CHIEF COMPLAINT: morbid obesity

PRESENT ILLNESS: [**Known firstname 87221**] has class III extreme morbid obesity with BMI of 60.7.
Previous weight loss efforts have included Weight Watchers,
Slim-Fast, prescription [**Street Address(1) 87222**]/PCP [**Name Initial (PRE) 51433**]. She has
been struggling with weight her entire life and  cites as
contributors large portions, late night eating, too many
carbohydrates and saturated fats, stress and lack of exercise.
She denies history of eating disorders - no anorexia, bulimia,
diuretic or laxative abuse.  Has history of depression but has
not been followed by a therapist nor has she been hospitalized
for mental health issues. She was once on psychotropic
medication (citalopram), but is no longer.

MEDICAL HISTORY: HTN, migraine, OSA(recommended CPAP), fatty liver,
cholelithiasis

MEDICATION ON ADMISSION: chlorthalidone 25'

ALLERGIES: Penicillins

PHYSICAL EXAM: Admission Physical Exam:
BP 129/79, pulse 73, respirations 18 and O2 saturation 100% on
room air.
GEN: casually dressed, pleasant and in no distress.
SKIN: warm, dry with no rashes.
HEENT: Sclerae were anicteric, conjunctiva clear except for mild
hyperemia of the right lower conjunctiva, pupils were equal
round and reactive to light, fundi noted sharp optic disks
without hemorrhage, mucous membranes were moist,
tongue was pink and the oropharynx was without exudates or
hyperemia. Trachea was in the midline and the neck was large but
supple with no adenopathy, thyromegaly or carotid bruits.
CHEST: CTAB, symmetric, good air movement
CV: distant but present S1 and S2 heart sounds, regular rate and
rhythm, no murmurs, rubs or gallops.
ABD: very obese, soft and non-tender, non-distended with bowel
sounds activity and no appreciable masses or hernias, no
incision scars. No spinal tenderness or flank pain.
EXT: Lower extremities 1+ edema to the mid-shin of the left
lower extremity, very mild venous insufficiency, no clubbing and
perfusion was good.  There was no joint swelling or inflammation
of the joints.
NEURO: There were no gross neurological deficits and gait was
normal.

FAMILY HISTORY: Father deceased age 72 with cancer, diabetes and hyperlipidemia.
Mother living age 62 with heart disease, hyperlipidemia, DM, OA
and obesity.  Sister in her 40s also with obesity and underwent
Roux-en-Y gastric bypass.

SOCIAL HISTORY: Denies tobacco or recreational drug usage, does drink about 8
alcoholic beverages weekly and has both carbonated and
caffeinated drinks. Works as a day care teacher and she is
single living with her mother age 62 and she has no children.
Morbid obesity,Cardiac complications, not elsewhere classified,Other chronic nonalcoholic liver disease,Body Mass Index 60.0-69.9, adult,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction,Obstructive sleep apnea (adult)(pediatric),Other abnormal glucose,Tachycardia, unspecified,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation
Morbid obesity,Surg compl-heart,Chronic liver dis NEC,BMI 60.0-69.9, adult,Cholelithiasis NOS,Obstructive sleep apnea,Abnormal glucose NEC,Tachycardia NOS,Abn react-anastom/graft
Admission Date:  [**2101-5-17**]              Discharge Date:   [**2101-5-22**]

Date of Birth:  [**2072-12-18**]             Sex:   F

Service: SURGERY

Allergies:
Penicillins

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

Major Surgical or Invasive Procedure:
[**2101-5-17**]
1. Open cholecystectomy.
2. Open Roux-en-Y gastric bypass.


History of Present Illness:
[**Known firstname 87221**] has class III extreme morbid obesity with BMI of 60.7.
Previous weight loss efforts have included Weight Watchers,
Slim-Fast, prescription [**Street Address(1) 87222**]/PCP [**Name Initial (PRE) 51433**]. She has
been struggling with weight her entire life and  cites as
contributors large portions, late night eating, too many
carbohydrates and saturated fats, stress and lack of exercise.
She denies history of eating disorders - no anorexia, bulimia,
diuretic or laxative abuse.  Has history of depression but has
not been followed by a therapist nor has she been hospitalized
for mental health issues. She was once on psychotropic
medication (citalopram), but is no longer.


Past Medical History:
HTN, migraine, OSA(recommended CPAP), fatty liver,
cholelithiasis


Social History:
Denies tobacco or recreational drug usage, does drink about 8
alcoholic beverages weekly and has both carbonated and
caffeinated drinks. Works as a day care teacher and she is
single living with her mother age 62 and she has no children.

Family History:
Father deceased age 72 with cancer, diabetes and hyperlipidemia.
Mother living age 62 with heart disease, hyperlipidemia, DM, OA
and obesity.  Sister in her 40s also with obesity and underwent
Roux-en-Y gastric bypass.

Physical Exam:
Admission Physical Exam:
BP 129/79, pulse 73, respirations 18 and O2 saturation 100% on
room air.
GEN: casually dressed, pleasant and in no distress.
SKIN: warm, dry with no rashes.
HEENT: Sclerae were anicteric, conjunctiva clear except for mild
hyperemia of the right lower conjunctiva, pupils were equal
round and reactive to light, fundi noted sharp optic disks
without hemorrhage, mucous membranes were moist,
tongue was pink and the oropharynx was without exudates or
hyperemia. Trachea was in the midline and the neck was large but
supple with no adenopathy, thyromegaly or carotid bruits.
CHEST: CTAB, symmetric, good air movement
CV: distant but present S1 and S2 heart sounds, regular rate and
rhythm, no murmurs, rubs or gallops.
ABD: very obese, soft and non-tender, non-distended with bowel
sounds activity and no appreciable masses or hernias, no
incision scars. No spinal tenderness or flank pain.
EXT: Lower extremities 1+ edema to the mid-shin of the left
lower extremity, very mild venous insufficiency, no clubbing and
perfusion was good.  There was no joint swelling or inflammation
of the joints.
NEURO: There were no gross neurological deficits and gait was
normal.

Pertinent Results:
Post-operative: [**2101-5-17**] 03:27PM
HCT-45.7

Discharge Labs: [**2101-5-21**] 03:06AM
WBC-7.2  Hgb-11.4*  Hct-34.1*  Plt-210
Na-136 K-3.6 Cl-101 HCO3-28 UreaN-8 Creat-0.7 Glucose-109*
Calcium-8.3* Phos-3.0 Mg-2.0

[**2101-5-19**] - CTA Chest
No large central PE. Evaluation of segmental and subsegmental
branches is limited.

[**2101-5-19**] - CT Abdomen
The patient is status post recent gastric bypass surgery. No
contrast is noted in the peritoneal cavity. The liver, spleen,
both adrenals, both kidneys, pancreas are unremarkable. The
patient is status post cholecystectomy. A drain is noted in the
right upper quadrant appropriately. The small bowel loops are
mildly prominent, likely representing ileus. The large bowel is
unremarkable. No free fluid or air noted. No evidence of leak.

[**2101-5-19**] - UGI
Approximately 20 cc of Optiray contrast was administered orally
which passed freely into the gastric pouch and proximal loops of
bowel without evidence of a leak. Subsequently, thin barium was
orally administered, which demonstrated no further evidence of a
leak.


Brief Hospital Course:
Ms [**Known firstname 87221**] was evaluated by anaesthesia and taken to the
operating room for open cholecystectomy and Roux-en-Y gastric
bypass. There were no adverse events in the operating room;
please see Dr[**Name (NI) 78793**] operative note for details. She was
extubated in the OR, taken to the PACU until stable, then
transferred to the [**Hospital1 **] for observation. She remained on the
surgical [**Hospital1 **] for 2 days then was transferred to the ICU given
her persistent tachycardia and concern for anastamotic leak. She
was transferred back to the floor 2 days later and was
discharged on POD 5.

Neuro: She was alert and oriented throughout her
hospitalization. Her pain was initially managed with an epidural
which was removed on post-operative day 4. She was transitioned
to low dose oral Roxicet but this appeared to make her
somnolent, so she was provided liquid acetaminophen as
monotherapy for pain relief.

CV: She was persistently hypertensive and tachycardic beginning
immediately post-operatively. This was felt to be due primarily
to fluid deficit, given her post-op hemoconcentration (hct 45).
She was refractory to hydralazine and metoprolol IV. She
responded partially to fluid boluses, but not until starting a
labetolol drip in the ICU were we able to control her heartrate
and blood pressure. After weaning her off the drip, her
hemodynamics sustained in a normal range using only her home
dose of chlorthalidone. Serial EKGs were performed for
intermittent dull epigastric pain; these showed no changes from
prior.

Pulmonary: She was administered CPAP during some of her nights
while admitted. She did not tolerate this well, and preferred to
sleep without it. She had mild oxygen demand POD [**3-17**] and given
persisent tachycardia, she was evaluated by CTA chest to
rule-out pulmonary embolus. The study was negative albeit
limited by body habitus. Good pulmonary toilet, early ambulation
and incentive spirometry were encouraged throughout
hospitalization.

GI/GU/FEN: She was initially kept NPO until an upper GI study,
methylene blue test, and CT abdomen were performed on
post-operative day 2. All were negative for leak, therefore, her
diet was advanced to a bariatric stage I. She tolerated this for
over 24 hours before being advanced to Stage II. After a day of
Stage II, she was put on Stage III which was well tolerated. Her
intake and output were closely monitored.
The JP bulb was removed on post op day 5 immediately prior to
discharge.

ID: Her fever curves and WBC count were closely watched for
signs of infection. Perioperative antibiotics were
adminitstered; none other were warranted.

HEME: Her blood counts were closely watched for signs of
bleeding, of which there were none. Her hematocrit returned back
down to baseline following resuscitation.

Prophylaxis: She received subcutaneous heparin and venodyne
boots were used during this stay; she was encouraged to ambulate
as early as possible. She was ambulating independently by POD 4.


At the time of discharge, she was doing well, afebrile with
stable vital signs. She was tolerating a stage 3 diet,
ambulating, voiding without assistance, and pain was well
controlled. She received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.

Medications on Admission:
chlorthalidone 25'

Discharge Medications:
1. acetaminophen 650 mg/20.3 mL Solution Sig: 20-30 mL PO Q6H
(every 6 hours) as needed for Pain / Fever: Maximum 120mL per
day.
Disp:*1000 mL* Refills:*0*
2. Colace 60 mg/15 mL Syrup Sig: Two (2) tsp PO twice a day:
hold for loose stool.
Disp:*600 mL* Refills:*0*
3. pediatric multivitamin-iron     Tablet, Chewable Sig: One (1)
Tablet, Chewable PO once a day.
4. Zantac 15 mg/mL Syrup Sig: Ten (10) mL PO twice a day.
Disp:*600 mL* Refills:*0*
5. chlorthalidone 25 mg Tablet Sig: One (1) Tablet PO once a
day: Please crush and mix with liquid.


Discharge Disposition:
Home

Discharge Diagnosis:
1. Obesity, body mass index of 64, weight of 394 pounds.
2. Obstructive sleep apnea.
3. Fatty liver.
4. Gallstones.
5. Borderline type 2 diabetes.


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


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 on 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 your home medications, CRUSH ALL PILLS.
You will be starting some new medications:
1.  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.
2. You should begin taking a chewable complete multivitamin with
minerals. 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 should take a stool softener, Colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
6. You must not use NSAIDS (non-steroidal anti-inflammatory
drugs) Examples are Ibuprofen, Motrin, Aleve, Nuprin and
Naproxen. These agents will cause bleeding and ulcers in your
digestive system.

Activity:
No heavy lifting of items [**11-26**] 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.
Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.


Followup Instructions:
[**Hospital 1560**] Clinic, Surgical Subspecialties, [**Hospital Ward Name 23**] Building
[**Hospital1 **] [**Last Name (Titles) 516**]
[**2101-6-1**] 11:00   Dr. [**Last Name (STitle) **],MD  [**Telephone/Fax (1) 305**]
[**2101-6-1**] 11:30   [**First Name8 (NamePattern2) **] [**Doctor Last Name **],RD,LDN  [**Telephone/Fax (1) 305**]
{'Morbid obesity,Cardiac complications, not elsewhere classified,Other chronic nonalcoholic liver disease,Body Mass Index 60.0-69.9, adult,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction,Obstructive sleep apnea (adult)(pediatric),Other abnormal glucose,Tachycardia, unspecified,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation'}


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: [**Known firstname 87221**] has class III extreme morbid obesity with BMI of 60.7.
Previous weight loss efforts have included Weight Watchers,
Slim-Fast, prescription [**Street Address(1) 87222**]/PCP [**Name Initial (PRE) 51433**]. She has
been struggling with weight her entire life and  cites as
contributors large portions, late night eating, too many
carbohydrates and saturated fats, stress and lack of exercise.
She denies history of eating disorders - no anorexia, bulimia,
diuretic or laxative abuse.  Has history of depression but has
not been followed by a therapist nor has she been hospitalized
for mental health issues. She was once on psychotropic
medication (citalopram), but is no longer.

MEDICAL HISTORY: HTN, migraine, OSA(recommended CPAP), fatty liver,
cholelithiasis

MEDICATION ON ADMISSION: chlorthalidone 25'

ALLERGIES: Penicillins

PHYSICAL EXAM: Admission Physical Exam:
BP 129/79, pulse 73, respirations 18 and O2 saturation 100% on
room air.
GEN: casually dressed, pleasant and in no distress.
SKIN: warm, dry with no rashes.
HEENT: Sclerae were anicteric, conjunctiva clear except for mild
hyperemia of the right lower conjunctiva, pupils were equal
round and reactive to light, fundi noted sharp optic disks
without hemorrhage, mucous membranes were moist,
tongue was pink and the oropharynx was without exudates or
hyperemia. Trachea was in the midline and the neck was large but
supple with no adenopathy, thyromegaly or carotid bruits.
CHEST: CTAB, symmetric, good air movement
CV: distant but present S1 and S2 heart sounds, regular rate and
rhythm, no murmurs, rubs or gallops.
ABD: very obese, soft and non-tender, non-distended with bowel
sounds activity and no appreciable masses or hernias, no
incision scars. No spinal tenderness or flank pain.
EXT: Lower extremities 1+ edema to the mid-shin of the left
lower extremity, very mild venous insufficiency, no clubbing and
perfusion was good.  There was no joint swelling or inflammation
of the joints.
NEURO: There were no gross neurological deficits and gait was
normal.

FAMILY HISTORY: Father deceased age 72 with cancer, diabetes and hyperlipidemia.
Mother living age 62 with heart disease, hyperlipidemia, DM, OA
and obesity.  Sister in her 40s also with obesity and underwent
Roux-en-Y gastric bypass.

SOCIAL HISTORY: Denies tobacco or recreational drug usage, does drink about 8
alcoholic beverages weekly and has both carbonated and
caffeinated drinks. Works as a day care teacher and she is
single living with her mother age 62 and she has no children. 

### Response:
{'Morbid obesity,Cardiac complications, not elsewhere classified,Other chronic nonalcoholic liver disease,Body Mass Index 60.0-69.9, adult,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction,Obstructive sleep apnea (adult)(pediatric),Other abnormal glucose,Tachycardia, unspecified,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation'}
