CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is an 83 [**Hospital **]
nursing home resident with a history of Alzheimer's disease,
coronary artery disease status post coronary artery bypass
graft who developed acute onset of abdominal pain in the
morning of [**2181-6-14**].  The pain was mainly periumbilical
without radiation and without fevers or chills.  The patient
was taken to the outside hospital where an abdominal x-ray
showed no evidence of obstruction and moderate feces.  A
decision was made to transfer the patient to [**Hospital1 346**] for further evaluation.

MEDICAL HISTORY: 

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Acute duodenal ulcer with hemorrhage and perforation, without mention of obstruction,Other specified disorders of peritoneum,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance,Unspecified acquired hypothyroidism,Aortocoronary bypass status
Ac duoden ulc w hem/perf,Peritoneal disorder NEC,Alzheimer's disease,Dementia w/o behav dist,Hypothyroidism NOS,Aortocoronary bypass
Admission Date:  [**2181-6-15**]       Discharge Date:  [**2181-6-22**]


Service:

DIAGNOSIS:
Perforated duodenal ulcer.

HISTORY OF PRESENT ILLNESS:  The patient is an 83 [**Hospital **]
nursing home resident with a history of Alzheimer's disease,
coronary artery disease status post coronary artery bypass
graft who developed acute onset of abdominal pain in the
morning of [**2181-6-14**].  The pain was mainly periumbilical
without radiation and without fevers or chills.  The patient
was taken to the outside hospital where an abdominal x-ray
showed no evidence of obstruction and moderate feces.  A
decision was made to transfer the patient to [**Hospital1 346**] for further evaluation.

HOSPITAL COURSE:  On arrival the patient had vital signs of
98.5, 90, 161/84 and was saturating at 90% on room air, which
increased to 98% with 3 liters of oxygen.  She was started on
Ampicillin, Levofloxacin and Flagyl in the Emergency
Department.

Pertinent physical examination findings included a minimally
distended abdomen with tenderness to palpation and
epigastrium and right abdomen.  Voluntary guarding with
minimal rebound.  Rectal examination revealed heme positive
brown stool with no masses.

White blood cell count was 43 with left shift.  Alkaline
phosphatase was 120.  Urinalysis was negative.  Nasogastric
retrieved approximately 200 cc of coffee ground material.
Chest x-ray obtained revealed no obvious free air in the
abdomen.  Further workup with CT revealed free air and fluid
in the abdomen thought likely to be from the first part of
the duodenum.  No other abnormal pathology was revealed on
this CT.

The decision was made to take the patient to the Operating
Room where an exploratory laparotomy revealed a large
duodenal perforation secondary to a duodenal ulcer.  A
Billroth two, tube duodenostomy, J tube placement and
antecolic gastrojejunostomy were performed over five hours.

The patient was then admitted to the CICU where she remained
sedated and intubated.  Triple antibiotic coverage was
continued.  The patient was extubated on postoperative day
number two that is on [**2181-6-17**].  Trophic tube feeds were
started on postop day number three at the time the patient's
white blood cell count was down to 16.8.  Results of belly
swab from [**6-14**] were reported to be growing yeast on [**6-17**] and
Fluconazole was started.  On postoperative day number five
the decision was made that the patient was stable enough for
transfer to a regular medical surgical floor.  During her
Intensive Care Unit stay the patient was awake and alert
following discontinuation of sedation and extubation even
though she had periods of confusion possibly secondary to her
underlying dementia.  Her white blood cell count continued to
trend downward.

On [**2181-6-20**] postop day number five the patient remained stable
on the floor with satisfactory oxygen saturation on 2 to 4
liters of oxygen via nasal cannula.  She received q 6
Albuterol and Atrovent nebulizer treatments.  Tube feeds
continued.  The patient's medications were changed from
intravenous to J tube administration route.  Also on postop
day number five the patient's antibiotic therapy with Flagyl,
Levofloxacin and Metronidazole was discontinued.  Case
management and social work in put on discharge planning was
requested, which revealed the patient had a compromise
family support system, but had ready access to a bed at her
previous nursing home facility.  Plans were therefore made
for discharging the patient back to [**Hospital 9013**] on [**6-22**].

During her entire stay on the floor the patient was kept on
soft restraints following attempts by the patient to remove
some of her lines.  The head of her bed was also kept
elevated as an aspiration precaution.  On the night of [**6-20**]
and again on the morning of [**6-21**] the patient was found to be
experiencing some respiratory difficulty with desaturations
to the upper 80s and then later to the mid 70s.  This was
suspected to be secondary to the patient's hydration status
contributing to thickening of pulmonary mucous secretions.
Fluid management was adjusted to resolve this problem with
orders written for installation of 750 cc of free water into
her J tube in one 8 cc boluses q.i.d., q 4 Albuterol and
Atrovent nebulizer treatments continued as well as
intermittent pulmonary hygiene treatments by suction.  A
duodenal tube study was scheduled for the morning of [**6-22**] and
is currently pending.  A comment on the results of this study
will be noted in the patient care referral form that the
patient will carry with her to her nursing home.  At this
moment the patient remains stable and discharge is
anticipated early in the afternoon of [**2181-6-22**].

PERTINENT DIAGNOSTIC STUDIES:  CT of the abdomen with and
without contrast performed on [**2181-6-15**] revealed three
intraperitoneal gas with ascites, likely site of rupture is
in the duodenal blood.  The gallbladder might be secondarily
inflamed.

LABORATORIES ON ADMISSION:  White blood cell count was 35.4,
hemoglobin 14.7, platelets 229, sodium 134, potassium 5.1,
chloride 93, bicarb 25, BUN 35, creatinine 8.2, glucose 82.






                            [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D.  [**MD Number(1) 4984**]

Dictated By:[**Doctor Last Name 14026**]
MEDQUIST36

D:  [**2181-6-22**]  09:28
T:  [**2181-6-22**]  09:43
JOB#:  [**Job Number 14027**]
{"Acute duodenal ulcer with hemorrhage and perforation, without mention of obstruction,Other specified disorders of peritoneum,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance,Unspecified acquired hypothyroidism,Aortocoronary bypass status"}


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: 

PRESENT ILLNESS: The patient is an 83 [**Hospital **]
nursing home resident with a history of Alzheimer's disease,
coronary artery disease status post coronary artery bypass
graft who developed acute onset of abdominal pain in the
morning of [**2181-6-14**].  The pain was mainly periumbilical
without radiation and without fevers or chills.  The patient
was taken to the outside hospital where an abdominal x-ray
showed no evidence of obstruction and moderate feces.  A
decision was made to transfer the patient to [**Hospital1 346**] for further evaluation.

MEDICAL HISTORY: 

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{"Acute duodenal ulcer with hemorrhage and perforation, without mention of obstruction,Other specified disorders of peritoneum,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance,Unspecified acquired hypothyroidism,Aortocoronary bypass status"}
