CHIEF COMPLAINT: Nauseated and Vomiting

PRESENT ILLNESS: Mr. [**Name13 (STitle) **] is a 74-year-old gentleman who i salmost one month
out from a difficult Exploratory laparotomy, Extended
adhesiolysis, Duodenal cutaneous fistula takedown with primary
closure of the duodenum, Choledochojejunostomy (Roux-en-Y),
Gastroenterostomy, J-tube placement, Drainage of retroperitoneal
sepsis, Small-bowel resection and later G-tube placement. He had
been battling recurrent retroperitoneal and intrabdominal sepsis
for almost eight months before his operation while his
nutritional and physical status was being buffed. As expected,
he
had along post-op course in the hospital that involved extensive
w/u for vomitting with tube feeds, eventually leading to G-tube
placement (and with which he can tolerate TF when vented), also
an antibiotic course for the organsims groan out of his
peritoneal fluid and a questionable aspiration pneumonia. Was
finally discharged home four days ago on no antibiotics an
dminmal medications. Went back into [**Hospital3 635**] hospital after
having shaking chills, fever 100.7 and wbc of 24 in there
hospital. He also received zosyn there after which he broke out
in a full bodyred reaction. He also had not been venting his
G-tube at home, so vomitted with his tube feeds, improved once
his g-tube was opened. Here he is feeling okay. Denies any
n/v/d/c/CP/SOB/HA/ab pain.

MEDICAL HISTORY: PMH: HTN, Dyslipidemia, EGD [**9-/2199**] with gastric/duodenal ulcers,

MEDICATION ON ADMISSION: reglan, lisinopril 20, lopressor 50 tid, atorvastatin 40,
trazadone 100, testosterone rub, Oxycodone 5 , colace,
lansoprazole, tylenol, folic acid, Jevity 1.2 cans'''

ALLERGIES: Sulfa (Sulfonamides) / Ciprofloxacin

PHYSICAL EXAM: 97.2 78 85-110/30-50 16 98%RA
NAD AOx3
no scleral icterus,
skin erthematous, blanching from chin to thighs
RRR
CTA except for slightly decreased left base
+BS, nd, soft, slightly tender around G and J tube insertion
sights, incisions are well healed, no rebound or gurading
no c/c/e

FAMILY HISTORY: nc

SOCIAL HISTORY: Married, prior skoking history, retired reader's digest editor
Pneumonitis due to inhalation of food or vomitus,Unspecified essential hypertension,Pure hypercholesterolemia,Gout, unspecified
Food/vomit pneumonitis,Hypertension NOS,Pure hypercholesterolem,Gout NOS
Admission Date:  [**2201-2-15**]              Discharge Date:   [**2201-2-20**]

Date of Birth:  [**2126-10-4**]             Sex:   M

Service: SURGERY

Allergies:
Sulfa (Sulfonamides) / Ciprofloxacin

Attending:[**Known firstname 148**]
Chief Complaint:
Nauseated and Vomiting

Major Surgical or Invasive Procedure:
None


History of Present Illness:
Mr. [**Name13 (STitle) **] is a 74-year-old gentleman who i salmost one month
out from a difficult Exploratory laparotomy, Extended
adhesiolysis, Duodenal cutaneous fistula takedown with primary
closure of the duodenum, Choledochojejunostomy (Roux-en-Y),
Gastroenterostomy, J-tube placement, Drainage of retroperitoneal
sepsis, Small-bowel resection and later G-tube placement. He had
been battling recurrent retroperitoneal and intrabdominal sepsis
for almost eight months before his operation while his
nutritional and physical status was being buffed. As expected,
he
had along post-op course in the hospital that involved extensive
w/u for vomitting with tube feeds, eventually leading to G-tube
placement (and with which he can tolerate TF when vented), also
an antibiotic course for the organsims groan out of his
peritoneal fluid and a questionable aspiration pneumonia. Was
finally discharged home four days ago on no antibiotics an
dminmal medications. Went back into [**Hospital3 635**] hospital after
having shaking chills, fever 100.7 and wbc of 24 in there
hospital. He also received zosyn there after which he broke out
in a full bodyred reaction. He also had not been venting his
G-tube at home, so vomitted with his tube feeds, improved once
his g-tube was opened. Here he is feeling okay. Denies any
n/v/d/c/CP/SOB/HA/ab pain.


Past Medical History:
PMH: HTN, Dyslipidemia, EGD [**9-/2199**] with gastric/duodenal ulcers,

Gout, Neuropathy, Back pain, h/o carpal tunnel, cervical
radiculopathy
Retroperitoneal sepsis.
Duodenal cutaneous fistula.
Biliary obstruction.
Extensive adhesions of intraabdominal contents.

PSH:
1. Exploratory laparotomy.
2. Extended adhesiolysis.
3. Duodenal cutaneous fistula takedown with primary closure
    of the duodenum.
4. Choledochojejunostomy (Roux-en-Y).
5. Gastroenterostomy.
6. J-tube placement.
7. Drainage of retroperitoneal sepsis.
8. Small-bowel resection.


Social History:
Married, prior skoking history, retired reader's digest editor

Family History:
nc

Physical Exam:
97.2 78 85-110/30-50 16 98%RA
NAD AOx3
no scleral icterus,
skin erthematous, blanching from chin to thighs
RRR
CTA except for slightly decreased left base
+BS, nd, soft, slightly tender around G and J tube insertion
sights, incisions are well healed, no rebound or gurading
no c/c/e


Pertinent Results:
[**2201-2-15**] 06:00PM BLOOD WBC-22.2*# RBC-2.95* Hgb-9.9* Hct-28.3*
MCV-96 MCH-33.5* MCHC-35.1* RDW-14.7 Plt Ct-332
[**2201-2-20**] 07:05AM BLOOD WBC-14.1*

[**2201-2-18**] 06:40AM BLOOD Glucose-130* UreaN-24* Creat-0.8 Na-137
K-4.0 Cl-101 HCO3-27 AnGap-13
[**2201-2-15**] 06:00PM BLOOD ALT-9 AST-14 AlkPhos-94 TotBili-0.6
[**2201-2-18**] 06:40AM BLOOD Calcium-8.7 Phos-2.6* Mg-2.2
[**2201-2-16**] 03:20AM BLOOD calTIBC-130* Ferritn-790* TRF-100*
.
Radiology Report CHEST (PA & LAT) Study Date of [**2201-2-15**] 6:27 PM

FINDINGS:
There is a focus of dense pneumonic consolidation in the right
middle lobe.
There is also atelectasis present in the left lower lobe. The
heart remains enlarged.
CONCLUSION:
Dense pneumonic consolidation in the right middle lobe as well
as atelectasis in the left lower lobe. Please ensure followup to
clearance.




Brief Hospital Course:
ID wrote:
Mr [**Known lastname **] is a 74-year old man with a history of significant
abdominal infectious issues after complications of embolization
of pancreaticoduodenal artery for GI bleed in 4/[**2200**].
Currently, he is readmitted with fevers, rigors and vomiting
after a recent definitive surgery for treatment of his abdominal
issues.
Worrisome for etiology of his current symptoms is a recurrent
abdominal process, particularly in the setting of the peri-drain
purulence.  To further assess this will require some
microbiological data and imaging to clarify his post-procedural
abdomen.
Also of concern is potential for pneumonia--despite relatively
negative symptoms--likely due to aspiration for tube feeds.
This is a rather likely etiology, particularly given the time
frame he outlines; although his cognitive status is intact, a
supine position with nocturnal tube feeds may have predisposed
to
aspiration.
Third, further/Jtube dysfunction may account for his symptoms.
Lastly, he has a prominent murmur on exam.  If fever or
infectious symptoms persist or worsen, or if a blood culture is
positive, investigation for endocarditis (possibly from
hematogenous seeding during recent procedures) is warranted with
echocardiography.
For antibiotic coverage, would s suggest continuing with current
antibiotics.  This may be narrowed as more data is collected,
particularly to cover aspiration pneumonitis, but given prior
highly resistant organisms, antibiotics are
appropriate coverage.

After being admitted to the ICU, he responded to IVF and
antibiotics and was transferred to the floor the next day.
CV:Monitor blood pressures, bolus IVF for hypotension.
Resp:WNL
GI: There was a small area along the incision that was draining
minimal serous fluid.
Nutrition: Tubefeeding: jevity 1.2 Full strength; Sips. He was
tolerating tubefeedings and sips for comfort. The G-tube was
vented for nausea. We attempted capping of the G-tube but at
times he was nauseated and the G-tube vented when symptomatic.
Continue with G-tube clamping trials during the day to help
train his stomach. Uncap every night.
Heme: follow CBC, leukocytosis trending down
Endo: RISS
ID: He was started on Tobramycin 120 mg IV Q18H, Meropenem 500
mg IV Q8H, Vanco 1g q24. His antibiotics were stopped on HD 4.
He looked good clinically and had no fever and WBC was
improving. The initial WBC was felt to be related to aspiration
pneumonitis.
FEN: sips of clear liquid throughout the day for comfort.  If
able to tolerate a capped G-tube for 24 hours you may cautiously
increase your dietary intake of clear liquids and food (jello,
clear broth etc.). DO NOT advance diet beyond clears. You are
receiving all the necessary calories and nutrition via your
nightly tube feeds into your J-tube.


Medications on Admission:
reglan, lisinopril 20, lopressor 50 tid, atorvastatin 40,
trazadone 100, testosterone rub, Oxycodone 5 , colace,
lansoprazole, tylenol, folic acid, Jevity 1.2 cans'''

Discharge Medications:
1. Tylenol 325 mg Tablet [**Year (4 digits) **]: 1-2 Tablets PO three times a day
as needed for pain.
2. Colace 100 mg Capsule [**Year (4 digits) **]: One (1) Capsule PO twice a day.
3. Heparin (Porcine) 5,000 unit/mL Solution [**Year (4 digits) **]: One (1)
Injection TID (3 times a day).
4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
5. Oxycodone 5 mg/5 mL Solution [**Last Name (STitle) **]: One (1)  PO Q4H (every 4
hours) as needed.
6. Metoclopramide 5 mg/5 mL Solution [**Last Name (STitle) **]: Two (2)  PO QIDACHS (4
times a day (before meals and at bedtime)).
7. Testosterone 5 mg/24 hr Patch 24 hr [**Last Name (STitle) **]: One (1) Patch 24 hr
Transdermal DAILY (Daily).
8. Lisinopril 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).

9. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID
(2 times a day).
10. Atorvastatin 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
11. Trazodone 50 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO HS (at bedtime).
12. Folic Acid 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).



Discharge Disposition:
Extended Care

Facility:
Pleasant Bay Nursing & Rehabilitation Center - [**Location (un) 23638**]

Discharge Diagnosis:
Nauseated and Vomiting

Discharge Condition:
Good

Discharge Instructions:
Incision Care: Keep clean and dry.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
.
You have been given teaching for your feeding jejunostomy tube
and G-tube. Please flush the tube as you have been taught &
please call our office or come to the ED if you notice
increasing swelling, redness or drainage around the insertion
site. You may return to your original feeding regimen with
Jevity 1.2.
.
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 skin, or the whites of your eyes become yellow.
* 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.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to ambulate several times per day.
* No heavy ([**11-26**] lbs) until your follow up appointment.

G-Tube use:
The G-tube was placed to assist with managment of your nausea
and vomiting. The G-tube should remain capped during the day
unless you feel nauseous or your abdomen becomes distended and
uncomfortable. If you feel nauseous, remove the cap and attach
the G-tube to a drainage bag as you have been taught. Uncap the
G-tube at night. The bag will help to remove the contents of
your stomach and decrease the nausea. Please use care when
capping and uncapping the G-tube so you do not accidentally pull
it out. It is sutured in place, but care should be exercised. If
you develop increasing redness/pain/swelling at the site of the
G-tube call the office or come to the ED for evaluation.

Diet:
You may take sips of clear liquid throughout the day for
comfort. If you become nauseous uncap the G-tube and attach to a
bag for drainage. If you are able to tolerate a capped G-tube
for 24 hours you may cautiously increase your dietary intake of
clear liquids and food (jello, clear broth etc.). DO NOT advance
diet beyond clears. You are recieving all the necessary calories
and nutrition via your nightly tube feeds into your J-tube.


Followup Instructions:
Provider: [**Known firstname **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 2833**]
Date/Time:[**2201-3-6**] 11:30



Completed by:[**2201-2-20**]
{'Pneumonitis due to inhalation of food or vomitus,Unspecified essential hypertension,Pure hypercholesterolemia,Gout, 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: Nauseated and Vomiting

PRESENT ILLNESS: Mr. [**Name13 (STitle) **] is a 74-year-old gentleman who i salmost one month
out from a difficult Exploratory laparotomy, Extended
adhesiolysis, Duodenal cutaneous fistula takedown with primary
closure of the duodenum, Choledochojejunostomy (Roux-en-Y),
Gastroenterostomy, J-tube placement, Drainage of retroperitoneal
sepsis, Small-bowel resection and later G-tube placement. He had
been battling recurrent retroperitoneal and intrabdominal sepsis
for almost eight months before his operation while his
nutritional and physical status was being buffed. As expected,
he
had along post-op course in the hospital that involved extensive
w/u for vomitting with tube feeds, eventually leading to G-tube
placement (and with which he can tolerate TF when vented), also
an antibiotic course for the organsims groan out of his
peritoneal fluid and a questionable aspiration pneumonia. Was
finally discharged home four days ago on no antibiotics an
dminmal medications. Went back into [**Hospital3 635**] hospital after
having shaking chills, fever 100.7 and wbc of 24 in there
hospital. He also received zosyn there after which he broke out
in a full bodyred reaction. He also had not been venting his
G-tube at home, so vomitted with his tube feeds, improved once
his g-tube was opened. Here he is feeling okay. Denies any
n/v/d/c/CP/SOB/HA/ab pain.

MEDICAL HISTORY: PMH: HTN, Dyslipidemia, EGD [**9-/2199**] with gastric/duodenal ulcers,

MEDICATION ON ADMISSION: reglan, lisinopril 20, lopressor 50 tid, atorvastatin 40,
trazadone 100, testosterone rub, Oxycodone 5 , colace,
lansoprazole, tylenol, folic acid, Jevity 1.2 cans'''

ALLERGIES: Sulfa (Sulfonamides) / Ciprofloxacin

PHYSICAL EXAM: 97.2 78 85-110/30-50 16 98%RA
NAD AOx3
no scleral icterus,
skin erthematous, blanching from chin to thighs
RRR
CTA except for slightly decreased left base
+BS, nd, soft, slightly tender around G and J tube insertion
sights, incisions are well healed, no rebound or gurading
no c/c/e

FAMILY HISTORY: nc

SOCIAL HISTORY: Married, prior skoking history, retired reader's digest editor 

### Response:
{'Pneumonitis due to inhalation of food or vomitus,Unspecified essential hypertension,Pure hypercholesterolemia,Gout, unspecified'}
