CHIEF COMPLAINT: PERFORATED DUODENUM

PRESENT ILLNESS: Pt is a 88yoF with c/o abd pain and n/v/d x 3 days.
Pt reports being unwell x 3 days - initially generalized
malaise, followed by n/v and diarrhea (worsened than usual
diarrhea). After vomiting, she had sudden onset of periumbilical
pain. Pain sharp, constant, worsens w/ movement.
She denies fever/chills. Denies NSAIDS.
She was initially admitted to [**Hospital3 3765**] [**2173-2-10**] w/
diagnosis of pancreatitis ([**Doctor First Name **] 196, Lipase 140). CT abdomen
performed [**2173-2-11**] (after prep for ? IV contrast allergy) showed
retroperitoneal air concerning for posterior perforated duodenal
ulcer. Pt transferred to [**Hospital1 18**].

MEDICAL HISTORY: htxn, hypothyroidism, chronic diarrhea (? celiac disease),
diverticulosis, s/p hysterectomy & appy '[**56**], lower back pain

MEDICATION ON ADMISSION: quinapril 10mg daily, aldactone 25mg daily, HCTZ 25mg daily,
levoxyl 75mcg daily, ativan 0.5mg HS prn, glucosamine,
chondroitin, Ca, vitamin D, ibuprofen?

ALLERGIES: Iodine; Iodine Containing

PHYSICAL EXAM: At discharge:
V.S: 98.2, 63, 121/65, 18, 94% RA
Gen: A and O x 3, NAD
Resp: LSCTA bilat, denies SOB
CV: RRR, no m/r/g
Abd: soft, nt, nd, + bs
Ext: no c/c/e

FAMILY HISTORY: mother had chronic diarrhea as well

SOCIAL HISTORY: daily brandy 2oz HS, widow, lives at [**Location **] Commons [**Hospital3 12272**]
Chronic or unspecified duodenal ulcer with perforation, without mention of obstruction,Acute pancreatitis,Atrial fibrillation,Dehydration,Unspecified essential hypertension,Unspecified acquired hypothyroidism,Celiac disease,Diarrhea,Diverticulosis of colon (without mention of hemorrhage)
Chr duoden ulcer w perf,Acute pancreatitis,Atrial fibrillation,Dehydration,Hypertension NOS,Hypothyroidism NOS,Celiac disease,Diarrhea,Dvrtclo colon w/o hmrhg
Admission Date:  [**2173-2-11**]              Discharge Date:   [**2173-2-18**]


Service: SURGERY

Allergies:
Iodine; Iodine Containing

Attending:[**First Name3 (LF) 5547**]
Chief Complaint:
PERFORATED DUODENUM

Major Surgical or Invasive Procedure:
None.


History of Present Illness:
Pt is a 88yoF with c/o abd pain and n/v/d x 3 days.
Pt reports being unwell x 3 days - initially generalized
malaise, followed by n/v and diarrhea (worsened than usual
diarrhea). After vomiting, she had sudden onset of periumbilical
pain. Pain sharp, constant, worsens w/ movement.
She denies fever/chills. Denies NSAIDS.
She was initially admitted to [**Hospital3 3765**] [**2173-2-10**] w/
diagnosis of pancreatitis ([**Doctor First Name **] 196, Lipase 140). CT abdomen
performed [**2173-2-11**] (after prep for ? IV contrast allergy) showed
retroperitoneal air concerning for posterior perforated duodenal
ulcer. Pt transferred to [**Hospital1 18**].

On arrival, pt reports mild generalized abd pain, despite IV
morphine.

Of note, pt has had chronic diarrhea which has been worked up
w/o
final diagnosis. Initially, celiac disease was suspected and
trial on gluten-free diet seemed to improve diarrhea. However,
she was told by her physician she did not have celiac disease.


Past Medical History:
htxn, hypothyroidism, chronic diarrhea (? celiac disease),
diverticulosis, s/p hysterectomy & appy '[**56**], lower back pain


Social History:
daily brandy 2oz HS, widow, lives at [**Location **] Commons [**Hospital3 12272**]


Family History:
mother had chronic diarrhea as well

Physical Exam:
At discharge:
V.S: 98.2, 63, 121/65, 18, 94% RA
Gen: A and O x 3, NAD
Resp: LSCTA bilat, denies SOB
CV: RRR, no m/r/g
Abd: soft, nt, nd, + bs
Ext: no c/c/e

Pertinent Results:
[**2173-2-13**] 07:35AM BLOOD WBC-7.2# RBC-3.50* Hgb-11.3* Hct-34.6*
MCV-99* MCH-32.4* MCHC-32.7 RDW-13.4 Plt Ct-247
[**2173-2-11**] 03:36PM BLOOD Neuts-32* Bands-37* Lymphs-20 Monos-3
Eos-0 Baso-0 Atyps-3* Metas-5* Myelos-0 Other-0
[**2173-2-11**] 03:36PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-OCCASIONAL Microcy-OCCASIONAL Polychr-OCCASIONAL
[**2173-2-13**] 07:35AM BLOOD PT-12.3 PTT-26.2 INR(PT)-1.0
[**2173-2-17**] 07:00AM BLOOD Glucose-66* UreaN-17 Creat-0.6 Na-137
K-3.4 Cl-103 HCO3-26 AnGap-11
[**2173-2-15**] 09:10PM BLOOD CK(CPK)-31
[**2173-2-11**] 03:36PM BLOOD Lipase-74*
[**2173-2-16**] 07:25AM BLOOD CK-MB-2 cTropnT-0.03*
[**2173-2-17**] 07:00AM BLOOD Calcium-8.4 Phos-3.1 Mg-1.7
.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST: negative x 2
.
HELICOBACTER PYLORI ANTIBODY TEST: NEGATIVE BY EIA.
.
MRSA SCREEN: No MRSA isolated
.
Blood Culture, Routine [**2173-2-17**]: NO GROWTH X2
.
UGI SGL CONTRAST W/ KUB [**2173-2-15**]
No gross extravasation of contrast on this technically limited
examination. Known retroperitoneal free air on CT examination,
compatible
with duodenal ulcer perforation.
.
CHEST (PORTABLE AP) [**2173-2-13**]
Features of worsened CHF along with new opacities at the lung
bases. The latter could be due to atelectasis or pneumonia.
.
ABDOMEN (SUPINE ONLY) [**2173-2-12**]
Significant free intraperitoneal air largely unchanged from
prior study. Retroperitoneal air is likley present; however its
evaluation is limited. No bowel obstruction or dilatation.
.






Brief Hospital Course:
Pt was admitted to the TICU from OSH, she was evaluated by
surgery, abx and a protonix drip were started, NGT was placed,
CXR done without evidence of free air and she was closely
assessed overnight and schedule for upper GI in the am.
.
She was transferrd to [**Hospital Ward Name 1950**] 5 with IV hydration secondary to
dehydration/NGT, a foley and telemetry secondary to new IV beta
blocker. Her protonix drip was changed to IV q 12 hrs. The
patient had an upper GI study which indicated no gross
extravasation of contrast on this technically limited
examination, because patient could not shift positions as
requested. Known retroperitoneal free air on CT examination,
compatible with duodenal ulcer perforation. Her NGT was removed
and she was continued on po protonix and her medications were
changed to oral.
.
Patient was fluid overloaded and several doses of IV lasix were
administered with good effect and electrolytes were repleated as
necessary. [**2173-2-15**] the patient had an episode of new onset
tachycardia/A-Fib. She was administered IV lopressor with good
effect and her electrolytes were rechecked and repleated as
needed.
.
The patient's foley was d/c'd and she voided with out any
issues. C-dif x2 was sent secondary to loose stool-both
negative. She was started on her home dose of immodium.
.
Physical therapy recommended home physical therapy or rehab. The
patient and family discussed this issue and decided on home
physical therapy, the patient is already set up with the VNA and
will continue this.
.
Discharge paperwork was reviewed with paitent and family. She
was started on protonix, handout was provided and the purpose of
the medication was reviewed.  Her PCP was [**Name (NI) 653**] regarding
her situation, change in medications and an appointment was made
for 1 week. She will also follow up with Dr. [**Last Name (STitle) 1924**] on [**2173-3-2**]


Medications on Admission:
quinapril 10mg daily, aldactone 25mg daily, HCTZ 25mg daily,
levoxyl 75mcg daily, ativan 0.5mg HS prn, glucosamine,
chondroitin, Ca, vitamin D, ibuprofen?


Discharge Medications:
1. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Quinapril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for Pain: For neck pain. Please do not exceed
more than 4000 mg in 24 hours. .
7. 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*
8. Loperamide 2 mg Capsule Sig: Two (2) Capsule PO TID (3 times
a day).


Discharge Disposition:
Home With Service

Facility:
deaconness abundant life homecare

Discharge Diagnosis:
Primary:
Perforated Duodenum
Pancreatitis
Dehydration
Fluid over load
New on set A-fib
.
Secondary:
htxn, hypothyroidism, chronic diarrhea (? celiac disease),
diverticulosis, s/p hysterectomy & appy '[**56**], lower back pain


Discharge Condition:
Stable.
Tolerating regular diet.
Pain well controlled with oral medications.


Discharge Instructions:
Please call your doctor or return to the ER for 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.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or

back.
* 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.
* Continue to ambulate several times per day.
.
Medications:
1. Protonix:
-You were started on this medication because of your duodenal
ulcer.
-This medication will help prevent future ulcerations, by
decreasing  stomach acid swallowing.
-You should take this every 12 hrs.


Followup Instructions:
1. Please follow up with Dr. [**Last Name (STitle) 1924**] on [**2173-3-2**]. Please call his
office for the time [**Telephone/Fax (1) 7508**].
2. An appointment has been made for you to see [**Name8 (MD) 80591**] [**First Name5 (NamePattern1) 80592**] [**Last Name (NamePattern1) 80593**] on [**2173-3-1**]. If you can not make this
appointment please call to reschedule [**Telephone/Fax (1) 21640**].



Completed by:[**2173-2-18**]
{'Chronic or unspecified duodenal ulcer with perforation, without mention of obstruction,Acute pancreatitis,Atrial fibrillation,Dehydration,Unspecified essential hypertension,Unspecified acquired hypothyroidism,Celiac disease,Diarrhea,Diverticulosis of colon (without mention of hemorrhage)'}


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: PERFORATED DUODENUM

PRESENT ILLNESS: Pt is a 88yoF with c/o abd pain and n/v/d x 3 days.
Pt reports being unwell x 3 days - initially generalized
malaise, followed by n/v and diarrhea (worsened than usual
diarrhea). After vomiting, she had sudden onset of periumbilical
pain. Pain sharp, constant, worsens w/ movement.
She denies fever/chills. Denies NSAIDS.
She was initially admitted to [**Hospital3 3765**] [**2173-2-10**] w/
diagnosis of pancreatitis ([**Doctor First Name **] 196, Lipase 140). CT abdomen
performed [**2173-2-11**] (after prep for ? IV contrast allergy) showed
retroperitoneal air concerning for posterior perforated duodenal
ulcer. Pt transferred to [**Hospital1 18**].

MEDICAL HISTORY: htxn, hypothyroidism, chronic diarrhea (? celiac disease),
diverticulosis, s/p hysterectomy & appy '[**56**], lower back pain

MEDICATION ON ADMISSION: quinapril 10mg daily, aldactone 25mg daily, HCTZ 25mg daily,
levoxyl 75mcg daily, ativan 0.5mg HS prn, glucosamine,
chondroitin, Ca, vitamin D, ibuprofen?

ALLERGIES: Iodine; Iodine Containing

PHYSICAL EXAM: At discharge:
V.S: 98.2, 63, 121/65, 18, 94% RA
Gen: A and O x 3, NAD
Resp: LSCTA bilat, denies SOB
CV: RRR, no m/r/g
Abd: soft, nt, nd, + bs
Ext: no c/c/e

FAMILY HISTORY: mother had chronic diarrhea as well

SOCIAL HISTORY: daily brandy 2oz HS, widow, lives at [**Location **] Commons [**Hospital3 12272**] 

### Response:
{'Chronic or unspecified duodenal ulcer with perforation, without mention of obstruction,Acute pancreatitis,Atrial fibrillation,Dehydration,Unspecified essential hypertension,Unspecified acquired hypothyroidism,Celiac disease,Diarrhea,Diverticulosis of colon (without mention of hemorrhage)'}
