CHIEF COMPLAINT: Abdominal Pain

PRESENT ILLNESS: 33 yo female with history of gastric bypass in [**2174**] complicated
by leak and several surgies for bowel obstructions with
malabsorption and chronic pain with multiple hospital admiisions
and discussion of reversal of bypass, presents from
OSH complaining of acute onset severe abdominal pain that
started at 5pm last evening, more on the right side and in the
groin.  She describes it as intractable, constant,
aching/stabbing pain. [**11-16**].  States very different from
baseline pain that is usually RUQ simliar to prior gallbladder
attacks, this is much more intense. loss of appetite and
diarrhea, no nausea/ vomiting. Last BM yesterday, no blood.  OSH
imaging showed free air in retroperitoneum, concerning for
perforation. Received Zosyn at OSH and 1L NS and 1L LR.

MEDICAL HISTORY: PMHx:
- Community-acquired pneumonia
- Gastric bypass [**2174**], multiple hospitalizations for abdominal
pain, nausea, vomiting
- Recurrent small bowel obstructions secondary to adhesions s/p
multiple adhesiolysis
- Hypertension
- Migraine headaches
- Post traumatic stress disorder
- Obesity
- Chronic pain with narcotic use
- Chronic anemia
- B12 deficiency
- Electrolyte disturbance secondary to dehydration from diarrhea
- poor access, has venous access port in Right chest, states has
been on TPN in past

MEDICATION ON ADMISSION: - Atenolol 25 mg [**Hospital1 **]
- Percocet 1 tab tid
- Metoclopramide 10 mg 4x/day
- Fioricet 1-2 tabs prn
- Miralax and Dulcolax

ALLERGIES: Vicodin

PHYSICAL EXAM: PHYSICAL EXAM AT ADMISSION:
Gen: Ill-appearing women, in acute distress, diaphoretic, pale,
moaning in pain but conversing appropriately
HEENT: MM dry, no scleral icterus
Resp: Decreased breath sounds bases, distant
CV: Tachycardic
Abd: Obese, non-distended, diffusely tender with rebound and
guarding, peritoneal, guiaic negative, no stool in vault
Ext: no C/C/E

FAMILY HISTORY: Father with hypertension.  Mother died of pancreatic cancer.
History of alcohol abuse in sister and brother.

SOCIAL HISTORY: Lives with husband. 4 children. Denies tobacco or alcohol use.
Acute peptic ulcer of unspecified site with perforation, with obstruction,Systemic inflammatory response syndrome, unspecified,Unspecified peritonitis,Portal vein thrombosis,Fistula of intestine, excluding rectum and anus,Acidosis,Unspecified protein-calorie malnutrition,Other and unspecified postsurgical nonabsorption,Paralytic ileus,Iatrogenic pulmonary embolism and infarction,Cellulitis and abscess of trunk,Acute posthemorrhagic anemia,Other B-complex deficiencies,Iron deficiency anemia secondary to blood loss (chronic),Obesity, unspecified,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Bariatric surgery status,Unspecified essential hypertension,Diverticulosis of small intestine (without mention of hemorrhage),Infection with microorganisms without mention of resistance to multiple drugs,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Other chronic pain,Posttraumatic stress disorder,Other alteration of consciousness,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Panniculitis, other site,Candidiasis of skin and nails,Dysthymic disorder
Ac peptic ulc w perf-obs,SIRS, NOS,Peritonitis NOS,Portal vein thrombosis,Intestinal fistula,Acidosis,Protein-cal malnutr NOS,Intest postop nonabsorb,Paralytic ileus,Iatrogen pulm emb/infarc,Cellulitis of trunk,Ac posthemorrhag anemia,B-complex defic NEC,Chr blood loss anemia,Obesity NOS,Enterococcus group d,Bariatric surgery status,Hypertension NOS,Dvrtclo sml int w/o hmrg,Inf mcr rst ot drg nt ml,Migrne unsp wo ntrc mgrn,Chronic pain NEC,Posttraumatic stress dis,Other alter consciousnes,Abn react-surg proc NEC,Panniculitis, site NEC,Cutaneous candidiasis,Dysthymic disorder
Admission Date:  [**2183-1-9**]              Discharge Date:   [**2183-3-31**]

Date of Birth:  [**2149-3-31**]             Sex:   F

Service: SURGERY

Allergies:
Vicodin

Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Abdominal Pain

Major Surgical or Invasive Procedure:
Exploratory Laparotomy, repair of duodenal perforation and
placement of g -tube into the gastric remnant.

Multiple washouts of abdominal wound with vac placements.


History of Present Illness:
33 yo female with history of gastric bypass in [**2174**] complicated
by leak and several surgies for bowel obstructions with
malabsorption and chronic pain with multiple hospital admiisions
and discussion of reversal of bypass, presents from
OSH complaining of acute onset severe abdominal pain that
started at 5pm last evening, more on the right side and in the
groin.  She describes it as intractable, constant,
aching/stabbing pain. [**11-16**].  States very different from
baseline pain that is usually RUQ simliar to prior gallbladder
attacks, this is much more intense. loss of appetite and
diarrhea, no nausea/ vomiting. Last BM yesterday, no blood.  OSH
imaging showed free air in retroperitoneum, concerning for
perforation. Received Zosyn at OSH and 1L NS and 1L LR.

Past Medical History:
PMHx:
- Community-acquired pneumonia
- Gastric bypass [**2174**], multiple hospitalizations for abdominal
pain, nausea, vomiting
- Recurrent small bowel obstructions secondary to adhesions s/p
multiple adhesiolysis
- Hypertension
- Migraine headaches
- Post traumatic stress disorder
- Obesity
- Chronic pain with narcotic use
- Chronic anemia
- B12 deficiency
- Electrolyte disturbance secondary to dehydration from diarrhea
- poor access, has venous access port in Right chest, states has
been on TPN in past

Social History:
Lives with husband. 4 children. Denies tobacco or alcohol use.


Family History:
Father with hypertension.  Mother died of pancreatic cancer.
History of alcohol abuse in sister and brother.


Physical Exam:
PHYSICAL EXAM AT ADMISSION:
Gen: Ill-appearing women, in acute distress, diaphoretic, pale,
moaning in pain but conversing appropriately
HEENT: MM dry, no scleral icterus
Resp: Decreased breath sounds bases, distant
CV: Tachycardic
Abd: Obese, non-distended, diffusely tender with rebound and
guarding, peritoneal, guiaic negative, no stool in vault
Ext: no C/C/E


Pertinent Results:
LABS AT ADMISSION:
(OSH) WBC 14.3, Hg 12.5, Hct 39.6, Plt 476

([**Hospital1 18**])
K:3.8
Lactate:1.7
Hgb:13.8
CalcHCT:41

137| 109| 12  <138
3.9|  15| 0.7
ALT: 14 AP: 103 Tbili: 0.4
AST: 12   Lip: 70

(WBC 14)-> 4.6 >39.7<  456
N:80 Band:10 L:7 M:3 E:0 Bas:0 Hypochr: 1+ Anisocy: 1+ Plt-Est:
High

PT: 12.1  PTT: 20.8  INR: 1.0

IMAGING:
1) CT Abdomen: Significant for patchy infiltrate with left lung
base.  There is moderate perihepatic and perisplenic free fluid.

There is a large duodenal diverticulum on measuring 4.6 x 4.9 cm
(image 33, series 2).

2) CT Pelvis: Significant for diffuse small bowel dilatation
with
transition point in left lower quadrant.  There are two closely
apposed decompressed loops of small bowel suggesting a
closed-loop obstruction.  Distal loops of ileum are decompressed
compatible with high-grade obstruction.  Bowel loops within left
lower quadrant demonstrate mild wall thickening with a moderate
amount of free fluid in the pelvis.  Colon is decompressed.
Numerous colon diverticula.


Brief Hospital Course:
This is a 33 year old woman who is status post open Roux-en-Y
gastric bypass in [**2174**] with complicated postoperative course
including anastomotic leak as well as some element of
malnutrition. She was evidently recently under evaluation at
[**Hospital **] [**Hospital3 33807**] for possible revision of her
gastric bypass due to malnutrition.
She presented to an outside hospital with new onset abdominal
pain of approximately 5-hour duration. She was ultimately
transferred to [**Hospital1 18**] with 10 to 12 hour history of pain. Upon
presentation to [**Hospital1 18**] she had an acute abdomen with peritoneal
signs, acidemia and tachycardia.  The CT scan at the outside
hospital ([**Hospital 23925**] [**Hospital **] Hospital)demonstrated
retroperitoneal fluid consistent with abscess as well as free
air in the region of the duodenum, most likely consistent with a
perforated duodenal ulcer. She was resuscitated with intravenous
fluids, administered intravenous antibiotics and urgently taken
to the OR for an exploratory laparotomy.

Her intra-operative course ([**2183-1-8**] morning) was significant for
a perforated duodenal ulcer, which was repaired, closure of
internal hernia jejunojejunostomy, gastrostomy tube placement in
the gastric remnant, as well as drainage and wash out of the
retroperitoneal abcess. JP drains x2. Please refer to the
operative note for further details. Post-operatively, she was
taken to the ICU without pressor support.

On the evening of [**2183-1-8**], she was taken back to the OR for an
exploratory laporatomy because of continued tachycardia with
rising lactate. Ex lap was negative.

On the morning of [**1-10**], pt was showing improvement after
washout. LA returned to [**Location 213**]. Bladder pressure in teens
instead of 20's. PIP was 30's pre take back, with abd open and
with abd closed. Now PIP in 20s this AM. Still tachy HR 110-120
(but is it pt's baseline? on beta blockade) SBP 90's. Pt fluid
avid. 12L fluid positive.

Infectious Disease evaluated patient and in the setting of
intraabdominal peritoneal soiling [**3-11**] perforation emperic
treatment with Zosyn x 5-7 days was adequate. Pt was febrile
101.4 ([**1-10**]), likely sirs. Cxs from [**1-9**] were followed.

[**1-11**]: Minimized lasix gtt since auto-diuresing (~2L neg). Cont
w/ albumin. Fever to 101. Hct 22. Given 1u pRBC. LENI negative.
Morphine for pain control

[**1-12**] Confused started on zyprexa. Febrile blood and urine
cultures sent (neg)

[**Date range (1) 33808**]: Given 1 unit PRBC. Continued fevers to 102, new
onset right sided abdominal wall erythema/tenderness consisent
with cellulitis. CT showing intra-abdominal fluid collection
with necrotic tissue s/p retro exposure and I&D.  Confusion
resolved, patient lucid and oriented.

[**2183-1-19**] Given 1 unit PRBC. Due to CT scan showing fasciitis,
patient was brought to the Operating room for Right flank
incision, drainage and debridement of right retroperitoneum with
pulse lavage. The wound was packed with kerlex. The outer
dressing had to be changed frequently over the next several days
due to continued leakage of bilious material.

[**2183-1-20**] Given 1 unit PRBC

[**2183-1-21**] Patient brought to Operating room for exploration and
washout of retroperitoneal abscess. Her wound was repacked.
PICC line and TPN restarted.

[**2183-1-24**] Patient brought back to operating room for exploration
and washout of retroperitoneal abscess.  Kerlex noted to be
saturated with bilious material.  A wound vac was applied.
Patient given 1 unit PRBC. Wound vac output was nearly 1 liter
per day following this.

[**2183-1-27**]: Patient brought back to OR for exploration and washout
with vac change.  Still no visible fistula.

[**2183-2-2**]: patient brought back to OR for exploration and washout
with vac change

[**2183-2-5**]: abdominal CT with contrast showing markedly enlarged
intrabdominal abcess and fistula track from 2nd/3rd portion of
duodenum to flank.  1 JP drain was pulled (this drain had put
out only 5-10cc/day for weeks)

[**2183-2-6**]: went to IR for percutaneous drainage of intrabdominal
fluid collection with return of a large amount of pus.  Pig tail
catheter left in. Taken to OR for I+D and vac change.

[**2183-2-10**]:  patient brought back to OR for exploration and washout
with vac change.  LENIs of both lower extremities were negative
for clot formation.

[**2183-2-12**]:  patient underwent CT of abdomen that showed fluid
collection in lower abdominal wall and incidental finding of
thrombus of left renal vein.  Spoke with vascular team, and she
was started on heparin IV weight based dosing to reach
therapeutic levels of PTT.

[**2183-2-13**]:  patient underwent IR guided aspiration of fluid
collection in pelvis/lower abdomen and placement of pigtail
catheter.  She was continued on heparin IV.

[**2183-2-14**]:  patient brought back to OR for exploration and washout
with vac change.  Her heparin was stopped prior to leaving the
floor for the OR, and was restarted upon arriving back to the
floor.

[**2183-3-6**]:  patient went to IR for drainage of pelvic abscess.
Antibiotics adjusted per Infectious disease.

[**3-10**] and [**3-16**] Patient went to operating room for washout of R
flank abscess and placement of wound vac. device.

[**3-19**] Dermatology consulted for spreading red, raw rash on
buttocks. Started on fluconazole and fungal cream applied.

[**2183-3-20**] - Patient taken to the operating room for washout of R
flank abscess and placement of wound vac. device.

[**2183-3-26**] - Patient taken to the operating room for washout of R
flank abscess and removal of wound vac. Wet to dry dressings
applied.

[**2183-3-27**] - Wound care consult obtained. AMD dressings applied as
wound care suggest to R flank wound [**Hospital1 **].
[**2183-3-28**] - Infectious disease consulted regarding po antibiotics.

Problems at Discharge:
1. R flank wound abscess - continued dressing changes at home
with VNA to monitor. Oral Antibiotics per ID. Follow up with ID
to evaluate continued need for antibiotics.
2. LLL PE and thrombus of L renal vein - on Lovenox sq [**Hospital1 **] for
total 3 months. Follow up with Dr. [**Last Name (STitle) 1391**] made for one month
to assess continued need for lovenox.
3. Nutrition - On regular diet currently and tolerating well.
Has needed intravenous TPN and electrolytes in past. Will keep
existing port in at this time.

Recommended Follow up with Dr. [**Last Name (STitle) **] in 2 weeks, infectious
disease, vascular and primary care provider.


Medications on Admission:
- Atenolol 25 mg [**Hospital1 **]
- Percocet 1 tab tid
- Metoclopramide 10 mg 4x/day
- Fioricet 1-2 tabs prn
- Miralax and Dulcolax

Discharge Medications:
1. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
Disp:*30 Tablet(s)* Refills:*0*
2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Enoxaparin 120 mg/0.8 mL Syringe Sig: One Hundred-Ten (110)
mg Subcutaneous Q12H (every 12 hours).
Disp:*6600 mg* Refills:*2*
4. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release(s)* Refills:*0*
5. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for anxiety.
Disp:*30 Tablet(s)* Refills:*2*
6. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for pain with dressing changes.
Disp:*30 Tablet(s)* Refills:*0*
7. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: Two (2)
Tablet PO BID (2 times a day).
Disp:*120 Tablet(s)* Refills:*1*
8. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*30 Tablet(s)* Refills:*1*
9. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*60 Tablet(s)* Refills:*1*
10. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours).
Disp:*120 Tablet(s)* Refills:*1*
11. Medication and follow up
Please continue all antibiotics until you see Infectious disease
on [**4-23**]. Please eat yogurt daily. Please review all
medications with your primary care physician and please get any
new refills for narcotics from your primary care physician.
12. Multivitamin     Tablet Sig: One (1) Tablet PO twice a day.

13. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
14. commode
Please provide Commode for home use
15. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush: Please
flush portacath per policy.
Disp:*30 ML(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Hospital 33809**] Healthcare of [**Location (un) 33810**]

Discharge Diagnosis:
Primary Diagnosis: Duodenal Perforation


Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent


Discharge Instructions:
You are being discharged on medications to treat the pain from
your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST  refrain from such activities while
taking these medications.


Please call your doctor or return to the emergency room if you
have any of the following:

 * You experience new chest pain, pressure, squeezing or
 tightness.

* New or worsening cough or wheezing.

* If you are vomiting and cannot keep in fluids or your
 medications.

* You are getting dehydrated due to continued vomiting,
 diarrhea or other reasons. Signs of dehydration include dry
 mouth, rapid heartbeat or feeling dizzy or faint when standing.

* You see blood or dark/black material when you vomit or have a
 bowel movement.


* You have shaking chills, or a fever greater than 101.5 (F)
 degrees or 38(C) degrees.

* Any serious change in your symptoms, or any new symptoms that
 concern you.

* Please resume all regular home medications and take any new
meds
 as ordered.
Activity:
No heavy lifting of items [**11-21**] pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.


Followup Instructions:
1. Please follow up with Dr. [**Last Name (STitle) **] on [**4-18**] at 1:00 pm.
[**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Building [**Location (un) 470**]. Contact number
[**Telephone/Fax (1) 3201**] or [**Telephone/Fax (1) 305**].

2. Please follow up with Infectious Disease on Wednesday [**4-23**] at 11:30, Dr. [**First Name (STitle) **], [**Last Name (NamePattern1) 33811**]. Office number is [**Telephone/Fax (1) 457**].

3. Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**] (to follow up on
your L renal vein thrombosis and L pulmonary embolism) office
number = [**Telephone/Fax (1) 1393**], [**4-30**] Wednesday, 10:45. [**Doctor First Name **], suite 5C.

4. Please follow up with your primary care provider, [**Last Name (NamePattern4) **]. [**First Name (STitle) 3646**],
[**Telephone/Fax (1) 33812**] in one to two weeks to draw labs,  review your
current medications and current health status. Labwork needs to
be done weekly and faxed to Infectious Disease at [**Telephone/Fax (1) 6147**]
(Labwork CBC w/diff, bun, cre, lft's.)



Completed by:[**2183-3-31**]
{'Acute peptic ulcer of unspecified site with perforation, with obstruction,Systemic inflammatory response syndrome, unspecified,Unspecified peritonitis,Portal vein thrombosis,Fistula of intestine, excluding rectum and anus,Acidosis,Unspecified protein-calorie malnutrition,Other and unspecified postsurgical nonabsorption,Paralytic ileus,Iatrogenic pulmonary embolism and infarction,Cellulitis and abscess of trunk,Acute posthemorrhagic anemia,Other B-complex deficiencies,Iron deficiency anemia secondary to blood loss (chronic),Obesity, unspecified,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Bariatric surgery status,Unspecified essential hypertension,Diverticulosis of small intestine (without mention of hemorrhage),Infection with microorganisms without mention of resistance to multiple drugs,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Other chronic pain,Posttraumatic stress disorder,Other alteration of consciousness,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Panniculitis, other site,Candidiasis of skin and nails,Dysthymic disorder'}


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

PRESENT ILLNESS: 33 yo female with history of gastric bypass in [**2174**] complicated
by leak and several surgies for bowel obstructions with
malabsorption and chronic pain with multiple hospital admiisions
and discussion of reversal of bypass, presents from
OSH complaining of acute onset severe abdominal pain that
started at 5pm last evening, more on the right side and in the
groin.  She describes it as intractable, constant,
aching/stabbing pain. [**11-16**].  States very different from
baseline pain that is usually RUQ simliar to prior gallbladder
attacks, this is much more intense. loss of appetite and
diarrhea, no nausea/ vomiting. Last BM yesterday, no blood.  OSH
imaging showed free air in retroperitoneum, concerning for
perforation. Received Zosyn at OSH and 1L NS and 1L LR.

MEDICAL HISTORY: PMHx:
- Community-acquired pneumonia
- Gastric bypass [**2174**], multiple hospitalizations for abdominal
pain, nausea, vomiting
- Recurrent small bowel obstructions secondary to adhesions s/p
multiple adhesiolysis
- Hypertension
- Migraine headaches
- Post traumatic stress disorder
- Obesity
- Chronic pain with narcotic use
- Chronic anemia
- B12 deficiency
- Electrolyte disturbance secondary to dehydration from diarrhea
- poor access, has venous access port in Right chest, states has
been on TPN in past

MEDICATION ON ADMISSION: - Atenolol 25 mg [**Hospital1 **]
- Percocet 1 tab tid
- Metoclopramide 10 mg 4x/day
- Fioricet 1-2 tabs prn
- Miralax and Dulcolax

ALLERGIES: Vicodin

PHYSICAL EXAM: PHYSICAL EXAM AT ADMISSION:
Gen: Ill-appearing women, in acute distress, diaphoretic, pale,
moaning in pain but conversing appropriately
HEENT: MM dry, no scleral icterus
Resp: Decreased breath sounds bases, distant
CV: Tachycardic
Abd: Obese, non-distended, diffusely tender with rebound and
guarding, peritoneal, guiaic negative, no stool in vault
Ext: no C/C/E

FAMILY HISTORY: Father with hypertension.  Mother died of pancreatic cancer.
History of alcohol abuse in sister and brother.

SOCIAL HISTORY: Lives with husband. 4 children. Denies tobacco or alcohol use. 

### Response:
{'Acute peptic ulcer of unspecified site with perforation, with obstruction,Systemic inflammatory response syndrome, unspecified,Unspecified peritonitis,Portal vein thrombosis,Fistula of intestine, excluding rectum and anus,Acidosis,Unspecified protein-calorie malnutrition,Other and unspecified postsurgical nonabsorption,Paralytic ileus,Iatrogenic pulmonary embolism and infarction,Cellulitis and abscess of trunk,Acute posthemorrhagic anemia,Other B-complex deficiencies,Iron deficiency anemia secondary to blood loss (chronic),Obesity, unspecified,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Bariatric surgery status,Unspecified essential hypertension,Diverticulosis of small intestine (without mention of hemorrhage),Infection with microorganisms without mention of resistance to multiple drugs,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Other chronic pain,Posttraumatic stress disorder,Other alteration of consciousness,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Panniculitis, other site,Candidiasis of skin and nails,Dysthymic disorder'}
