CHIEF COMPLAINT: abdominal pain, free air on KUB

PRESENT ILLNESS: 81M recently d/c'd from [**Hospital1 18**] following an IPH of the right
parietooccipital region presented to ED with severe abdominal
pain in the epigastrium.  The history is somewhat unclear, but
it seems that the pain had been present over the past few days
and had worsened acutely on the day of presentation.  No
reported nausea or vomiting.  Last BM had been a few days prior.

MEDICAL HISTORY: PMH: aortic stenosis s/p porcine AVR ([**3-20**]), pneumonia (04), CAD
s/p stenting ([**3-20**]), IPH of R parieto-occipital region ([**6-22**])

MEDICATION ON ADMISSION: Zocor 40 mg qday, Lopressor 12.5 mg [**Hospital1 **], Colace

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On admission:
T 98.5  HR 110 (A fib)  BP 95/60  RR 22  O2sat 93%RA
Gen: [**Name (NI) 3584**], mostly oriented, uncomfortable, pale
CVS: tachycardic, irregular rhythm
Pulm: CTA b/l
Abd: distended, diffusely tender, + rebound, + guarding, guiaic
positive

FAMILY HISTORY: No coagulopathy, aneurysms, stroke. No known cardiopulmonary
disease. His parents lived until they reached ages greater than
90.

SOCIAL HISTORY: No tobacco, very rare and limited alcohol, no drug use. Widowed.
 Retired research physicist at [**University/College **]. HCP: [**Name (NI) **] and [**Name (NI) 31626**]
[**Name (NI) 31627**] (sister-in-law and brother-in-law) in [**Name (NI) 31628**], CT
(does not know phone or street #).
Chronic or unspecified duodenal ulcer with hemorrhage and perforation, without mention of obstruction,Atrial fibrillation,Heart valve replaced by transplant,Chronic kidney disease, unspecified,Personal history of other diseases of circulatory system,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Pure hypercholesterolemia
Chr duoden ulc hem/perf,Atrial fibrillation,Heart valve transplant,Chronic kidney dis NOS,Hx-circulatory dis NEC,Crnry athrscl natve vssl,Status-post ptca,Hy kid NOS w cr kid I-IV,Pure hypercholesterolem
Admission Date:  [**2134-7-21**]              Discharge Date:   [**2134-7-27**]

Date of Birth:  [**2052-11-16**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 4111**]
Chief Complaint:
abdominal pain, free air on KUB

Major Surgical or Invasive Procedure:
1. Closure of a perforated duodenal ulcer, omental patch,
    draining gastrostomy.
2. #20 feeding tube and feeding jejunostomy #14 whistle-
    tip.

History of Present Illness:
81M recently d/c'd from [**Hospital1 18**] following an IPH of the right
parietooccipital region presented to ED with severe abdominal
pain in the epigastrium.  The history is somewhat unclear, but
it seems that the pain had been present over the past few days
and had worsened acutely on the day of presentation.  No
reported nausea or vomiting.  Last BM had been a few days prior.


He was found in new onset Afib in the ED.  His hematocrit was
18.2, a drop from 42 on his prior admission.  Free air was found
on X-ray.  An NGT placed in the ED returned grossly bloody
fluid.

Past Medical History:
PMH: aortic stenosis s/p porcine AVR ([**3-20**]), pneumonia (04), CAD
s/p stenting ([**3-20**]), IPH of R parieto-occipital region ([**6-22**])

PSH: b/l inguinal hernia repair, deviated septum repair,
tonsillectomy, porcine AVR, R coronary stents, b/l saphenous
vein stripping

Social History:
No tobacco, very rare and limited alcohol, no drug use. Widowed.
 Retired research physicist at [**University/College **]. HCP: [**Name (NI) **] and [**Name (NI) 31626**]
[**Name (NI) 31627**] (sister-in-law and brother-in-law) in [**Name (NI) 31628**], CT
(does not know phone or street #).


Family History:
No coagulopathy, aneurysms, stroke. No known cardiopulmonary
disease. His parents lived until they reached ages greater than
90.

Physical Exam:
On admission:
T 98.5  HR 110 (A fib)  BP 95/60  RR 22  O2sat 93%RA
Gen: [**Name (NI) 3584**], mostly oriented, uncomfortable, pale
CVS: tachycardic, irregular rhythm
Pulm: CTA b/l
Abd: distended, diffusely tender, + rebound, + guarding, guiaic
positive

On discharge:
T 98.9  P 76  BP 132/75  RR 18  O2sat 95%RA
Gen: NAD, A&O x 3
CVS: RRR, nl S1S2, no MRG
Pulm: CTA b/l
Abd: soft, NT, ND, +BS,
Inc: dressings c/d/i, G tube c/d/i, J tube c/d/i
Ext: no c/c/e

Pertinent Results:
On admission:
[**2134-7-21**] 04:00AM BLOOD WBC-16.6*# RBC-1.96*# Hgb-6.5*#
Hct-18.9*# MCV-97 MCH-33.1* MCHC-34.3 RDW-17.2* Plt Ct-344#
[**2134-7-21**] 04:00AM BLOOD Neuts-73.8* Lymphs-24.3 Monos-1.6*
Eos-0.1 Baso-0.2
[**2134-7-21**] 09:10AM BLOOD PT-15.0* PTT-33.1 INR(PT)-1.4*
[**2134-7-21**] 09:10AM BLOOD Fibrino-253
[**2134-7-21**] 04:00AM BLOOD Glucose-197* UreaN-40* Creat-1.5* Na-134
K-4.1 Cl-100 HCO3-18* AnGap-20
[**2134-7-21**] 04:00AM BLOOD ALT-20 AST-24 LD(LDH)-234 CK(CPK)-39
AlkPhos-51 Amylase-136* TotBili-0.3
[**2134-7-21**] 04:00AM BLOOD Lipase-90*
[**2134-7-21**] 04:00AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2134-7-21**] 04:00AM BLOOD Albumin-3.5 Calcium-9.1 Phos-3.2 Mg-2.4
[**2134-7-21**] 04:00AM BLOOD Acetone-SMALL
[**2134-7-21**] 04:40AM BLOOD Lactate-3.8*
[**2134-7-21**] 06:39AM BLOOD Hgb-5.0* calcHCT-15
[**2134-7-21**] 09:10AM BLOOD calTIBC-178* Ferritn-131 TRF-137*
[**2134-7-21**] 09:10AM BLOOD Triglyc-48

AXR ([**2134-7-21**], 03:11): No evidence of bowel obstruction.
Intraperitoneal free air.
Multiple puctate lucenct foci overlying the bowel loops, raising
the
possibility of pneumatosis intestinalis.

CXR ([**2134-7-21**], 03:11): Unchanged appearance of the chest with
tortuous aorta.  Free air below the diaphragm and mid-upper
abdomen.

EKG ([**2134-7-21**], 02:48): Sinus rhythm. Left atrial abnormality. A-V
conduction delay. Frequent atrial ectopy and wandering atrial
pacemaker, new compared to the previous tracing  of [**2134-6-17**]. The
effective rate has increased. Clinical correlation is suggested.
 Read by: [**Last Name (LF) 578**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 579**]

Postoperative troponin elevation:
[**2134-7-21**] 09:10AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2134-7-21**] 03:55PM BLOOD CK-MB-7 cTropnT-0.04*
[**2134-7-21**] 10:10PM BLOOD CK-MB-7 cTropnT-0.05*
[**2134-7-22**] 05:00AM BLOOD CK-MB-6 cTropnT-0.04*
[**2134-7-23**] 11:58AM BLOOD CK-MB-4 cTropnT-0.01

CT head ([**2134-7-23**], 14:12): There is continued evolution of the
previously identified intraparenchymal hemorrhage.  The
subarachnoid hemorrhage is less apparent on the current study.
There is resolution of the intraventricular hemorrhage. No
evidence of new hemorrhage, mass effect, hydrocephalus, or acute
infarction.

U/S upper ext ([**2134-7-23**], 14:22): Thrombus in the right cephalic
and basilic veins in the region of the antecubital fossa.  No
DVT identified in the right arm.

EKG ([**2134-7-23**], 14:01): Sinus rhythm with frequent supraventricular
premature depolarizations and a ventricular premature
depolarizations. Non-diagnostic repolarization abnormalities.
Compared to the previous tracing of [**2134-7-21**] frequent
supraventricular ectopic activity now evident.

On discharge:
[**2134-7-27**] 07:50AM BLOOD WBC-5.8 RBC-3.43* Hgb-10.4* Hct-29.7*
MCV-87 MCH-30.3 MCHC-35.0 RDW-16.9* Plt Ct-245
[**2134-7-27**] 07:50AM BLOOD Glucose-133* UreaN-15 Creat-1.1 Na-137
K-3.5 Cl-104 HCO3-24 AnGap-13
[**2134-7-27**] 07:50AM BLOOD Calcium-8.1* Phos-2.8 Mg-1.7

Brief Hospital Course:
Surgery was consulted in the ED for free air.  He was taken
emergently to the operating room for closure of his perforated
duodenal ulcer with omental patch, draining gastrostomy tube,
and feeding J tube.  Amp, gent, and Flagyl were started.

On POD 1, Cardiology was consulted for his rising troponins.  In
the setting of low hematocrit, Cardiology believed that his
enzyme leak was secondary to demand ischemia as opposed to
primary MI.  The NGT was d/c'd on POD 1 and J tube feeds (Impact
1/2 strength) were started at 20 cc/hr.

On POD 2, Neurology was consulted for intermittent
disorientation; his mental status was confirmed to be baseline.
A repeat CT demonstrated improved IPH since his previous
imaging.  Tube feeds were increased to 30 cc/hr.  His right arm
was found to be swollen.  An ultrasound demonstrated thrombus in
the right cephalic and basilic veins in the region of the
antecubital fossa, but no DVT.

On POD 3, patient was transferred to the floor.  His tube feeds
were increased to 40 cc/hr (goal).  Adequate bowel sounds were
noted, and patient was started on sips, which he tolerated.

On POD 4, patient was advanced to clears.  A G-tube clamp trial
was successful.  He received 1 U PRBCs overnight.  He had bowel
movements overnight.

On POD 5, patient was advanced to soft diet.

On POD 6, patient was stable for discharge to [**Location (un) **].  He was
afebrile, with stable vital signs.  His WBC, Hct, and troponins
had normalized.  He was to complete his course of
amp/gent/Flagyl on [**2134-7-29**], to continue tube feeds of [**11-17**]
strength Impact at 40 cc/hr with regular diet ad lib, and to
clamp his G-tube continuously.  PT was ordered to continue
working with him in rehab.

Medications on Admission:
Zocor 40 mg qday, Lopressor 12.5 mg [**Hospital1 **], Colace

Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Disp:*270 Tablet(s)* Refills:*2*
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
One (1)  Intravenous Q8H (every 8 hours).
Disp:*10 units* Refills:*2*
4. Ampicillin Sodium 1 g Recon Soln Sig: One (1) Recon Soln
Injection Q6H (every 6 hours).
Disp:*10 Recon Soln(s)* Refills:*2*
5. Gentamicin 40 mg/mL Solution Sig: One (1)  Injection Q24H
(every 24 hours).
Disp:*10 units* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]

Discharge Diagnosis:
perforated duodenal ulcer


Discharge Condition:
stable


Discharge Instructions:
If you develop fever >101.5, abdominal pain or distention,
nausea or vomiting, chest pain, shortness of breath, redness of
your incisions or any other symptom or sign concerning to you
please call [**Hospital1 18**].  Take all medications as prescribed.  You can
shower immediately, but no swimming or bathing until you have
followed up with Dr. [**Last Name (STitle) 957**] in clinic.

Followup Instructions:
Arrange to see your PCP as soon as possible following discharge.
 Call Dr.[**Name (NI) 6275**] office to arrange an appointment 10-14 days
after discharge from the hospital. At this appointment he will
decide whether to remove your tubes.



Completed by:[**2134-8-27**]
{'Chronic or unspecified duodenal ulcer with hemorrhage and perforation, without mention of obstruction,Atrial fibrillation,Heart valve replaced by transplant,Chronic kidney disease, unspecified,Personal history of other diseases of circulatory system,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Pure hypercholesterolemia'}


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: abdominal pain, free air on KUB

PRESENT ILLNESS: 81M recently d/c'd from [**Hospital1 18**] following an IPH of the right
parietooccipital region presented to ED with severe abdominal
pain in the epigastrium.  The history is somewhat unclear, but
it seems that the pain had been present over the past few days
and had worsened acutely on the day of presentation.  No
reported nausea or vomiting.  Last BM had been a few days prior.

MEDICAL HISTORY: PMH: aortic stenosis s/p porcine AVR ([**3-20**]), pneumonia (04), CAD
s/p stenting ([**3-20**]), IPH of R parieto-occipital region ([**6-22**])

MEDICATION ON ADMISSION: Zocor 40 mg qday, Lopressor 12.5 mg [**Hospital1 **], Colace

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On admission:
T 98.5  HR 110 (A fib)  BP 95/60  RR 22  O2sat 93%RA
Gen: [**Name (NI) 3584**], mostly oriented, uncomfortable, pale
CVS: tachycardic, irregular rhythm
Pulm: CTA b/l
Abd: distended, diffusely tender, + rebound, + guarding, guiaic
positive

FAMILY HISTORY: No coagulopathy, aneurysms, stroke. No known cardiopulmonary
disease. His parents lived until they reached ages greater than
90.

SOCIAL HISTORY: No tobacco, very rare and limited alcohol, no drug use. Widowed.
 Retired research physicist at [**University/College **]. HCP: [**Name (NI) **] and [**Name (NI) 31626**]
[**Name (NI) 31627**] (sister-in-law and brother-in-law) in [**Name (NI) 31628**], CT
(does not know phone or street #). 

### Response:
{'Chronic or unspecified duodenal ulcer with hemorrhage and perforation, without mention of obstruction,Atrial fibrillation,Heart valve replaced by transplant,Chronic kidney disease, unspecified,Personal history of other diseases of circulatory system,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Pure hypercholesterolemia'}
