CHIEF COMPLAINT: Nausea, vomiting, and abdominal pain.

PRESENT ILLNESS: A 79-year-old female with 36
hours of abdominal pain, nausea, and emesis.  She is noted to
have recurring abdominal pain over the past three months with
36 hours of severe, unremitting, colicky band like upper
abdominal pain, but at times is sharp that is associated with
nausea and emesis of more than 10x, nonbloody, nonbilious,
brownish in color, no fevers, no chills, although she has
felt shaky after multiple bouts of emesis today.  She does
not have any dysuria.  Last bowel movement was today, normal
caliber and color.  Normal color of urine.

MEDICAL HISTORY: 1. Coronary artery disease as described above.
2. Peripheral vascular disease as described above.
3. Carotid stenosis.
4. Diverticulosis.
5. Hypercholesterolemia.
6. Esophagitis status post EGD in [**10-9**] showing mild
esophagitis, antral ulcers, and duodenitis.  Colonoscopy
shows grade 2 small internal hemorrhoids, diverticulosis, and
the patient had an echocardiogram with an EF of 35%, 3+
mitral regurgitation.

MEDICATION ON ADMISSION: 1. Lisinopril 5 a day.
2. Toprol 12.5 q.d.
3. Lipitor 40 q.d.
4. Protonix 40 q.d.
5. Hydrochlorothiazide/triamterene 37.5/2.5 [**2-8**] tablet
Monday, Wednesday, Friday.
6. Desipramine 10 mg with meals.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection),Urinary tract infection, site not specified,Unspecified septicemia,Severe sepsis,Pneumonia, organism unspecified,Subendocardial infarction, initial episode of care,Acute kidney failure, unspecified,Congestive heart failure, unspecified
Intestinal adhes w obstr,Urin tract infection NOS,Septicemia NOS,Severe sepsis,Pneumonia, organism NOS,Subendo infarct, initial,Acute kidney failure NOS,CHF NOS
Admission Date:  [**2177-1-9**]     Discharge Date:  [**2177-1-11**]


Service:  Green Surgery

ADMISSION DIAGNOSIS:  Partial small bowel obstruction.

SECONDARY DIAGNOSES:
1. Coronary artery disease status post coronary artery bypass
graft x3, last in [**2170**].
2. Myocardial infarction.
3. History of congestive heart failure status post Bovine
aortic valve replacement.
4. Peripheral vascular disease status post aortobifemoral
bypass.
5. Right femoral-popliteal bypass.
6. Status post bilateral carotid endarterectomies.
7. Hypertension.
8. Diverticulosis.
9. Hypercholesterolemia.
10. Chronic renal insufficiency.
11. History of delirium.
12. History of chronic bilirubin elevation.

CHIEF COMPLAINT:  Nausea, vomiting, and abdominal pain.

HISTORY OF PRESENT ILLNESS:  A 79-year-old female with 36
hours of abdominal pain, nausea, and emesis.  She is noted to
have recurring abdominal pain over the past three months with
36 hours of severe, unremitting, colicky band like upper
abdominal pain, but at times is sharp that is associated with
nausea and emesis of more than 10x, nonbloody, nonbilious,
brownish in color, no fevers, no chills, although she has
felt shaky after multiple bouts of emesis today.  She does
not have any dysuria.  Last bowel movement was today, normal
caliber and color.  Normal color of urine.

No change in her usual problems with shortness of breath and
chest pain which improves with sublingual nitroglycerin
tablets.  There has been weight loss over the past few months
and she feels eating can precipitate her abdominal pain.  She
avoids fatty foods because of her history of coronary artery
disease and peripheral vascular disease.  She has also had no
bloody bowel movements.

PAST MEDICAL HISTORY:
1. Coronary artery disease as described above.
2. Peripheral vascular disease as described above.
3. Carotid stenosis.
4. Diverticulosis.
5. Hypercholesterolemia.
6. Esophagitis status post EGD in [**10-9**] showing mild
esophagitis, antral ulcers, and duodenitis.  Colonoscopy
shows grade 2 small internal hemorrhoids, diverticulosis, and
the patient had an echocardiogram with an EF of 35%, 3+
mitral regurgitation.

PAST SURGICAL HISTORY:
1. Aortobifemoral bypass, status post redo as well.
2. Right fem-[**Doctor Last Name **] bypass.
3. Carotid endarterectomy.
4. Left second toe amputation.
5. CABG x3.
6. AVR.

MEDICATIONS ON ADMISSION:
1. Lisinopril 5 a day.
2. Toprol 12.5 q.d.
3. Lipitor 40 q.d.
4. Protonix 40 q.d.
5. Hydrochlorothiazide/triamterene 37.5/2.5 [**2-8**] tablet
Monday, Wednesday, Friday.
6. Desipramine 10 mg with meals.

ALLERGIES:  No known drug allergies.

PHYSICAL EXAMINATION:  Temperature 97.1, pulse 84, blood
pressure 157/69, respirations 16, saturations of 100% on room
air.  Appears uncomfortable with intermittent paroxysms of
pain.  Chest is clear bilaterally.  Heart examination reveals
a systolic murmur, regular S1, S2.  Abdomen shows a
well-healed surgical scar with no hernias palpable.  There is
no [**Doctor Last Name 515**] sign, although she has some mild right upper
quadrant abdominal pain.  Extremities warm.  Rectal done by
ED staff is negative.  Peripheral pulses:  The patient has 1+
palpable pulses on her right.  Femorals are 2+.  Dorsalis
pedis 1+ biphasic, PT is 1+ monophasic.  Left side femoral is
2+, dorsalis pedis and PT are not dopplerable and not
palpable.

ADMISSION LABORATORIES:  White count 7.9, hematocrit 39.0,
platelets 182.  Chemistry shows a sodium of 142, potassium
5.3, chloride 102, bicarb 26, BUN 38, creatinine 1.7, glucose
127.

EKG shows sinus rhythm without ST changes, left ventricular
hypertrophy.

Ultrasound shows cholelithiasis without evidence of
cholecystitis.  Common bile duct is 3 mm in diameter.  No
wall edema and no free fluid, no [**Doctor Last Name 515**] sign.

CT scan shows dilated loops of small bowel to the distal
jejunum and proximal ileum with collapsed loops of small
intestine distally and collapsed colon.  No evidence of
hernia or masses, no free fluid.

ASSESSMENT:  A 79-year-old female with multiple medical
issues and partial small bowel obstruction.

BRIEF HOSPITAL COURSE:  The patient was admitted to the
floor.  A nasogastric tube was placed.  She was placed on IV
fluids.  Patient remained afebrile with stable vital signs on
the floor and her urine output was chronically low between
20-40 cc an hour.  She responded appropriately to fluid
boluses.  She is kept on IV fluids throughout her stay until
the day of discharge.  Eventually, her abdominal pain and
distention was resolved on hospital day two and the
nasogastric tube was discontinued.  She tolerated a regular
diet prior to discharge, and had no nausea or vomiting.
Patient also had her Foley D/C'd without events.

While in-house, patient's gastroenterologist Dr. [**First Name (STitle) 2643**] was
consulted.  They recommended an antimitochondrial antibody
and lead levels be taken due to the patient's chronically
elevated bilirubin.  These laboratories will be followed up
by the [**Hospital **] Clinic.  They also suggested for her to get an
ERCP, which will be done as an outpatient.

DISCHARGE INSTRUCTIONS:  Patient will be discharged to home
with a regular diet.  She will follow up with Dr. [**Last Name (STitle) **] in
four weeks.  She will follow up with Dr. [**First Name (STitle) 2643**] in [**3-11**] weeks.
She will also get outpatient ERCP and have these laboratories
followed up with her gastroenterologist.

ADDENDUM:  The patient developed abdominal distention once again
and was not discharge... see next dictation for remainder of
hospital course.

                          [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 28129**], M.D.  [**MD Number(1) **]

Dictated By:[**Last Name (NamePattern1) **]

MEDQUIST36

D:  [**2177-1-11**]  07:43
T:  [**2177-1-11**]  08:36
JOB#:  [**Job Number 102573**]




Admission Date:  [**2177-1-9**]       Discharge Date: [**2177-2-6**]


Service:  [**Doctor Last Name **]-IM

This is an interim discharge summary with date of discharge
to be determined pending clinical course.

CHIEF COMPLAINT:   Abdominal pain, nausea, vomiting.

HISTORY OF PRESENT ILLNESS:   This 79 year old woman with a
history of coronary artery disease status post coronary
artery bypass graft and aortic valve replacement and history
of diverticulosis presents to the Emergency Department at
[**Hospital1 69**] with complaints of
abdominal pain as well as nausea and vomiting.  She reports
that she has been having vague abdominal complaints with
periodic vomiting for several months.  Over this time, she
has experienced an approximately fifteen pounds of weight
loss.

She had sudden worsening of her symptoms since last night
including periumbilical pain with no radiation, multiple
episodes of emesis (over 10 since last night).  She reports
that her emesis is non-bloody and non-bilious.  She is having
no diarrhea or constipation, no bright red blood per rectum
and no melena.  No fever or chills.  She had two normal bowel
movements yesterday.

She reports that she has had a longstanding history of anemia
that has been worked up but no source found.  In her previous
work-up she has had a negative esophagogastroduodenoscopy,
negative colonoscopy and negative abdominal CT scan.

PAST MEDICAL HISTORY:
1.  She has a history of coronary artery disease status post
stent placement during a [**2168**] catheterization.
2.  She is status post second coronary artery bypass graft,
the first performed in [**2162**]; the second a three vessel re-do
performed in [**2170**].  She had an aortic valve replacement for
bicuspid valve performed during that second coronary artery
bypass graft.
3.  History of hypertension.
4.  History of congestive heart failure with [**Month (only) 958**]
echocardiogram showing an ejection fraction of 30 to 40%.
5.  History of hypercholesterolemia.
6   History of diverticulosis.
7.  Anemia.
8.  Three to four plus mitral regurgitation and tricuspid
regurgitation.

PAST SURGICAL HISTORY:
1.  As mentioned, including the coronary artery bypass graft
and aortic valve replacement.
2.  She has a history of carotid stenosis status post a left
carotid endarterectomy in [**2168**] and a right carotid
endarterectomy in [**2162**].
3.  Aorta-bifemoral bypass in [**2155**].
4.  Left second toe amputation in [**2174**].

HOME MEDICATIONS:
1.  Lisinopril 5 q. day.
2.  Toprol 12.5 q. day.
3.  Lipitor 40 q. day.
4.  Isordil 30.
5.  Protonix 40 q. day.

ALLERGIES:   She has two sensitivities noted, including itch
in response to morphine and epistaxis in response to aspirin.


PHYSICAL EXAMINATION:   Her vital signs on presentation to
the Emergency Department on the [**2-9**] were
temperature of 97.1 F.; heart rate of 84; blood pressure of
157/69; respiratory rate of 16 and 100% on room air.  She was
an elderly woman in no apparent distress, noted to be alert
and oriented times three.  She has dry mucous membranes but a
clear oropharynx.  She had jugular venous distention noted at
8 to 9.  Her heart was a regular rate and rhythm with no
murmurs noted on initial examination.  She had occasional
crackles at her bases.  The patient was unable to lie flat
secondary to active nausea and vomiting.  She had some slight
right upper quadrant tenderness noted on examination.  Her
rectal examination was guaiac negative.  She had no guarding
or rebound at that time.

LABORATORY:  Initial labs showed her CBC with a white blood
cell count of 7.9, hematocrit of 39, and platelet count of
182.

Her Chem-7 was a sodium of 142, potassium of 5.3, chloride of
102, carbon dioxide of 26, BUN of 38; creatinine of 1.7 and
glucose of 127.  She had an ALT of 20, AST of 36, alkaline
phosphatase of 157 and LDH of 420, total bilirubin of 2.1.

An EKG was performed which showed normal sinus rhythm at 80
with some left ventricular hypertrophy noted but no ST
changes.

An abdominal CT scan was performed at the request of the
Emergency Department staff on the 4th which showed a mid to
distal small bowel obstruction.  No mass lesion was
identified by imaging.  There was no evidence of free fluid
or free air.  Also, there was evidence the previous
aorta-bifemoral bypass. There was a left adnexal cystic
lesion that appeared unchanged with prior study.  Sigmoid
diverticulosis was noted without any evidence of
diverticulitises and there was evidence of cholelithiasis
without cholecystitis.

A right upper quadrant ultrasound was also acquired while the
patient was in the Emergency Department which also showed
cholelithiasis without cholecystitis.

HOSPITAL COURSE:   The patient was admitted to the Surgical
Service for management of a partial high grade small bowel
obstruction.  She was made n.p.o. for bowel rest and an
nasogastric tube was put down.  She was followed by Green
Surgery as well as the Gastrointestinal Service.

The patient was tried on a p.o. diet a few days later but did
not tolerate liquids and had increasing distention, nausea
and vomiting despite passing flatus.   Small bowel follow
through performed revealed dilated loops of small bowel and
slow transit of contrast.

The most likely etiology of her high grade partial small
bowel obstruction was assumed to be adhesions from prior
abdominal surgeries.

She was given total parenteral nutrition for nutrition and
was maintained with an nasogastric tube for decompression.
The patient was having bowel movements and appeared to be
improving over the next several days.

On the evening of the 14th, into the morning of the [**2-20**], the patient decompensated on the floor and was
found to be hypotensive into the systolic 70s to 60s,
tachycardic with heart rates above 100, and tachypneic into
the high 20s.

An EKG performed showed new ST elevations in V2 and V3 and
although CK and CK MB were normal, her peak troponin was
0.64. She was evaluated by Cardiology as well as the Coronary
Care Unit team and was transferred to the Trauma Surgical
Intensive Care Unit for further monitoring and treatment.
She had no chest pain or shortness of breath heart rate this
episode.

Cardiology felt after evaluating the patient that the source
of her hypotension was not cardiac in origin.  However, given
her past cardiac history she was started on a heparin bolus
and GTT.  She was also given low dose ASA.  She was also
found to have a positive urine culture at that time with pan
sensitive enterococcus and there was some question as to
whether or not urosepsis might have contributed to her
episode of hypotension that had her moved to the Unit.

A shock assessment with a Swan-Ganz was attempted while she
was in the unit, but interpretation of the numbers was made
difficult by her large mitral regurgitation and tricuspid
regurgitation.  The team at that time felt that infection was
a more likely cause of her shock than cardiogenic.

She was transferred to the Medical Intensive Care Unit on the
[**2-21**] and initially placed on Levofloxacin,
Flagyl, Vancomycin.  She was pan cultured and her PICC line
was discontinued and the tips sent for culture.

Her heparin course was discontinued and she was placed on an
ACE inhibitor.

Once the sensitivities returned on the enterococcus, she was
maintained on Levaquin to cover her urinary tract infection
as well as this question of possible pulmonary infiltrate
seen on the chest x-ray.

From an Endocrine perspective, she had a cortisol stimulation
in the Intensive Care Unit which showed adrenal insufficiency
so she was put on a seven day replacement course of
hydrocortisone and flutocortisone.  She was taken off total
parenteral nutrition while in the Medical Intensive Care Unit
as her small bowel obstruction seemed to be resolved and she
was tolerating p.o.  She clinically improved over several
days in the Medical Intensive Care Unit. It was decided on
the 19th that she was well enough to be transferred to the
floor.

During the end of her Medical Intensive Care Unit stay, there
was a family meeting between the caretakers and her daughter
[**Name (NI) **], her power of attorney, as well as other family members,
during which it was decided to make her a "Do Not
Resuscitate", "Do Not Intubate".

Over the first several days of her stay on the floor, the
patient was tolerating p.o. and feeling well with no
abdominal pain and no nausea or vomiting.  She had
significant volume overload from her stay in the Intensive
Care Unit and the resuscitation that she received there.
This was problem[**Name (NI) 115**] secondary to bad mitral regurgitation
and tricuspid regurgitation as well as poor ejection fraction
of 20%.  Aspirin was declined by the patient secondary to the
side effect of epistaxis.  However, other cardiac medicines
were titrated up in order to give her good blood pressure and
rate control as well as to attempt mild diuresis to remove
some of the fluid given in the unit.

Her beta blocker was restarted; her ACE inhibitor was
increased gradually and spironolactone was added.  Also, a
formal congestive heart failure consultation was called on
the patient in order to optimize medication regimens as well
as hook her into care upon discharge.

On the [**3-3**], the patient's white blood cell count
went from 13 to 23 necessitating a search for possible source
of infection.  A chest x-ray was ordered which showed no
evidence of pneumonia and improved congestive heart failure
pattern.  A KUB was ordered which was consistent with partial
small bowel obstruction with scattered fluid levels but no
free air. Cultures were taken which were no growth to date
over the first several days.

She was on Levaquin still for her enterococcal urinary tract
infection at the time of this white count jump, so
clindamycin was added to broaden coverage.  No evidence of
infection was found on these studies, however, over the next
day or so, the patient began to have episodes of nausea,
vomiting and increasing abdominal girth.  There was concern
that there was a recurrence of her small bowel obstruction so
she was placed on n.p.o. and intravenous fluids were
restarted with the plan to drop an nasogastric tube if emesis
persistent.

She was advanced to sips on the 28th but developed repeated
episodes of emesis and returned to n.p.o. status.  A repeat
KUB showed some stool, raising concern that this was
constipation versus an small bowel obstruction and she was
given several enemas with some small bowel movements and
passing flatus and decreasing distention as a result.

Antibiotics were discontinued on the 30th secondary to there
being no evidence for active infection.  She was managed for
the presumed recurrence of her small bowel obstruction versus
constipation.


This is an interim dictation with subsequent course to be
determined.


                            [**First Name11 (Name Pattern1) 312**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 313**], M.D.  [**MD Number(1) 314**]

Dictated By:[**Last Name (NamePattern1) 10454**]
MEDQUIST36

D:  [**2177-2-6**]  15:30
T:  [**2177-2-6**]  15:36
JOB#:  [**Job Number **]


Admission Date:  [**2177-1-9**]     Discharge Date:


Service:  MEDICINE

CHIEF COMPLAINT:  Abdominal pain.

HISTORY OF PRESENT ILLNESS:  This is a 79 year old woman with
past medical history of coronary artery disease status post
coronary artery bypass graft and aortic valve replacement,
and sigmoid diverticulitis, who presented to [**Hospital1 346**] with complaints of nausea, vomiting
(over 10 episodes) and abdominal pain.  Patient reports that
she has been having vague abdominal complaints with periodic
vomiting for several months.  She reports non-bloody,
non-bilious emesis, no melena, or bright red blood per
rectum. She reports a weight loss of about 15 pounds over the
past three months.  She has had no fevers or chills at home,
no diarrhea, and two normal bowel movements yesterday.

PAST MEDICAL HISTORY:
1.  Coronary artery disease status post stent placement,
coronary artery bypass graft performed initially in [**2162**],
redone three vessel coronary artery bypass graft in [**2170**] with
concomitant aortic valve replacement.
2.  History of hypertension.
3.  Congestive heart failure with an ejection fraction of 20%
(ejection fraction 30-40% documented only this past [**Month (only) 958**]).
4.  Hypercholesterolemia.
5.  Diverticulosis.
6.  Anemia.
7.  [**4-10**]+ mitral regurgitation and tricuspid regurgitation.

PAST SURGICAL HISTORY:
1.  Left carotid endarterectomy in [**2168**].
2.  Aortobifemoral bypass in [**2155**].
3.  Right carotid endarterectomy in [**2162**].
4.  Left second toe amputation in [**2174**].



                          [**First Name11 (Name Pattern1) 312**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 313**], M.D.  [**MD Number(1) 314**]

Dictated By:[**Last Name (NamePattern1) 10454**]

MEDQUIST36

D:  [**2177-2-6**]  14:59
T:  [**2177-2-8**]  22:11
JOB#:  [**Job Number 102650**]


Admission Date:                   Discharge Date:  [**2177-2-14**]

Date of Birth:                    Sex:

Service:

ADDENDUM:  The revised date of discharge is [**2177-2-14**].

HOSPITAL COURSE:  Since the previous dictation, the major
events were essentially that the patient had a continued
small bowel obstruction and a possibility of recurrent
urinary tract infection.  For the small bowel obstruction,
the patient had intermittently been on nasogastric tube
suction and had been kept n.p.o. in the hopes that it would
resolve on its own, since the patient was a severely high
surgical risk, due to end stage valvular disease.  On [**2177-2-12**], the patient showed some sudden signs of improvement
in her bowel obstruction, having had five bowel movements,
passing flatus and marked decrease in distention in her
abdomen. Therefore, surgical consideration was deferred, in
the hopes that it would continue to resolve on its own.  The
patient did tolerate clears and the nasogastric tube was
clamped and then removed and planned to be removed on the
morning of [**2-14**], therefore, avoiding any surgical
intervention in this patient.  She will slowly be advancing
her diet from this point.

As far as the enterococcus in the urine, currently the
patient is to continue on a short course of Linezolid.  This
will further be discussed with infectious disease prior to
discharge from the hospital, to determine the proper course
of antibiotics.  It is currently believed that this is likely
colonization, although the possibility still exits for
infection having resolved at this point in time.

for her congestive heart failure and valvular disease, we
continued Metoprolol and nitroglycerin.  The plan was to
restart Spironolactone first when the patient is taking p.o.
and then restarting her ace inhibitor.

For her coronary artery disease, we were again continuing
Metoprolol.  Lipid panel showed no signs of needing any
statins.  The patient deferred any aspirin use.  Overall, the
plan was to discharge the patient to a rehabilitation
facility, which is more likely than to be discharged to home
with services.  This will have to be followed up with the
daughter prior to eventual discharge.  However, the ultimate
plan is to continue physical therapy and rehabilitation to
help her ambulate and gain strength; to discontinue the TPN
and allow the patient to start taking a regular diet and

recontinuing all medications for her congestive heart
failure, valvular disease and coronary artery disease.
Therefore, at the time of this discharge, the patient was
deemed to be almost stable for discharge to rehabilitation
facility.  The final results of her hospitalization will be
followed up in the final discharge dictation.





                            [**Name6 (MD) 251**] [**Name8 (MD) **], M.D.  [**MD Number(1) 1197**]

Dictated By:[**Last Name (NamePattern1) 13389**]
MEDQUIST36

D:  [**2177-2-14**]  12:13
T:  [**2177-2-14**]  05:23
JOB#:  [**Job Number 102574**]


Admission Date:                   Discharge Date:  [**2177-2-17**]

Date of Birth:                    Sex:

Service:

ADDENDUM:  Changes in the discharge summary dictated prior to
this dictation is that the patient had a completely resolved
small bowel obstruction by the time of discharge. She had no
signs of recurrent small bowel obstruction and was maintained
on a regular diet, with medications for bowel regimen.  She
will be sent home on these medications.

The other changes is that the patient was put back on p.o.
medications for her congestive heart failure and coronary
artery disease.  She was maintained well on these medications
prior to discharge.  The only final issue was just from an
infectious disease standpoint.  The patient was not restarted
on Linezolid after it was discontinued after a three day
course for likely colonization from enterococcus from urine.
There was never any enterococcal bacteremia and after
discontinuation of the Linezolid, the patient continued to do
well without any leukocytosis, symptoms of urinary tract
infection or fevers.  Thus, the patient will be discharged in
stable condition to the care of her primary care physician as
well as with 24 hour nursing care at home.

FINAL DISCHARGE MEDICATIONS:
1.  Isordil 10 mg p.o. three times a day.
2.  Combivent MDI prn.
3.  Spironolactone 25 mg p.o. q. day.
4.  Lisinopril 2.5 mg p.o. q. day.
5.  Metoprolol 12.5 mg p.o. three times a day.
6.  Senna.
7.  Docusate.
8.  Dulcolax prn.

FOLLOW-UP PLANS:  The patient will follow-up with her primary
care physician within one to two weeks and also will
follow-up with cardiology within one to two weeks after
discharge from hospital.

                            [**Name6 (MD) 251**] [**Name8 (MD) **], M.D.  [**MD Number(1) 1197**]

Dictated By:  [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D.
MEDQUIST36
D:  [**2177-2-17**]  01:54
T:  [**2177-2-17**]  14:07
JOB#:  [**Job Number 102714**]
{'Intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection),Urinary tract infection, site not specified,Unspecified septicemia,Severe sepsis,Pneumonia, organism unspecified,Subendocardial infarction, initial episode of care,Acute kidney failure, unspecified,Congestive heart failure, unspecified'}


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: Nausea, vomiting, and abdominal pain.

PRESENT ILLNESS: A 79-year-old female with 36
hours of abdominal pain, nausea, and emesis.  She is noted to
have recurring abdominal pain over the past three months with
36 hours of severe, unremitting, colicky band like upper
abdominal pain, but at times is sharp that is associated with
nausea and emesis of more than 10x, nonbloody, nonbilious,
brownish in color, no fevers, no chills, although she has
felt shaky after multiple bouts of emesis today.  She does
not have any dysuria.  Last bowel movement was today, normal
caliber and color.  Normal color of urine.

MEDICAL HISTORY: 1. Coronary artery disease as described above.
2. Peripheral vascular disease as described above.
3. Carotid stenosis.
4. Diverticulosis.
5. Hypercholesterolemia.
6. Esophagitis status post EGD in [**10-9**] showing mild
esophagitis, antral ulcers, and duodenitis.  Colonoscopy
shows grade 2 small internal hemorrhoids, diverticulosis, and
the patient had an echocardiogram with an EF of 35%, 3+
mitral regurgitation.

MEDICATION ON ADMISSION: 1. Lisinopril 5 a day.
2. Toprol 12.5 q.d.
3. Lipitor 40 q.d.
4. Protonix 40 q.d.
5. Hydrochlorothiazide/triamterene 37.5/2.5 [**2-8**] tablet
Monday, Wednesday, Friday.
6. Desipramine 10 mg with meals.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection),Urinary tract infection, site not specified,Unspecified septicemia,Severe sepsis,Pneumonia, organism unspecified,Subendocardial infarction, initial episode of care,Acute kidney failure, unspecified,Congestive heart failure, unspecified'}
