CHIEF COMPLAINT: Foreign body swallowed

PRESENT ILLNESS: 87M with history of atrial fibrillation not currently on
coumadin, chronic renal insufficiency (baseline Cr mid 2s),
hypertension, hyperlipidemia, gout, mild dementia, bilateral
sensorineural hearing loss who ingested a drill bit at a dentist
appointment on the morning of AM of [**11-13**].
.
In the ED, initial VS were:  97.1 109 140/95 16 100% RA. CXR
demonstrated foreign body in cervical region. Foreign body was
not directly visualized by nasopharyngoscope per ENT. Seen by
surgery for possible open retrieval, transferred to MICU for EGD
by GI instead.
.
In MICU, VS were: 98.9 98 103/65 15 100% on RA. Foreign body
could not be visualized by EGD.  Progression followed with
serial XRays.  Serial abdominal exams benign.  VS and hematocrit
remained stable. EKG with 2nd degree heart block with 4:1 and
3:1 conduction and the patient remained in Atrial fibrillation
vs. atrial flutter. ACEi and BB held and patient was kept NPO on
IVF in the interim as the foreign body is waiting to pass.
.
Vitals on the floor were T98.4 BP134/80 P84 RR18 O2 98RA.
Denied pain or discomfort.
.
Review of systems:  Difficult historian given mild dementia
(+) Per HPI
(-) Denies fever/chills, cough, shortness of breath. Denies
pain, nausea, vomiting.

MEDICAL HISTORY: Chronic renal failure (baseline creatinine ~2.5)
Hypertension
Hyperlipidemia
Atrial fibrillation off coumadin for dental work (CHADS2 is 2,
no h/o stroke or TIA)
Gout
Benign prostatic hyperplasia

MEDICATION ON ADMISSION: Lisinopril 2.5mg daily
Simvastatin 40mg daily (? dose)
Coumadin 2.5mg 5x/week and 1.25mg 2x/week (T/Th)
Metoprolol SR 25 mg daily
Colchicine 0.6mg M/W/F
Flomax 0.4mg qhs
Aspirin 81 mg QD
Vitamin D 50,000 U 1x/week
Tums Ultra 1000 QD
Prednisone 10 mg QD:PRN evening gout flares

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: 98.9 98 103/65 15 100% on RA
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op with some dried blood on
teeth and evidence of recent dental work
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/
NEURO: oriented to self and date
.
On transfer to the floor:
Vitals: T:98.4 BP:134/80 P:84 R:18 O2:98RA
General: alert, comfortable, no acute distress, hearing impaired

FAMILY HISTORY: No history of coronary artery disease or MIs.

SOCIAL HISTORY: Retired pediatric endocrinologist, former Chief of division at
[**Hospital 4415**]. Originally from South [**Country 480**].
Married, lives with wife. Denies tobacco, illicit drug use. One
glass wine/night. Has three sons, one who lives in the area and
owns restaurants.
Foreign body in intestine and colon,Atrial flutter,Helicobacter pylori [H. pylori],Foreign body accidentally entering other orifice,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Gout, unspecified,Nontoxic multinodular goiter,Mixed hearing loss, bilateral,Other and unspecified hyperlipidemia,Abdominal aneurysm without mention of rupture,Senile dementia, uncomplicated,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS)
FB in intestine & colon,Atrial flutter,Helicobacter pylori,FB entering oth orifice,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Gout NOS,Nontox multinodul goiter,Mixed hearing loss,bilat,Hyperlipidemia NEC/NOS,Abdom aortic aneurysm,Senile dementia uncomp,BPH w/o urinary obs/LUTS
Admission Date:  [**2142-11-13**]              Discharge Date:   [**2142-11-20**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2290**]
Chief Complaint:
Foreign body swallowed

Major Surgical or Invasive Procedure:
Laryngoscopy
Esophagealgastroduodenoscopy (EGD)


History of Present Illness:
87M with history of atrial fibrillation not currently on
coumadin, chronic renal insufficiency (baseline Cr mid 2s),
hypertension, hyperlipidemia, gout, mild dementia, bilateral
sensorineural hearing loss who ingested a drill bit at a dentist
appointment on the morning of AM of [**11-13**].
.
In the ED, initial VS were:  97.1 109 140/95 16 100% RA. CXR
demonstrated foreign body in cervical region. Foreign body was
not directly visualized by nasopharyngoscope per ENT. Seen by
surgery for possible open retrieval, transferred to MICU for EGD
by GI instead.
.
In MICU, VS were: 98.9 98 103/65 15 100% on RA. Foreign body
could not be visualized by EGD.  Progression followed with
serial XRays.  Serial abdominal exams benign.  VS and hematocrit
remained stable. EKG with 2nd degree heart block with 4:1 and
3:1 conduction and the patient remained in Atrial fibrillation
vs. atrial flutter. ACEi and BB held and patient was kept NPO on
IVF in the interim as the foreign body is waiting to pass.
.
Vitals on the floor were T98.4 BP134/80 P84 RR18 O2 98RA.
Denied pain or discomfort.
.
Review of systems:  Difficult historian given mild dementia
(+) Per HPI
(-) Denies fever/chills, cough, shortness of breath. Denies
pain, nausea, vomiting.

Past Medical History:
Chronic renal failure (baseline creatinine ~2.5)
Hypertension
Hyperlipidemia
Atrial fibrillation off coumadin for dental work (CHADS2 is 2,
no h/o stroke or TIA)
Gout
Benign prostatic hyperplasia

Social History:
Retired pediatric endocrinologist, former Chief of division at
[**Hospital 4415**]. Originally from South [**Country 480**].
Married, lives with wife. Denies tobacco, illicit drug use. One
glass wine/night. Has three sons, one who lives in the area and
owns restaurants.

Family History:
No history of coronary artery disease or MIs.

Physical Exam:
VS: 98.9 98 103/65 15 100% on RA
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op with some dried blood on
teeth and evidence of recent dental work
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/
NEURO: oriented to self and date
.
On transfer to the floor:
Vitals: T:98.4 BP:134/80 P:84 R:18 O2:98RA
General: alert, comfortable, no acute distress, hearing impaired

HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Irregular. No m/r/g
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
Ext: Warm, well perfused, 2+ pulses, no edema

Pertinent Results:
Admission Labs:
[**2142-11-13**] 05:40PM   WBC-8.2 RBC-4.34* HGB-12.4* HCT-36.7* MCV-85#
MCH-28.6 MCHC-33.8 RDW-14.8
[**2142-11-13**] 05:40PM   NEUTS-57.6 LYMPHS-29.2 MONOS-6.4 EOS-6.4*
BASOS-0.4
[**2142-11-13**] 05:40PM   PLT COUNT-259
[**2142-11-13**] 05:40PM   PT-16.7* PTT-29.3 INR(PT)-1.5*
[**2142-11-13**] 05:40PM   GLUCOSE-101* UREA N-36* CREAT-2.4* SODIUM-141
POTASSIUM-4.7 CHLORIDE-107 TOTAL CO2-22 ANION GAP-17
[**2142-11-13**] 05:49PM   GLUCOSE-97 NA+-142 K+-4.7 CL--105 TCO2-24
.
Imaging:
[**11-14**] CXR: Small rod-like radiopaque foreign body seen within the
lower
cervical region. This finding was reported to patient's primary
care doctor, Dr. [**Last Name (STitle) 77644**] and suggestion was made that the
patient undergo bronchoscopy or video guided removal of the
foreign radiopaque object.
.
[**11-13**] CT Neck: 1. Previously noted retained foreign body within
the right aspect of the neck seen on chest radiograph is no
longer visualized on the current study.  Recommend further
evaluation with plain radiographs of the chest and abdomen to
evaluate for passage of the radiopaque structure.
2. Multinodular goiter with coarse calcifications in the right
lobe of the
thyroid gland. Clinical correlation is recommended, and if there
is continued clinical concern, an ultrasound can be obtained.
3. Cervical spondylosis with mild-to-moderate central canal
narrowing at
multiple levels.
.
[**11-13**] KUB: Linear radiopaque foreign body projecting over the
right upper
quadrant of the abdomen, likely within a bowel loop, but it
cannot be
discerned whether it lies within large or small bowel. No free
intraperitoneal air or evidence of bowel obstruction.
.
[**11-16**] CT abdomen/pelvis:
ABDOMEN: The visualized portion of the chest demonstrates
calcified
atherosclerotic disease of the coronary arteries as well as the
intrathoracic
aorta. The intrathoracic aorta is also noted to take a tortuous
course.

Within the limits of a non-contrast study, the liver shows no
focal lesion or
intrahepatic biliary dilatation. The gall bladder shows no
stones or wall
edema. The spleen is normal in size and appearance. The pancreas
shows no
evidence of masses. The adrenal glands are normal appearing
bilaterally. The
right kidney is more atrophic-appearing than the left. The left
kidney
demonstrates a cyst in the upper pole which measures 23 x 16 mm
(2; 23).

The small and large bowel show no evidence of obstruction. In a
loop of small
bowel is seen a linear density, and there does not appear to be
evidence of
perforation or fat stranding in this region. Compared to the KUB
performed on
the same day, there has been no appreciable movement. Compared
to multiple
KUBs from [**11-13**] to the present, there has been gradual
movement of this
object. It does not appear to be within the colon. There is no
free air or
free fluid.

Calcified atherosclerotic disease is seen throughout the
abdominal aorta and
into the iliac branches. There is an infrarenal abdominal aortic
aneurysm
that measures 39 x 37 mm in the axial plane and spans
approximately 4.5 cm
longitudinally. There is no intimal calcification displacement
or periaortic
stranding to suggest rupture.

BONES: Severe degenerative changes are seen in the thoracolumbar
spine
primarily in the form of marginal osteophytes and facet joint
hypertrophy.

IMPRESSION:
1. Metallic density likely representing swallowed drill bit
within the loop
of small bowel without evidence of perforation - finding
discussed with [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 5144**] at 14:49 on [**2142-11-16**].
2. Infrarenal aortic aneurysm without evidence of rupture.
3. Severe spinal degenerative changes.
4. Atrophic kidneys, right worse than left.
.
[**11-19**] KUB
 Radiodense foreign body attributed to a drill bit continues to
project over the L3 vertebral body level, but now has a change
in its
orientation, with a more diagonal position compared to the
vertical position
on the prior study of one day earlier. A non-obstructive bowel
gas pattern is
again visualized, and there is no evidence of free
intraperitoneal air.
Within the imaged portion of the lung bases, nonspecific
bibasilar fibrosis is
evident.


Brief Hospital Course:
7M with history of atrial fibrillation not currently on
coumadin, chronic renal insufficiency (baseline Cr mid 2s),
hypertension, hyperlipidemia, gout, mild dementia, bilateral
sensorineural hearing loss with 2.5cm long foreign body (drill
bit) ingestion, awaiting passage per rectum/stools
.
#  Foreign body ingestion:
ENT could not get the drill bit out by laryngoscopy and GI did
EGD in MICU without success either. The patient was initially
NPO but his diet advanced to fulls and then regular to encourage
natural/gentle peristasis. Serial abdominal exams remained
benign and KUBs were ordered 2-3 times daily; all stool was
collected and monitored for passage of the drill bit. It was
progressing but then stopped. CT abdomen confirmed it is in the
small bowel and may be sticking to the side of the lumen. No
perforations although Gen [**Doctor First Name **] and GI both continued to follow.
On the day of discharge the drill bit was noted to have passed
into the ileum (and perhaps the cecum).  Given that the patient
was asymptomatic the decision was to discharge with follow up in
[**Hospital **] clinic the day after discharge.
.
#  Atrial fibrillation: Patient's CHADS2 score ~2 and his
coumadin was held for any possibility of surgical interventions
on the foreign body. His INR drifted down to 1.2. He was
initially also off rate control with his Toprol XL, which was
resumed as his heart rates crept up and his diet was advanced.
.
# Dental procedure: Recently and the setting in which the
patient ingested the drill bit. He was on amoxicillin PO for a
two week course, which was continued in house. The patient was
initially on ampicillin IV when he was strictly NPO. He will
need to complete his amoxicillin course (7 more days) as
outpatient.
.
#Chronic renal insufficiency: Creatinine near baseline of 2.5.
His lisinopril was initially held but then resumed.
.
#Benign Prostatic Hyperplasia: No urinalysis this admission.
Patient denied symptoms. He was resumed on his home flomax when
diet was advanced.
.
#Hyperlipidemia: Statin held in MICU. LFTs in [**2140**] were WNL. He
was resumed on his home simvastatin when diet was advanced.
.
#Hypertension: The patient's lisinopril and metoprolol were held
while NPO and resumed when his diet was advanced, with general
stability of his blood pressures.
.
#Gout: Stable, without flares while in-house. The patient's
colchicine was held while NPO and then resumed when his diet was
advanced.
.
#Hpylori positive - Lab drawn inadvertently in MICU. The patient
and wife are aware and were encouraged to follow this up with
his primary care doctor, particularly ?triple therapy.
.
#Multinodular goiter: Asymptomatic during this hospitalization.
This was incidental finding on CT with no evidence of thyroid
dysfunction. Patient and wife are aware and were encouraged to
follow this up as an outpatient with his primary care doctor.
.
# Code: Full code, confirmed in MICU

Medications on Admission:
Lisinopril 2.5mg daily
Simvastatin 40mg daily (? dose)
Coumadin 2.5mg 5x/week and 1.25mg 2x/week (T/Th)
Metoprolol SR 25 mg daily
Colchicine 0.6mg M/W/F
Flomax 0.4mg qhs
Aspirin 81 mg QD
Vitamin D 50,000 U 1x/week
Tums Ultra 1000 QD
Prednisone 10 mg QD:PRN evening gout flares

Discharge Medications:
1. metoprolol succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO MWF
(Monday-Wednesday-Friday).
4. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. amoxicillin 250 mg Capsule Sig: Two (2) Capsule PO Q12H
(every 12 hours) for 7 days: Complete the total 14 day course of
antibiotics for your dental work.
6. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
7. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO DAILY (Daily).
8. rivastigmine 9.5 mg/24 hour Patch 24 hr Sig: One (1) patch
Transdermal DAILY (Daily).
9. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).


Discharge Disposition:
Home

Discharge Diagnosis:
Primary:
Foreign body ingestion
Multinodular goiter
Helicobacter pylori
Infrarenal abdominal aortic aneurysm that measures 39 x 37 mm
.
Secondary:
Hypertension/hyperlipidemia
Atrial fibrillation
Chronic renal insufficiency
Mild dementia


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
-You were admitted after swallowing a drill bit at your
dentist's office. The Ears, Nose and Throat doctors attempted to
remove the drill bit by laryngoscopy but were unsuccessful. The
gastroenterologists attempted to remove it by EGD but were also
unable to. You were closely monitored, initially in the ICU, as
the passage of this sharp object was potentially dangerous as it
can cut through your gastrointestinal tract. Your diet was
gradually advanced and the drill bit safely passed into your
small bowel where it remains. In discussions with the
gastroenterologists, it was felt that further attempts to remove
the drill bit via more invasive techniques may be more harmful
than beneficial. The plan is to discharge you home where you
will be watched closely until the drill bit passes through your
system and into your stool.
.
-It is important that you continue to take your medications as
directed. We made the following changes to your medications
during this admission:
--> STOP Coumadin until the drill bit passes and you follow up
with your primary care physician.
.
-Contact your doctor or come to the Emergency Room should your
symptoms return. Also seek medical attention if you develop any
new fever, chills, trouble breathing, chest pain, nausea,
vomiting or unusual stools.

Followup Instructions:
Please follow-up with your primary care doctor, Dr. [**Last Name (STitle) **]
[**Name (STitle) 77645**]. You should discuss, in particular, management of your
goiter and H.pylori infection (whether to treat these). You can
reach his office at: [**Telephone/Fax (1) 77646**].

Name: [**Telephone/Fax (1) **],[**Telephone/Fax (1) **] A. MD
Location: [**Hospital **] MEDICAL ASSOCIATES
Address: [**Street Address(2) **] [**Apartment Address(1) 77647**], [**University/College **],[**Numeric Identifier **]
Phone: [**Telephone/Fax (1) 77646**]
Appointment: Wednesday [**2142-11-21**] 10:15am
.
Please follow up with gastroenterology tomorrow, [**11-21**] for an
appointment to have another x-ray performed.  They will call you
this afternoon with the time and place of the appointment



Completed by:[**2142-11-20**]
{'Foreign body in intestine and colon,Atrial flutter,Helicobacter pylori [H. pylori],Foreign body accidentally entering other orifice,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Gout, unspecified,Nontoxic multinodular goiter,Mixed hearing loss, bilateral,Other and unspecified hyperlipidemia,Abdominal aneurysm without mention of rupture,Senile dementia, uncomplicated,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS)'}


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: Foreign body swallowed

PRESENT ILLNESS: 87M with history of atrial fibrillation not currently on
coumadin, chronic renal insufficiency (baseline Cr mid 2s),
hypertension, hyperlipidemia, gout, mild dementia, bilateral
sensorineural hearing loss who ingested a drill bit at a dentist
appointment on the morning of AM of [**11-13**].
.
In the ED, initial VS were:  97.1 109 140/95 16 100% RA. CXR
demonstrated foreign body in cervical region. Foreign body was
not directly visualized by nasopharyngoscope per ENT. Seen by
surgery for possible open retrieval, transferred to MICU for EGD
by GI instead.
.
In MICU, VS were: 98.9 98 103/65 15 100% on RA. Foreign body
could not be visualized by EGD.  Progression followed with
serial XRays.  Serial abdominal exams benign.  VS and hematocrit
remained stable. EKG with 2nd degree heart block with 4:1 and
3:1 conduction and the patient remained in Atrial fibrillation
vs. atrial flutter. ACEi and BB held and patient was kept NPO on
IVF in the interim as the foreign body is waiting to pass.
.
Vitals on the floor were T98.4 BP134/80 P84 RR18 O2 98RA.
Denied pain or discomfort.
.
Review of systems:  Difficult historian given mild dementia
(+) Per HPI
(-) Denies fever/chills, cough, shortness of breath. Denies
pain, nausea, vomiting.

MEDICAL HISTORY: Chronic renal failure (baseline creatinine ~2.5)
Hypertension
Hyperlipidemia
Atrial fibrillation off coumadin for dental work (CHADS2 is 2,
no h/o stroke or TIA)
Gout
Benign prostatic hyperplasia

MEDICATION ON ADMISSION: Lisinopril 2.5mg daily
Simvastatin 40mg daily (? dose)
Coumadin 2.5mg 5x/week and 1.25mg 2x/week (T/Th)
Metoprolol SR 25 mg daily
Colchicine 0.6mg M/W/F
Flomax 0.4mg qhs
Aspirin 81 mg QD
Vitamin D 50,000 U 1x/week
Tums Ultra 1000 QD
Prednisone 10 mg QD:PRN evening gout flares

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: 98.9 98 103/65 15 100% on RA
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op with some dried blood on
teeth and evidence of recent dental work
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/
NEURO: oriented to self and date
.
On transfer to the floor:
Vitals: T:98.4 BP:134/80 P:84 R:18 O2:98RA
General: alert, comfortable, no acute distress, hearing impaired

FAMILY HISTORY: No history of coronary artery disease or MIs.

SOCIAL HISTORY: Retired pediatric endocrinologist, former Chief of division at
[**Hospital 4415**]. Originally from South [**Country 480**].
Married, lives with wife. Denies tobacco, illicit drug use. One
glass wine/night. Has three sons, one who lives in the area and
owns restaurants. 

### Response:
{'Foreign body in intestine and colon,Atrial flutter,Helicobacter pylori [H. pylori],Foreign body accidentally entering other orifice,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Gout, unspecified,Nontoxic multinodular goiter,Mixed hearing loss, bilateral,Other and unspecified hyperlipidemia,Abdominal aneurysm without mention of rupture,Senile dementia, uncomplicated,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS)'}
