CHIEF COMPLAINT: Diffuse Abdominal Pain

PRESENT ILLNESS: This is a 66 year old male with the onset of epigastric
abdominal pain [**2173-1-25**]. He was admitted to [**Hospital3 8544**] with
pancreatitis complicated by oliguria (ATN). A CT revealed acute
pancreatitis and large gallstones with possible cholecystitis
and the patient was relatively stable. At the OSH, he developed
respiratory distress and delirium on [**2173-1-28**] and was started on
Bipap. He was eventually intubated on [**2173-1-31**]. Due to the
prolonged ileus, he was started on TPN. He was then transferred
to [**Hospital1 18**]. This progressed to infected pancreatitic necrosis.

MEDICAL HISTORY: HTN, HLD, s/p prostatectomy and hernia repair

MEDICATION ON ADMISSION: Tx Meds: insulin, imipenem 500 Q6, protonix, lopressor 5 Q4,
tylenol, fentanyl PRN

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: 99.5, 95, 125/70, 24, 99%
Gen: Intubated, sedated
CV: RRR
Pulm: coarse bilaterally at bases
Abd: soft, distended, NT (patient sedated)
Ext: no C/C/E

FAMILY HISTORY: N/C

SOCIAL HISTORY: Lives with wife.
2 beers/day
Acute pancreatitis,Streptococcal septicemia,Severe sepsis,Septic shock,Acquired coagulation factor deficiency,Acute respiratory failure,Acute kidney failure with lesion of tubular necrosis,Unspecified pleural effusion,Calculus of gallbladder with acute cholecystitis, without mention of obstruction,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Encephalopathy, unspecified,Obstructive sleep apnea (adult)(pediatric),Unspecified essential hypertension,Obesity, unspecified,Other and unspecified hyperlipidemia,Other musculoskeletal symptoms referable to limbs,Retention of urine, unspecified
Acute pancreatitis,Streptococcal septicemia,Severe sepsis,Septic shock,Acq coagul factor defic,Acute respiratry failure,Ac kidny fail, tubr necr,Pleural effusion NOS,Cholelith w ac cholecyst,DMII wo cmp nt st uncntr,Encephalopathy NOS,Obstructive sleep apnea,Hypertension NOS,Obesity NOS,Hyperlipidemia NEC/NOS,Muscskel sympt limb NEC,Retention urine NOS
Admission Date:  [**2173-2-2**]              Discharge Date:   [**2173-3-29**]

Date of Birth:  [**2106-5-8**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Diffuse Abdominal Pain

Major Surgical or Invasive Procedure:
1.  Pancreatic necrosectomy with wide drainage.
2.  Gastrostomy tube placement.
3.  Feeding jejunostomy tube placement.
4.  Cholecystostomy tube placement


History of Present Illness:
This is a 66 year old male with the onset of epigastric
abdominal pain [**2173-1-25**]. He was admitted to [**Hospital3 8544**] with
pancreatitis complicated by oliguria (ATN). A CT revealed acute
pancreatitis and large gallstones with possible cholecystitis
and the patient was relatively stable. At the OSH, he developed
respiratory distress and delirium on [**2173-1-28**] and was started on
Bipap. He was eventually intubated on [**2173-1-31**]. Due to the
prolonged ileus, he was started on TPN. He was then transferred
to [**Hospital1 18**]. This progressed to infected pancreatitic necrosis.

The pain radiated to his back and the patient had never
described similar episodes in the past.

Past Medical History:
HTN, HLD, s/p prostatectomy and hernia repair

Social History:
Lives with wife.
2 beers/day

Family History:
N/C

Physical Exam:
VS: 99.5, 95, 125/70, 24, 99%
Gen: Intubated, sedated
CV: RRR
Pulm: coarse bilaterally at bases
Abd: soft, distended, NT (patient sedated)
Ext: no C/C/E


Pertinent Results:
CT ABDOMEN W/CONTRAST  [**2173-2-7**] 2:07 PM
IMPRESSION: Compared to the outside study of [**2173-2-1**],
there has been progression of the inflammatory changes
surrounding the pancreas, consistent with the patient's history
of necrotizing pancreatitis. There is near total necrosis of the
pancreatic head with necrotic relative low attenuation material
in this region. No well-defined drainable fluid collections are
present at this time.
.
CT ABD W&W/O C  [**2173-2-13**] 5:22 PM
IMPRESSION:
1. No evidence of pulmonary embolism.

2. No significant changes in the peripancreatic inflammatory
changes due to necrotizing pancreatitis.

3. Diverticulosis.
.
CT ABD W&W/O C  [**2173-2-21**] 8:29 AM
IMPRESSION:
1. Progression of necrotizing pancreatitis with significant
interval increase in peripancreatic fluid. 8.3 x 6 cm rounded
collection impressing on the greater curvature of the stomach is
starting to form a more discrete wall. Additional similar
rounded collections along the duodenum.

2. Cholelithiasis without evidence of cholecystitis.

3. Consolidation at the right base which could represent
atelectasis or less likely aspiration. The appearance is not
significantly changed from prior exam.

4. Sigmoid diverticulosis without evidence of diverticulitis.
.
CT ABDOMEN W/O CONTRAST  [**2173-2-24**] 1:41 PM
IMPRESSION:

1. Persistent right basilar opacity with air bronchograms, which
may represent atelectasis, although pneumonia cannot be
excluded.

2. New perihepatic fluid collection, perhaps a new pseudocyst,
but otherwise the overall contour of multiple fluid collections
associated with the partially necrotic pancreas do not appear
significantly changed.

3. Increased ascites.
.
CT ABD W&W/O C  [**2173-3-10**] 12:51 PM
IMPRESSION:
1. Status post pancreatitis debridement with significant
reduction of the fluid collection in the pancreatic bed. No
evidence of pancreatic hemorrhage is seen.
2. Nonenhancing areas within the pancreatic head and body are
consistent with pancreatic necrosis with no complication
including gas collection.
3. Severe attenuation of proximal portion of a splenic vein and
superior mesenteric vein. Thrombosis cannot be excluded in these
vessels. No pseudoaneurysm is found although this study is not
CT angiogram.
4. Status post cholecystostomy, jejunostomy, gastrostomy and two
drainage tubes placement within the pancreatic bed.
5. Atelectasis of the right lower lobe.
.
CTA ABD W&W/O C & RECONS  [**2173-3-12**] 1:02 PM
IMPRESSION:
1. Status post necrotizing pancreatitis with debridement and
cholecystostomy, jejunostomy, gastrostomy, and placement of
drainage catheter within the pancreatic bed.
2. Moderate degree of attenuation of proximal portion of splenic
vein and superior mesenteric vein is unchanged. No thrombosis is
noted. No pseudoaneurysm is seen.
3. Unchanged nonenhancing areas within the pancreatic head and
the body consistent with pancreatic necrosis with no
complication including gas collection.
4. Atelectatic changes of the right lower lobe.
.
MRA BRAIN W/O CONTRAST  [**2173-3-17**] 8:45 AM
MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST
IMPRESSION:
1. No acute intracranial pathology, including no sign of
intracranial mass or bleed.
2. Unremarkable MRA of the circle of [**Location (un) 431**] and unremarkable MRA
of the vertebral and carotid arteries.
.
CTA ABD W&W/O C & RECONS  [**2173-3-23**] 10:32 AM
IMPRESSION:
1. Essentially stable appearance of multiple intra-abdominal
fluid collections in this patient with necrotizing pancreatitis.
2. Unchanged focal attenuation of proximal splenic vein, which
is patent. No evidence of pseudoaneurysm.
3. Essentially unchanged appearance to pancreas, with
non-enhancing regions consistent with pancreatic necrosis.
4. Right lower lobe atelectasis.
5. Markedly distended urinary bladder.
.


Brief Hospital Course:
He presented to the ICU and was manaaged conservatively. He
remained intubated and was on Meropenum empirically. Prior to
going to the OR on [**2173-2-24**], he was weaned from the ventilator
and transferred to the floor on two separate occasions. Each
transfer to the floor, he developed respiratory distress and was
sent back to the ICU and eventually was reintubated. Transfered
to floor [**2-12**] and readmitted [**2-13**] with hypotension, respiratory
distress, oliguria, and intubated on Levophed. Again, he was
transferred to the floor on [**2173-2-19**] and then returned to ICU on
[**2173-2-20**].

FEN: He went to IR for a Dobhoff tube placement on [**2173-2-3**] and
was started on trophic tube feedings. He showed improvement and
was reporting +flatus and +BM. The NGT was D/C'd. His TF were
advanced slowly to goal and the TPN was stopped on [**2-8**].

GI: He was NPO. He vomitted a large amount of bile emesis. He
require repositioning of the Dobhoff. He also had a NGT in
place. Once he had +flatus and +BM, the NGT was D/C'd.

CV: He was on Lopressor to control for tachycardia and
hypertension.

GU: He was responding to IV lasix with brisk urine output.
Post-operatively he was continued on Lasix for diuresis. He had
a foley in place and had good urine output.

Pulm: He was intubated. Post pyloric tube was placed on [**2-3**]. He
required Lasix for crackles and had good response. He was
started on Levoquin on [**2-21**] for possible pneumonia
When he was transferred back to the ICU on [**2173-2-20**], he had a
slow decline. He had a temperature to 102.3, he appeared more
somulent, he was having frequent PVC's, he was expectorating
thick, green secretions, his BUN and Cr were on the rise.
He was becoming septic and had +blood cultures. It was becoming
more concerning that surgery may be unavoidable.

He went to the OR on [**2173-2-24**] for a:
1.  Pancreatic necrosectomy with wide drainage.
2.  Gastrostomy tube placement.
3.  Feeding jejunostomy tube placement.
4.  Cholecystostomy tube placement.

He had a prolonged ICU course and was intubated for 2 weeks. He
slowly improved with much ICU care.

ABD: Post-operatively he had a G-tube, J-tube, Cholecystostomy
tube, and 2 JP drains. In the OR, he had 1200 IVF, 3 RBC, 2 FFP,
EBL 50, 1500 murky fluid and 1500 ascites.
He had a large midline incision that was being packed with wet
to dry dressing. The wound was brownish and had thick, tan
drainage. Granulation tissue began to show and the wound was
VAC'd on [**2173-3-16**]. He continued to have much drainage from the
wound. The Cholecystostomy tube was changed from being clamped
to gravity drainage due to concerns that he had enzymes leaking
through the wound. His skin around the incision looked red. The
VAC was removed and dressing changes were performed TID. He
received Vancomycin for 10 days for wound erythema, which
improved.

On [**3-23**], a surveillance CT showed: 1. Essentially stable
appearance of multiple intra-abdominal fluid collections in this
patient with necrotizing pancreatitis.
2. Unchanged focal attenuation of proximal splenic vein, which
is patent. No evidence of pseudoaneurysm. 3. Essentially
unchanged appearance to pancreas, with non-enhancing regions
consistent with pancreatic necrosis.

Resp: He had a pro-longed intubation and was eventaully weaned
to extubation on [**2173-3-8**]. He continued to need good pulmonary
toilet and chest PT.

GI: His G-tube was to gravity initially and then eventually
capped. J-tube feedings were started and slowly advanced to
goal.
The Cholecystostomy tube was to gravity and draining a moderate
volume of biliuos fluid. This was left to gravity while his
abdominal incision continued to heal.
He was followed by Speech and Swallow who recommended clear
fluids with supervision. He was noted to aspirate on [**2173-3-19**]
when attempting fluids. Speech and Swallow again saw the patient
and he had improved and was cleared for clear fluids with
supervision.

He was having daily loose stool. He was ordered for Immodium and
banana flakes. His stool eventually was becoming more formed.

Cards: Cards consulted because they noted transient ST
depression on tele (strips not available for review), 12 EKG
done is not substantially changed from EKG from [**2165**]. Patient
never c/o CP.
Recs: Perhaps there are trasient ischemia when the pt is under
extreme stress.
He had an ECHO which was negative.

[**Last Name (un) **]: He was followed by [**Last Name (un) **] for continued blood glucose
management.
.

Neuro: He was A+O x 1. He often spoke in nonsensical sentences.
He slowly improved and became more alert, awake and conversant.
He had right sided weakness, but pattern is difficult to clarify
given limited cooperation and pain. He may have proximal>distal
right UE weakness and mildly right leg weakness. Isolated right
deltoid weakness could reflect axillary nerve injury, but
weakness may be more diffuse in right arm and leg. Etiology of
encephalopathy also is unclear. Mild uremia could be a
contributing factor. Normal LFTs, He may have slight right sided
visual neglect (though not certain on exam). Head CT negative
from [**2173-3-8**] (except fluid in mastoid air cells), but an MRI
brain should be obtained when possible to rule out a left
hemisphere lesion. A MRI on [**3-16**] showed: no pathology, no masses
or bleeding, and unremarkable MRA of the circle of [**Location (un) 431**] and
unremarkable MRA of the vertebral and carotid arteries.
He slowly continued to clear mentally and become more alert and
oriented.

Activity: He was having orthostatic symptoms when PT was
attempting to transfer him to the chair. He was dizzy, weak,
confused and was having 20-30 mmHg systolic drop with change of
position. His Lopressor was decreased and as his strength
improved, he was able to tolerate more activity. He will need
continued PT.

ID:Finished abx course Meropenem([**Date range (1) 27725**]) fluconazole
([**Date range (1) 27726**]) Zosyn ([**Date range (1) 2820**]), Vancomycin ([**Date range (1) 27727**]).
Ampicillin ([**2-28**]-), fluconazole ([**2-25**]-?, [**Date range (1) 27726**]) [Levoflox
([**2178-3-4**], [**2096-2-21**]), Meropenem([**Date range (1) 27725**], [**Date range (1) 15078**]), Vancomycin
([**Date range (1) 27727**], [**Date range (1) 27728**], [**Date range (1) 27729**]), Zosyn ([**Date range (1) 2820**])]; {[**3-1**] MRSA
(+) at nares}
.
Imaging:
[**3-17**] MR [**Name13 (STitle) 430**]: No acute intracranial pathology, including no sign
of intracranial mass or bleed.
2. Unremarkable MRA of the circle of [**Location (un) 431**] and unremarkable MRA
of the vertebral and carotid arteries.

[**3-12**] CT Abd: No thrombosis, No pseudoaneurysm. Unchanged
nonenhancing areas within the pancreatic head and the body
consistent with pancreatic necrosis.
[**3-10**]: CT abdomen: Significaant reduction in peripancreatic fluid
collections. Pancreatic necrosis, no gas. Attenuation in splenic
vein, thrombosis cannot be ruled out.
[**3-8**]: CT head: no pathology/stroke
[**3-5**]: b/l UE U/S- superficial thrombus in R basilic vein
[**3-1**] CXR: bilateral effusions and bibasilar air space opacities.

[**2-24**] CT abd: R basilar opacity, new peri-hepatic fluid
collection, unchanged pancreatic necrosis, ascites
[**2-24**] RUQ US: cholelithiasis, no cholecystitis, 15 mm CBD,
cholesterol polyp
[**2-15**] LENI:wnl, echo- wnl, EF > 55;
[**2-7**] CT Abd: evolving pancreatic head necrosis
[**2173-2-1**]: Head CT - no bleeding or mass effect
[**2173-2-1**]: Abd. CT - evolution of pancreatitis w/ markedly
diminshed perfusion c/w pancreatitic necrosis
[**2163-1-29**]: U/S - 1.3 cm stone in neck of gallbladder assoc. w/
thickening of the wall of GB w/ small pericholecystic fluid
[**2173-1-25**]: Abd. CT - cholelithiasis, pancreatitis.
.
Micro:
[**3-9**] C diff neg [**3-4**]: Cdiff (-); [**3-3**]: C.diff (-) x 2, [**3-2**]: swab:
enterococcus, fluid: enterococcus; [**3-1**]: C.diff (-), BCx:(-),
SCx:(-), Tip:(-); [**2-24**]: swab GB: Enterococcus Amp sensitive.
peritoneal swab #1- NG, #2- E-coccus, pancreas #1- E-coccus, #2
e-coccus; [**2-22**]: UCx yeast


Medications on Admission:
Tx Meds: insulin, imipenem 500 Q6, protonix, lopressor 5 Q4,
tylenol, fentanyl PRN

Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Oxycodone 5 mg/5 mL Solution Sig: One (1)  PO Q4H (every 4
hours) as needed.
3. Amylase-Lipase-Protease 468 mg Tablet Sig: Two (2) Tablet PO
Q 8H (Every 8 Hours).
4. Loperamide 1 mg/5 mL Liquid Sig: Two (2)  PO TID (3 times a
day) as needed.
5. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1)  PO DAILY
(Daily).
6. Acetaminophen 160 mg/5 mL Solution Sig: Two (2)  PO Q4H
(every 4 hours) as needed.
7. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO HS (at bedtime) as needed.
9. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
12. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1)  PO BID (2
times a day).
13. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
14. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty
(20) Units Subcutaneous twice a day.
15. Insulin Regular Human 100 unit/mL Solution Sig: Sliding
Scale  Injection four times a day: See Sliding Scale.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 700**] - [**Location (un) 701**]

Discharge Diagnosis:
1.  Fulminant pancreatitis.
2.  Necrotizing pancreatitis.
3.  Multiple system organ failure, progressing
4.  Cholelithiasis.
5. Respiratory failure resulting in prolonged intubation
6. Post-op Delerium/Confusion
7. Post-op Urinary Retention
8. Right arm proximal weakness post surgery
9. Mild oral phase deficit


Discharge Condition:
Good

Discharge Instructions:
* Increasing pain
* Fever (>101.5 F)
* Persistent vomiting
* Inability to pass gas or stool
* Increasing shortness of breath
* Chest pain
.
Please resume all of your regular medications and take any new
meds as ordered.
.
Ambulate several times per day.

Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 468**] in 3 weeks. Call ([**Telephone/Fax (1) 27730**] to schedule an appointment.


Completed by:[**2173-3-29**]
{'Acute pancreatitis,Streptococcal septicemia,Severe sepsis,Septic shock,Acquired coagulation factor deficiency,Acute respiratory failure,Acute kidney failure with lesion of tubular necrosis,Unspecified pleural effusion,Calculus of gallbladder with acute cholecystitis, without mention of obstruction,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Encephalopathy, unspecified,Obstructive sleep apnea (adult)(pediatric),Unspecified essential hypertension,Obesity, unspecified,Other and unspecified hyperlipidemia,Other musculoskeletal symptoms referable to limbs,Retention of urine, 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: Diffuse Abdominal Pain

PRESENT ILLNESS: This is a 66 year old male with the onset of epigastric
abdominal pain [**2173-1-25**]. He was admitted to [**Hospital3 8544**] with
pancreatitis complicated by oliguria (ATN). A CT revealed acute
pancreatitis and large gallstones with possible cholecystitis
and the patient was relatively stable. At the OSH, he developed
respiratory distress and delirium on [**2173-1-28**] and was started on
Bipap. He was eventually intubated on [**2173-1-31**]. Due to the
prolonged ileus, he was started on TPN. He was then transferred
to [**Hospital1 18**]. This progressed to infected pancreatitic necrosis.

MEDICAL HISTORY: HTN, HLD, s/p prostatectomy and hernia repair

MEDICATION ON ADMISSION: Tx Meds: insulin, imipenem 500 Q6, protonix, lopressor 5 Q4,
tylenol, fentanyl PRN

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: 99.5, 95, 125/70, 24, 99%
Gen: Intubated, sedated
CV: RRR
Pulm: coarse bilaterally at bases
Abd: soft, distended, NT (patient sedated)
Ext: no C/C/E

FAMILY HISTORY: N/C

SOCIAL HISTORY: Lives with wife.
2 beers/day 

### Response:
{'Acute pancreatitis,Streptococcal septicemia,Severe sepsis,Septic shock,Acquired coagulation factor deficiency,Acute respiratory failure,Acute kidney failure with lesion of tubular necrosis,Unspecified pleural effusion,Calculus of gallbladder with acute cholecystitis, without mention of obstruction,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Encephalopathy, unspecified,Obstructive sleep apnea (adult)(pediatric),Unspecified essential hypertension,Obesity, unspecified,Other and unspecified hyperlipidemia,Other musculoskeletal symptoms referable to limbs,Retention of urine, unspecified'}
