CHIEF COMPLAINT: Morbid obesity

PRESENT ILLNESS: 45M with a history of obesity for 40 years.  He has tried
multiple exercise and diet programs without any sustained
success.  He has been extensively evaluated and medically
cleared for bariatric surgery.

MEDICAL HISTORY: GERD, HTN, hyperlipidemia, OSA

MEDICATION ON ADMISSION: Prozac 60mg
Trazodone 50mg
Topamax 50mg

ALLERGIES: Sulfa (Sulfonamides)

PHYSICAL EXAM: Gen: no acute distress, alert and oriented
CV: RRR, no murmurs
Pulm: clear bilaterally
Abd: obese, soft, nontender, normal bowel sounds
Ext: no edema, normal strength and tone

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: He denies alcohol and tobacco use.
Morbid obesity,Hemorrhage complicating a procedure,Iatrogenic pulmonary embolism and infarction,Pulmonary collapse,Obstructive sleep apnea (adult)(pediatric),Unspecified essential hypertension,Other and unspecified hyperlipidemia
Morbid obesity,Hemorrhage complic proc,Iatrogen pulm emb/infarc,Pulmonary collapse,Obstructive sleep apnea,Hypertension NOS,Hyperlipidemia NEC/NOS
Admission Date:  [**2179-6-8**]              Discharge Date:   [**2179-6-14**]

Date of Birth:  [**2134-4-2**]             Sex:   M

Service: SURGERY

Allergies:
Sulfa (Sulfonamides)

Attending:[**First Name3 (LF) 301**]
Chief Complaint:
Morbid obesity

Major Surgical or Invasive Procedure:
Laprascopic roux-en-y gastric bypass.  EGD with endoscopic
clipping of bleeding artery at gastro-jejunal anastomosis.  IVC
filter placement.


History of Present Illness:
45M with a history of obesity for 40 years.  He has tried
multiple exercise and diet programs without any sustained
success.  He has been extensively evaluated and medically
cleared for bariatric surgery.

Past Medical History:
GERD, HTN, hyperlipidemia, OSA

Social History:
He denies alcohol and tobacco use.

Family History:
Non-contributory

Physical Exam:
Gen: no acute distress, alert and oriented
CV: RRR, no murmurs
Pulm: clear bilaterally
Abd: obese, soft, nontender, normal bowel sounds
Ext: no edema, normal strength and tone

Pertinent Results:
Barium swallow: post-op
IMPRESSION:
Moderately dilated gastric pouch with no evidence of obstruction
or leak.

CT scan of chest, abdomen, pelvis
IMPRESSION:
1. Markedly limited examination due to respiratory motion and
patient body habitus. There are equivocal filling defects noted
within the right main pulmonary artery with possible extension
into the right upper lobe branch. Nonocclusive emboli cannot be
excluded. If high clinical suspicion, treatment is recommended,
alternatively a repeat scan (if patient can provide adequate
breath hold) or dedicated catheter PA angiogram may be
attempted.

2. Bilateral segmental lower lobe and right middle lobe
atelectasis. Scattered centrilobular ground-glass opacities
predominantly within the upper lobes are nonspecific; however,
infectious or inflammatory process such as aspiration
pneumonitis/developing pneumonia cannot be excluded. Small
amount of secretions is likely present within the upper trachea.

3. No evidence of Roux-en-Y gastric bypass leak. No evidence of
obstruction with previously administered barium progressed into
the large bowel.

Pre-Op CBC
[**2179-6-8**] 01:55PM BLOOD WBC-19.9* RBC-4.01* Hgb-11.9* Hct-35.4*
MCV-88 MCH-29.6 MCHC-33.5 RDW-15.2 Plt Ct-425

Post-Op CBC
[**2179-6-10**] 04:30AM BLOOD WBC-11.9* RBC-2.77* Hgb-8.0* Hct-24.0*
MCV-86 MCH-28.9 MCHC-33.5 RDW-15.6* Plt Ct-226

Post-transfusion CBC
[**2179-6-12**] 06:23AM BLOOD WBC-10.1 RBC-3.12* Hgb-9.2* Hct-27.2*
MCV-87 MCH-29.6 MCHC-34.0 RDW-16.2* Plt Ct-241

ABG prior to CTA of chest
[**2179-6-10**] 04:00PM BLOOD Type-ART pO2-53* pCO2-41 pH-7.46*
calTCO2-30 Base XS-4

Brief Hospital Course:
Mr. [**Known lastname 73078**] was admitted and underwent a laparoscopic roux-en-Y
gastric bypass on [**2179-6-8**].  After the operation and extubation
of the patient the anesthesiologist noticed blood coming out of
the NG tube and the nasal trumpet.  This was thought to be an
upper airway bleed at first.  ENT was emergently consulted and
an upper airway bleed was not identified as the nasal passages
were packed and blood was still coming from the oropharynx.
Gastroenterology was then consulted and the patient was prepped
for an emergent exploratory laparoscopy with intra-operative EGD
to assess for bleeding within the GI tract.  Upon exploration of
the abdomen no extraluminal intra-abdominal bleed was
identified.  The anastomosis was tested for a leak and there was
none.  However, on upper endoscopy, a brisk arterial bleed was
noted at the gastro-jejunal anastomosis.  An endoclip was
successfully placed and stopped the bleeding.  The endoscope was
passed down to the jejuno-jejunal anastomosis and no blood or
bleeding was identified.  The patient was transferred to the ICU
for ventilatory support.  On POD1 he was extubated without
difficulty.  On POD2 he passed his barium swallow as no leak or
obstruction was noted.  In the early afternoon he acutely
desaturated down to 80% and complained of some dyspnea.  An
arterial blood gas was obtained and his pO2 was 54.  He remained
hemodynamically stable throughout this course of events.  He was
emergently taken to radiology for a CT angio of his chest and
due to the fact that he received barium earlier in the day it
was decided to scan his abdomen and pelvis to further evaluate
for an anastomotic leak.  There was a suspicious filling defect
in his right main pulmonary artery and it was uncertain as to
whether or not this was a pulmonary embolus.  There was no
extraluminal contrast seen in the abdomen.  Due to the
uncertainty of the pulmonary artery filling defect it was
decided to proceed with care as if it was a pulmonary embolus.
An IVC filter was placed by interventional radiology on the
evening of POD2.  He was started on a heparin drip for
anticoagulation.  His respiratory status improved on POD3 and
his right groin was free from hematoma.  He was able to get out
of bed and into a chair and he was started on stage I bariatric
diet.  His hematocrit had dropped to 24, but he remained
hemodynamically stable and his urine output was adequate.  He
was transfused with 2 units of packed RBCs.  On POD 4 he was
transferred out of the intensive care unit and to the floor.
His saturations on room air have been stable and his diet was
advanced to stage II.  He continued to ambulate and his
respiratory status improved.  On POD 5 he was advanced to a
stage III diet without complication.  His hematocrit has been
rechecked and it is stable at 27.  He oxygen saturations are now
in the high 90's on room air and he is out of bed frequently.
Anticoagulation was discussed with a hematologist and it was
decided that he should be treated for 6 months.  He will be
discharged on a Lovenox bridge and transition to coumadin with
his primary care physician.  [**Name Initial (NameIs) **] have talked to the primary care
physician's partner, Dr. [**Last Name (STitle) 9037**], and she is in agreement with
this plan; they have the desire and capabilities to monitor his
INR level.  This is also the wish of the patient.

Medications on Admission:
Prozac 60mg
Trazodone 50mg
Topamax 50mg

Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO every four (4) hours as needed.
Disp:*250 ML(s)* Refills:*0*
2. Acetaminophen 160 mg/5 mL Solution Sig: Fifteen (15) MLs PO
Q6H (every 6 hours) as needed.
3. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
5. Zantac 15 mg/mL Syrup Sig: Ten (10) MLs PO twice a day for 7
days.
Disp:*140 MLs* Refills:*0*
6. Zantac 15 mg/mL Syrup Sig: Ten (10) MLs PO twice a day for 23
days.
Disp:*460 MLs* Refills:*0*
7. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day) for 1 weeks.
Disp:*14 Capsule(s)* Refills:*0*
8. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO twice a day
for 6 months.
Disp:*360 Capsule(s)* Refills:*0*
9. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous [**Hospital1 **] (2 times a day) for 4 days.
Disp:*8 syringe* Refills:*0*
10. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous twice a day for 10 days.
Disp:*20 syringes* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Morbid obesity


Discharge Condition:
Good


Discharge Instructions:
Please call your surgeon or return to the emergency department
if you
develop a fever greater than 101.5, chest pain, shortness of
breath, severe abdominal pain, pain unrelieved by your pain
medication, severe nausea or vomiting, severe abdominal
bloating, inability to eat or drink, foul smelling or colorful
drainage from your incisions, redness or swelling around your
incisions, or any other symptoms which are concerning to you.

Diet:
Stay in Stage III diet until your follow up appointment. Do not
self advance diet, do not drink out of a straw or chew gum.

Medication Instructions:
Resume all of your home medications except topamax, CRUSH ALL
PILLS.

You will be starting some new medications:
1. You will be given a prescription for pain medication, which
may make you drowsy. Do not drive while taking pain medication.
You may switch to tylenol elixir which you can buy over the
counter.
2. You should begin taking a Flintstones chewable complete
multivitamin. No gummy vitamins.
3. You will be taking Zantac liquid 150 mg twice daily for one
month. This medicine prevents gastric reflux.
4. You will be taking Actigall 300 mg twice daily for 6 months.
This
medicine prevents you from having problems with your
gallbladder.
5. You will be starting Lovenox injections twice a day to
prevent blood clots.  Follow up with your primary care physician
to transition over the coumadin pills.

Activity:
No heavy lifting of items [**8-30**] pounds for 6 weeks. You may
resume moderate exercise at your discretion, no abdominal
exercises.

Wound Care:
You may shower, no tub baths or swimming. If there is clear
drainage from your incisions, cover with clean, dry gauze. Leave
white strips above your incisions in place, allow them to fall
off on their own.


Followup Instructions:
See Dr. [**Last Name (STitle) **] in his office on Wednesday [**6-16**] at 10am
before you fly back to [**Location (un) 14336**].  Follow up with Dr. [**Last Name (STitle) **] at
your regularly scheduled appointment in [**1-17**] weeks.  Call his
office at [**Telephone/Fax (1) 305**] to confirm your appointment.  Follow up
with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 73079**], on Tuesday [**6-22**] at 12:45pm.  She will transition you over to oral coumadin
and check your INR level.
{'Morbid obesity,Hemorrhage complicating a procedure,Iatrogenic pulmonary embolism and infarction,Pulmonary collapse,Obstructive sleep apnea (adult)(pediatric),Unspecified essential hypertension,Other and unspecified hyperlipidemia'}


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: Morbid obesity

PRESENT ILLNESS: 45M with a history of obesity for 40 years.  He has tried
multiple exercise and diet programs without any sustained
success.  He has been extensively evaluated and medically
cleared for bariatric surgery.

MEDICAL HISTORY: GERD, HTN, hyperlipidemia, OSA

MEDICATION ON ADMISSION: Prozac 60mg
Trazodone 50mg
Topamax 50mg

ALLERGIES: Sulfa (Sulfonamides)

PHYSICAL EXAM: Gen: no acute distress, alert and oriented
CV: RRR, no murmurs
Pulm: clear bilaterally
Abd: obese, soft, nontender, normal bowel sounds
Ext: no edema, normal strength and tone

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: He denies alcohol and tobacco use. 

### Response:
{'Morbid obesity,Hemorrhage complicating a procedure,Iatrogenic pulmonary embolism and infarction,Pulmonary collapse,Obstructive sleep apnea (adult)(pediatric),Unspecified essential hypertension,Other and unspecified hyperlipidemia'}
