had been covered by the intravenous vancomycin.

3.  HEMATOLOGY:  The hem/onc service was consulted and
followed the patient for issues pertaining to his history of
myelodysplasia.  The patient was transfused several units of
packed red blood cells over the course of his
hospitalization; this was fully consistent with his periodic
requirement for red blood cell transfusion related to the
above noted condition.  The patient's platelets remained low
throughout his hospitalization and for this reason he was not
given aspirin.  In terms of the patient's neutropenia, much
discussion was held as to whether or not the patient should
be given G-CSF in an attempt to improve his white count.
However, because the patient had a history of having blast
cells in his smears, the risk of possible conversion to AML
was felt too high to warrant use of G-CSF at that time.

4.  RHEUMATOLOGIC ISSUES:  The rheumatology service was
consulted for evaluation of the patient's Wegener's
granulomatosis.  They advised continued use of prednisone 5
mg p.o. q.d. and thus the prednisone was continued.

5.  FLUIDS, ELECTROLYTES AND NUTRITION:  The patient's
electrolytes remained stable overall throughout his course.
The patient suffered a brief bout of odynophagia early in his
admission; however, his ability to take adequate p.o.
nutrition was not significantly hampered and he maintained a
healthy appetite throughout his hospitalization.  It should
be noted that the patient did have several bouts of diarrhea
for which he was found to be Clostridium difficile negative
on a number of tests.  His diarrhea eventually subsided and
as noted above he continued to have good p.o. intake with no
nausea or vomiting.  The patient also ambulated well
throughout his ambulation.

DISCHARGE CONDITION:  As noted above, the patient's overall
course improved over his hospitalization.  On the day of
discharge, his vital signs were stable and he was afebrile
with a temperature of 98.1??????.  His intravenous cellulitis
revealed some continued palpable cords with decreased
erythema and tenderness.  The patient very much wished to go
home after his protracted hospital stay and following much
discussion with the various consult services and primary team
it was felt that the patient was indeed healthy enough to go
home, so long as he had adequate and intense follow up in the
near future.

DISCHARGE DIAGNOSES:
1.  Neutropenia
2.  Coronary artery disease, status post non Q-wave
myocardial infarction
3.  Wegener's granulomatosis
4.  Myelodysplasia

DISCHARGE MEDICATIONS:  For the most part, the patient was
discharged home on the above noted outpatient medication
regimen.  Changes included the fact that his aspirin had been
discontinued due to his low platelet count.  Also, he was
prescribed four doses of p.o. Linezolid to finish the course
of intravenous vancomycin he had received.  The patient had
received five days of vancomycin at the time of discharge.
Also, the patient was restarted on his amiodarone 200 mg q
day; this was begun on [**2114-8-23**].

FOLLOW UP:  The patient is to follow up with [**Hospital3 328**] on
[**2114-9-5**].  The patient is also to follow up with
the hem/onc service, specifically Dr. [**Last Name (STitle) 410**] within one week
of discharge.  Also, the patient is to follow up with his
attending physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] [**Location (un) 1683**] in approximately
two weeks following discharge.




                            [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8873**] [**Name8 (MD) **], M.D.  [**MD Number(1) 8874**]

Dictated By:[**Last Name (NamePattern1) 1550**]
MEDQUIST36

D:  [**2114-9-5**]  07:29
T:  [**2114-9-5**]  07:41
JOB#:  [**Job Number 16298**]
{"Subendocardial infarction, initial episode of care,Other vascular complications of medical care, not elsewhere classified,Wegener's granulomatosis,Coronary atherosclerosis of native coronary artery,Aortocoronary bypass status"}


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 67-year-old man
with a past medical history significant for coronary artery
disease, Wegener's granulomatosis and myelodysplasia (please
see past medical history below) who presented with chest pain
over the prior three days, as well as fevers and chills.

MEDICAL HISTORY: 1.  Coronary artery disease
    A.  Status post multiple interventions: Coronary artery
bypass graft in [**2105**] with left internal mammary artery to the
LAD, saphenous vein graft to the PL and saphenous vein graft
to the PDA.
    B.  Multiple catheter procedures:  Stent x2 to the left
circumflex, stent to the LAD, distal to the left internal
mammary artery touchdown.  Most recent catheter procedure:
[**2114-6-4**], normal hemodynamics.  Angiography
significant for occlusion of the LAD mid segment with a
patent left internal mammary artery and a patent distal LAD
stent.  Old RCA occlusion.  Saphenous vein graft to the PL
was found to be widely patent.  Saphenous vein graft to the
PDA was found to have 70% mid vessel stenosis.  The patient
underwent stenting of the saphenous vein graft to the PDA
with 0% residual stenosis.
   C.  Last echocardiogram prior to current admission
(performed [**2114-1-29**]):  The study was of relatively
poor quality and revealed a left ventricular ejection
fraction of 35% to 40%.  Mild concentric left ventricular
hypertrophy was seen with moderate depression of LV systolic
function.  Dyskinesis of the basal inferior and mid inferior
segments was noted, as was hypokinesis of the basal
inferolateral and mid inferolateral portions.  Right
ventricular size and function was normal.  The patient was
found to have moderate mitral regurgitation.
2.  Wegener's granulomatosis was initially diagnosed as RA,
later felt to be Wegener's in [**2111**].  The patient had been
treated with prednisone and Cytoxan.  Cytoxan was started in
[**2113-10-18**] and discontinued in [**2113-12-18**].
3.  Myelodysplasia, receives transfusions every one to two
weeks.
4.  Hypertension
5.  Hyperlipidemia

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.  REPORTS
GASTROINTESTINAL UPSET WITH CODEINE.

PHYSICAL EXAM: 

FAMILY HISTORY: The patient's brother has coronary artery
disease.  The patient's mother was diagnosed with [**Name (NI) 2481**]
disease.

SOCIAL HISTORY: The patient is married and lives at home
with his wife.  [**Name (NI) **] smoked one pack per day x20 years, quit
about 17 years ago.  The patient reports alcohol use of
approximately one to two drinks per week. 

### Response:
{"Subendocardial infarction, initial episode of care,Other vascular complications of medical care, not elsewhere classified,Wegener's granulomatosis,Coronary atherosclerosis of native coronary artery,Aortocoronary bypass status"}
