CHIEF COMPLAINT: Esophageal perforation s/p  EGD

PRESENT ILLNESS: 80 yo female transferred from [**Hospital3 7569**] w/ esophageal
perforation after EGD for evaluation of esophageal and duodenal
ulcers. CXR post EGD w/ right pneumothorax. A Chest tube was
placed at OSH. Swallow study confirmed esophageal perforation.

MEDICAL HISTORY: Rheumatoid Arthritis
Mild Dementia
Hyperlipidemia
Osteoporosis.

MEDICATION ON ADMISSION: plaquenil 200", lipitor 10', remeron 30',

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: General: frail, cachetic 80 yo female
HEENT: tongue very dry and cracked despite mouth care and
humidified face tent.
Chest: right chest tubes w/ very pale green/white thick
draiange. chest tubes to water seal.
COR; Tachy w/ regular rhythm
GI: abd: soft, round, NT, Nd, +BS. j- tube -Feeding tube in
place. G-tube->capped
Extrem: no c/c/e. left Picc line placed [**12-30**]
Neuro: alert, cooperative, intermittantly confused. baseline
mild dementia.

FAMILY HISTORY: unknown

SOCIAL HISTORY: lives alone w/ VNA services
Accidental puncture or laceration during a procedure, not elsewhere classified,Perforation of esophagus,Secondary malignant neoplasm of retroperitoneum and peritoneum,Cachexia,Pneumonia, organism unspecified,Acute kidney failure, unspecified,Accidental cut, puncture, perforation or hemorrhage during other specified medical care,Other malignant neoplasm without specification of site,Anemia, unspecified,Pure hypercholesterolemia,Other persistent mental disorders due to conditions classified elsewhere,Rheumatoid arthritis,Other specified forms of chronic ischemic heart disease,Other iatrogenic hypotension
Accidental op laceration,Perforation of esophagus,Sec mal neo peritoneum,Cachexia,Pneumonia, organism NOS,Acute kidney failure NOS,Acc cut in med care NEC,Malignant neoplasm NOS,Anemia NOS,Pure hypercholesterolem,Mental disor NEC oth dis,Rheumatoid arthritis,Chr ischemic hrt dis NEC,Iatrogenc hypotnsion NEC
Admission Date:  [**2138-12-15**]              Discharge Date:   [**2139-1-6**]

Date of Birth:  [**2058-6-19**]             Sex:   F

Service: CARDIOTHORACIC

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Esophageal perforation s/p  EGD

Major Surgical or Invasive Procedure:
Exploratory laparotomy; placement of open tube gastrostomy (22
Malecot); placement of open tube jejunostomy (14-French
whistle-tip); gastric biopsy.


History of Present Illness:
80 yo female transferred from [**Hospital3 7569**] w/ esophageal
perforation after EGD for evaluation of esophageal and duodenal
ulcers. CXR post EGD w/ right pneumothorax. A Chest tube was
placed at OSH. Swallow study confirmed esophageal perforation.

Past Medical History:
Rheumatoid Arthritis
Mild Dementia
Hyperlipidemia
Osteoporosis.

Social History:
lives alone w/ VNA services

Family History:
unknown

Physical Exam:
General: frail, cachetic 80 yo female
HEENT: tongue very dry and cracked despite mouth care and
humidified face tent.
Chest: right chest tubes w/ very pale green/white thick
draiange. chest tubes to water seal.
COR; Tachy w/ regular rhythm
GI: abd: soft, round, NT, Nd, +BS. j- tube -Feeding tube in
place. G-tube->capped
Extrem: no c/c/e. left Picc line placed [**12-30**]
Neuro: alert, cooperative, intermittantly confused. baseline
mild dementia.

Pertinent Results:
Abd CT scan- [**2138-12-16**]
IMPRESSION:
1. Gross esophageal perforation, with extravasation of oral
contrast and air into the right pleural space. The right chest
tube is currently not lying within the pleural collection.
2. Nasogastric tube terminating at the gastroesophageal
junction, within a moderate hiatal hernia. The tube should be
advanced several centimeters.
3. Distended gallbladder, prominent common duct, unusual contour
of the left kidney, and focal low attenuation within the
gallbladder fossa. These findings can be further assessed with
ultrasound, to exclude gallbladder pathology, a left renal mass,
and a focal hepatic lesion.
4. Nonobstructing left renal calculus.

[**12-30**]
CHEST, ONE VIEW: Comparison with [**2138-12-29**], 8:10 a.m.
New left PICC terminates in the mid-to-distal SVC. Right-sided
IJ central venous line, right-sided chest tube, and esophageal
stent are unchanged. Also unchanged are bilateral moderate
pleural effusions, lower lobe atelectasis, and mild fluid
overload. Osseous structures are similar in appearance.

IMPRESSION: Successful left PICC placement. No pneumothorax.

Labs:
[**2138-12-16**] WBC-18.3* RBC-3.23* Hgb-8.4* Hct-26.7 Plt Ct-324
[**2139-1-5**] WBC-9.4 RBC-3.35* Hgb-8.8* Hct-27.3 Plt Ct-427
[**2138-12-16**] Glucose-115* UreaN-20 Creat-1.5* Na-146* K-4.1 Cl-111*
HCO3-26
[**2139-1-5**] Glucose-135* UreaN-27* Creat-1.0 Na-142 K-3.3 Cl-110*
HCO3-25
[**2139-1-6**] K-3.6

Brief Hospital Course:
Mrs. [**Known lastname 76612**] was admitted to SICU [**Hospital1 18**] from [**Hospital **] for surgical eval of esophageal perforation. Dr.
[**Last Name (STitle) **] had lengthy discussion w/ family and a plan for
aggressive non-operative  management was made based on pt's age
DNR/DNI status pre- hospitalization and co-morbidities. She was
started on Vanco/Zosyn, fluconazole. on HD #1 and a covered
esophageal stent was placed. She was weaned and extubated on
HD#2 without difficulty.  Pt was transferred from the ICU and
TPN was started on HD#3.  On HD#6 she was taken to the OR for
Exploratory laparotomy; placement of open tube gastrostomy (22
Malecot); placement of open tube jejunostomy (14-French
whistle-tip); gastric biopsy. Pt tolerated procedure well but
was found to have what appeared to be Poorly differentiated
adenocarcinoma of unknown primary confirmed by by pathology.
Oncology was consulted and their recommendation was that
aggressive measures including chemo or further surgery would not
be beneficial.  An esophageal stent was placed over the area of
perforation.  Initially pt's right chest tubes were draining
serosanguinous drainage in small/mod amounts but on approx HD #
9 the drainage increased and became bilious. It was thought that
her esophageal stent had migrated. She was sent for a EGD and
the stent was repositioned. Subsequently the drainage decreased
and over the next few days became very pale green, thick and
cloudy. Her leucocytosis resolved over the course of the ensuing
days and she remained afebrile. A left sided pleural effusion
was seen on CXR and a left chest tube was placed and
subsequently d/c'd when the effusion resolved.  She was
transfused 2 UPRBC for anemia. HCT has remained stable ~ 29-31.
Left PICC line placed [**12-30**]. She was maintained on broad spectrum
IVAB Vanco, Zosyn, Caspo which she will need to complete a 6
week course. TPN was d/c'd and tube feeds were started and
increased to goal. Dr.[**Last Name (STitle) **] had multiple discussions with
pt's family through out her hospital stay re: her prognosis and
course of treatment. A decision was made to continue treatment
so long as she continued to respond. Hospice was also consulted
but her, niece who is her proxy, [**Name (NI) 52213**] wanted to continue
current CT and IVAB management.


Medications on Admission:
plaquenil 200", lipitor 10', remeron 30',

Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet [**Name (NI) **]: One (1) Tablet PO TID
(3 times a day): via j-tube.
2. Morphine 2 mg/mL Syringe [**Name (NI) **]: 1-2 mg Injection Q4H (every 4
hours) as needed for pain.
3. Piperacillin-Tazobactam 2.25 gram Recon Soln [**Name (NI) **]: 2.25  gms
Recon Solns Intravenous Q6H (every 6 hours) for 6 weeks.
4. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Name (NI) **]: 1000
(1000) mg Intravenous Q48H (every 48 hours) for 6 weeks.
5. Haloperidol Lactate 5 mg/mL Solution [**Name (NI) **]: .5 mg Injection QAM
(once a day (in the morning)).
6. Haloperidol Lactate 5 mg/mL Solution [**Name (NI) **]: One (1) mg
Injection @[**2130**] ().
7. Prevacid 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day: via j-tube.
8. Acetaminophen 650 mg Suppository [**Last Name (STitle) **]: One (1) Suppository
Rectal Q4H (every 4 hours) as needed.
9. Caspofungin 70 mg Recon Soln [**Last Name (STitle) **]: Fifty (50) mg Recon Soln
Intravenous Q24H (every 24 hours) for 6 weeks.
10. Nystatin 100,000 unit/mL Suspension [**Last Name (STitle) **]: Five (5) ML PO QID
(4 times a day) as needed.
11. picc line
picc line care and flushes per protocol
12. Heparin Flush PICC (100 units/ml) 2 mL IV DAILY:PRN
10 ml NS followed by 2 mL of 100 Units/mL heparin (200 units
heparin) each lumen Daily and PRN.  Inspect site every shift.
13. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection three times a day: DVT prophylaxis.
14. meds
all po meds via j-tube


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 1293**] - [**Location (un) **]

Discharge Diagnosis:
Esophageal perforation following EGD s/p esophageal stent
esophageal/duodenal ulcers, RA, osteoporosis, dementia,
hyperchol
carcinomatosis of the gastric mucosa.


Discharge Condition:
deconditioned and frail


Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 170**] if you develop chest
pain, shortness of breath, fever, chills, change in the quality
or quantity of the chest tube output. If the chest tube sutures
break, they must be re-stured in place. If the chest tubes fall
out, place a dressing over the site and call Dr.[**Name (NI) 70522**]
office immediately [**Telephone/Fax (1) 170**]. You will need to come back to
the hospital.
Please measure  and record thr chest tube output daily and send
log of recordings to follow up appointment with pt.


Followup Instructions:
You have a follow up appointment with Dr. [**Last Name (STitle) **] [**Hospital Ward Name **]
[**Hospital Ward Name 121**] building, [**Location (un) **] [**Hospital1 **] one, Center for Chest Disease
[**2139-1-13**] at 9:30am. Please report to Radiology [**Location (un) 470**] clinical
center building [**Hospital Ward Name **] 30 minutes prior to your appointment
for a chest XRAY.



Completed by:[**2139-1-7**]
{'Accidental puncture or laceration during a procedure, not elsewhere classified,Perforation of esophagus,Secondary malignant neoplasm of retroperitoneum and peritoneum,Cachexia,Pneumonia, organism unspecified,Acute kidney failure, unspecified,Accidental cut, puncture, perforation or hemorrhage during other specified medical care,Other malignant neoplasm without specification of site,Anemia, unspecified,Pure hypercholesterolemia,Other persistent mental disorders due to conditions classified elsewhere,Rheumatoid arthritis,Other specified forms of chronic ischemic heart disease,Other iatrogenic hypotension'}


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: Esophageal perforation s/p  EGD

PRESENT ILLNESS: 80 yo female transferred from [**Hospital3 7569**] w/ esophageal
perforation after EGD for evaluation of esophageal and duodenal
ulcers. CXR post EGD w/ right pneumothorax. A Chest tube was
placed at OSH. Swallow study confirmed esophageal perforation.

MEDICAL HISTORY: Rheumatoid Arthritis
Mild Dementia
Hyperlipidemia
Osteoporosis.

MEDICATION ON ADMISSION: plaquenil 200", lipitor 10', remeron 30',

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: General: frail, cachetic 80 yo female
HEENT: tongue very dry and cracked despite mouth care and
humidified face tent.
Chest: right chest tubes w/ very pale green/white thick
draiange. chest tubes to water seal.
COR; Tachy w/ regular rhythm
GI: abd: soft, round, NT, Nd, +BS. j- tube -Feeding tube in
place. G-tube->capped
Extrem: no c/c/e. left Picc line placed [**12-30**]
Neuro: alert, cooperative, intermittantly confused. baseline
mild dementia.

FAMILY HISTORY: unknown

SOCIAL HISTORY: lives alone w/ VNA services 

### Response:
{'Accidental puncture or laceration during a procedure, not elsewhere classified,Perforation of esophagus,Secondary malignant neoplasm of retroperitoneum and peritoneum,Cachexia,Pneumonia, organism unspecified,Acute kidney failure, unspecified,Accidental cut, puncture, perforation or hemorrhage during other specified medical care,Other malignant neoplasm without specification of site,Anemia, unspecified,Pure hypercholesterolemia,Other persistent mental disorders due to conditions classified elsewhere,Rheumatoid arthritis,Other specified forms of chronic ischemic heart disease,Other iatrogenic hypotension'}
