CHIEF COMPLAINT: Presented with 3 day history of constipation with flatus and
abdominal distention and pain.

PRESENT ILLNESS: 76 yo M with PMHx sig for Parkinson's and history of
constipation who presents with no stools for the past four days
and abdominal pain and distention for the past few days.  pain
was initially in the lower abdomen, became increasingly severe,
which caused the patient to come to the [**Hospital1 18**] ER.  KUB in the ER
demonstrated sigmoid volvulus - CT scan confirmed, and the
patient was admitted to the SICU for decompression.

MEDICAL HISTORY: Parkinson disease s/p deep brain stimulator placement
Hypertension
Hyperlipidimia

MEDICATION ON ADMISSION: Sinemet 7 times a day
[**Last Name (un) 16285**] 2''3'
Trihexyphenidyl 1'
Zoloft75'
Lipitor20'
Vesicare5'
Patanol 2'
Dulcolax10'
Remeron 15'
Folplex 2.2'
Seroquel 25mg
Restasis
Protonix 40'
Florinef (new)

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: 122/68 P 86 RR 29 96% on FIO2 50% (after aspiration in ED)

FAMILY HISTORY: non contributory

SOCIAL HISTORY: non contributory
Unspecified vascular insufficiency of intestine,Volvulus,Perforation of intestine,Pneumonitis due to inhalation of food or vomitus,Paroxysmal ventricular tachycardia,Pressure ulcer, heel,Paralysis agitans,Unspecified essential hypertension,Pure hypercholesterolemia
Vasc insuff intest NOS,Volvulus of intestine,Perforation of intestine,Food/vomit pneumonitis,Parox ventric tachycard,Pressure ulcer, heel,Paralysis agitans,Hypertension NOS,Pure hypercholesterolem
Admission Date:  [**2199-7-22**]              Discharge Date:   [**2199-8-9**]

Date of Birth:  [**2123-1-29**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 974**]
Chief Complaint:
Presented with 3 day history of constipation with flatus and
abdominal distention and pain.


Major Surgical or Invasive Procedure:
[**2199-7-23**]: Subtotal colectomy Hartmann's pouch, End ileostomy,
Insertion of gastrointestinal feeding system.


History of Present Illness:
76 yo M with PMHx sig for Parkinson's and history of
constipation who presents with no stools for the past four days
and abdominal pain and distention for the past few days.  pain
was initially in the lower abdomen, became increasingly severe,
which caused the patient to come to the [**Hospital1 18**] ER.  KUB in the ER
demonstrated sigmoid volvulus - CT scan confirmed, and the
patient was admitted to the SICU for decompression.

Past Medical History:
Parkinson disease s/p deep brain stimulator placement
Hypertension
Hyperlipidimia

Social History:
non contributory

Family History:
non contributory

Physical Exam:
VS: 122/68 P 86 RR 29 96% on FIO2 50% (after aspiration in ED)

HEENT: NC/AT, PERRLA, EOMI
CV: pulses 2+ bilaterally, RRR, no M/R/G
LUNG: bilateral crackles and rhonchi
ABD: obese, distended, firm, +BS
EXT: able to MAE 5/5 strength bilaterally, notable parkinsonian
tremor


Pertinent Results:
Admission labs
---------------
[**2199-7-22**] 05:15PM URINE  SPERM-FEW
[**2199-7-22**] 05:15PM URINE  HYALINE-[**3-4**]*
[**2199-7-22**] 05:15PM URINE  RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2199-7-22**] 05:15PM URINE  BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-100 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2199-7-22**] 05:15PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.036*
[**2199-7-22**] 05:30PM   PT-11.9 PTT-26.0 INR(PT)-1.0
[**2199-7-22**] 05:30PM   PLT SMR-NORMAL PLT COUNT-293
[**2199-7-22**] 05:30PM   HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2199-7-22**] 05:30PM   NEUTS-92.8* BANDS-0 LYMPHS-4.3* MONOS-2.4
EOS-0.2 BASOS-0.3
[**2199-7-22**] 05:30PM   WBC-13.7*# RBC-4.54* HGB-14.7 HCT-45.2
MCV-100* MCH-32.4* MCHC-32.5 RDW-13.6
[**2199-7-22**] 05:30PM   CALCIUM-9.5 PHOSPHATE-2.4* MAGNESIUM-3.3*
[**2199-7-22**] 05:30PM   ALT(SGPT)-45* AST(SGOT)-44* ALK PHOS-143*
AMYLASE-35 TOT BILI-0.8
[**2199-7-22**] 05:30PM   estGFR-Using this
[**2199-7-22**] 05:30PM   GLUCOSE-189* UREA N-21* CREAT-1.2 SODIUM-137
POTASSIUM-4.0 CHLORIDE-97 TOTAL CO2-26 ANION GAP-18
[**2199-7-22**] 05:44PM   LACTATE-2.7* K+-3.9
[**2199-7-22**] 08:27PM   TYPE-ART TEMP-37.2 PO2-124* PCO2-43 PH-7.39
TOTAL CO2-27 BASE XS-1 INTUBATED-INTUBATED
.
.
Date: [**2199-8-8**]
Signed by [**Name6 (MD) 16283**] [**Name8 (MD) 13560**], MD on [**2199-8-8**]  Affiliation: [**Hospital1 18**]
Cosigned by [**Name (NI) 3557**] [**Name8 (MD) **], MD on [**2199-8-8**]

Movement Disorders Consult Note:
I have seen Mr [**Known lastname 16284**] today as requested by the Neurology
Consult
team for advice on management of his treatment for Parkinson's
disease. The plan of care was discussed with Dr [**First Name (STitle) **] [**Name (STitle) **], MD,
Movement Disorders attending, and the plan reflects her thoughts
and recommendations.
.
Current PD Medication:
Sinemet 25/100:
6:30   9:00   11:30   14:00   16:30   19:00   21:00
1 tb   1.5tb  1.5tb   1.75tb  1.5tb   2tb     1tb
.
[**Name (STitle) 16285**]:
6:30   9:00   11:30   14:00   16:30
2mg    2 mg   3mg     2mg     3mg
.
Artane 2 mg in AM
.
DBS IPG's investigated by me at bedside:
Left: 2-, case+, 2.6V, 120mcs, 135 Hz, continuous stim with no
interruptions since reset of [**7-10**], impedances OK with no short-
or open-circuits, battery voltage 3.72
Right: 0-, 2+, 3V, 150mcs, 185Hz, continuous stim with no
interruptions since reset of [**7-10**], impedances OK with no short-
or open-circuits, battery voltage 3.72

Exam: s/p abdominal surgery, G tube in place, continuous feeds
run.
Drowsy but easily arousable. Follows simple commands only. Not
oriented to time or place. Able to answer yes, no, and simple
one-item questions. Evaluation limited by complete aphonia.
Unable to see pupils due to forceful voluntary and reflex eye
closure. Increased tone diffusely with cogwheeling and some
spasticity. No resting tremor, but tremor of LUE and LLE emerges
when the stimulator turns off mom[**Name (NI) 11711**] while checking
impedances. Agile repeated hand movements, unable to do a full
PD
motor exam. Responds normally to pain. Toes R up, L down, DTR's
increased, b/l ankle clonus present.

Impression and plan: Patient with advanced PD s/p DBS surgery,
now in ICU post-op. Limited data on prior history. Attempted to
contact Dr [**First Name (STitle) 7951**] at BU at [**Numeric Identifier 16286**], awaiting call back after
page. Evidence of some encephalopathy and systemic impairment,
both confounding exam. It is expected that PD signs will be
worse
with the major intercurrent stressor, but adjusting medication
and especially DBS settings is not appropriate in this
environment. Would plan first for resolving the acute condition,
and taking measures to improve and prevent delirium. To maximize
gain from Sinemet, please hold feeds at least 30 min before and
after giving Sinemet to increase absorbtion. Continue current
dose. Continue [**Numeric Identifier 16285**]. DBS working normally, will not change
settings now, and there is evidence of good benefit at least on
the tremor. Doubt significant benefit from Artane, and tremor
controlled by DBS. Reduce dose to 1 mg daily for 3-4 days, then
D/C Artane, as it is likely to contribute to some of the
confusion. If after improving the patient's general condition he
remains delirious, contact us re: reducing the [**Name (NI) 16285**] dose
temporarily.
In response to the question regarding use of Reglan from Neuro
consult resident, please note that this medication is likely to
worsen the parkinsonian symptoms. Only use if vital and no
alternative, and only for short term.
UMN signs of unclear origin, possibly part of encephalopathy, to
be addressed by Neuro consult
Plan communicated to Dr [**Last Name (STitle) 623**] of Neurology and Neurology
Consult Resident.
We will gladly remain involved in management at the primary
team's request.
[**Name6 (MD) **] [**Name8 (MD) **], MD
.
Date: [**2199-8-9**]
BEDSIDE SWALLOWING EVALUATION:
SUMMARY / IMPRESSION:
There were no overt signs or symptoms of aspiration at the
bedside today. By patient and family report, the pt is doing
well
with thin liquids and puree, and repeat CXR [**2199-8-8**] shows
"gradual
improvement of bilateral upper lobe consolidations". It appears
safe for the pt to continue on this diet. He will likely be
discharged to a rehab facility, and if he continues to tolerate
these consistencies it may be appropriate to introduce trials of
soft solids.

However, "silent" aspiration cannot be ruled out at the bedside.
If there are any persistent concerns regarding aspiration, we
would be happy to perform a videoswallow evaluation.

RECOMMENDATIONS:
1. Continue PO trials of thin liquids and puree consistency
solids.
2. 1:1 assistance for feeding.
3. The pt should only be fed when he is most alert and awake.
4. Feeding trials should be discontinued if the pt demonstrates
any overt signs of aspiration such as coughing or significant
desaturation after eating or drinking.
5. If the patient continues to tolerate this diet without
problems, it may be appropriate to introduce trials of soft
solids.[**First Name8 (NamePattern2) 46**] [**Last Name (NamePattern1) **], MS [**Name13 (STitle) 16287**]

.
CHEST (PORTABLE AP)  [**2199-8-8**] 7:46 AM
Reason: f/u on pneumonia
IMPRESSION: Gradual improvement of bilateral upper lobe
consolidations.

Discharge Labs
--------------
[**2199-8-8**] 07:00AM BLOOD WBC-9.1 RBC-3.81* Hgb-12.2* Hct-37.5*
MCV-99* MCH-32.0 MCHC-32.5 RDW-15.0 Plt Ct-577*
[**2199-8-8**] 07:00AM BLOOD WBC-9.1 RBC-3.81* Hgb-12.2* Hct-37.5*
MCV-99* MCH-32.0 MCHC-32.5 RDW-15.0 Plt Ct-577*
[**2199-7-29**] 02:28AM BLOOD Neuts-88.5* Bands-3.1 Lymphs-2.1*
Monos-3.1 Eos-2.1 Baso-0 Metas-1.0*
[**2199-7-29**] 02:28AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-2+ Polychr-NORMAL
[**2199-8-8**] 01:20PM BLOOD UreaN-30* Creat-0.9 K-5.0
[**2199-8-8**] 07:00AM BLOOD Glucose-135* UreaN-29* Creat-0.9 Na-142
K-5.2* Cl-107 HCO3-26 AnGap-14
[**2199-8-3**] 01:00AM BLOOD ALT-12 AST-58* AlkPhos-424* Amylase-47
TotBili-0.9
[**2199-8-8**] 07:00AM BLOOD Calcium-9.1 Phos-4.1 Mg-2.2
[**2199-8-5**] 02:21AM BLOOD calTIBC-163* Ferritn-369 TRF-125*
[**2199-8-5**] 02:42AM BLOOD Type-ART Temp-37.2 FiO2-96 pO2-78*
pCO2-41 pH-7.45 calTCO2-29 Base XS-3 AADO2-580 REQ O2-93
Intubat-NOT INTUBA
[**2199-8-3**] 08:13AM BLOOD K-3.6
[**2199-8-3**] 08:13AM BLOOD K-3.6

Brief Hospital Course:
HD#1 - presentation to ED. Sigmoid volvulus evident on
radiography, aspirated in ED, requiring intubation, hypotensive
- thought secondary to aspiration moreso than bowel necrosis
from volvulus; transferred to SICU for volvulus reduction

HD#2 - Required levophed drip overnight to maintain blood
pressure, sedated on propofol, intubated on 100% FiO2, preop'ed
for surgery (subtotal colectom for sigmoid volvulus), returned
from surgery - sedation maintained, levophed drip continues with
sbp's in 100s. Lactate 5.5 for which patient received 1L saline
bolus
Abdominal wound left open with 10 wicks for granulation tissue
promostion and consolidation of granulous tracts.

HD#3 - Patient continues to wean off levophed, sedation
continues, maintains intubation, lactate level decreasing from
5.4->3.5

HD#4 - patient continues to wean off levophed, sedation
continues (levophed drip @ 0.030,  propofol drip @ 20),
intubated on CPAP (50 FiO2) with attempts to extubate today if
able to wean off pressors; neurology saw patient and recommended
restarting home meds by G tube

HD#5 - patient weaned from propofol, sedated on versed for
agitation. following commands spontaneously but not
purposefully, trophic tube feeds 25cc/hr.  oxygenation with PaO2
70s-80s and SPO2 94-96 - PEEP required increase to 12, CPAP+PS
continue for ventilation.  FiO2 increased that afternoon to 70%
due to PaO2 in 60's on PEEP 14

HD#6 - Lasix drip at 5.0/hr  Continues on antibiotics Zosyn,
flagyl, vancomycin, diflucan (sputum culture grew out yeast),
generalized edema noted, diuresis continues, trophic tube feeds
continue, respiratory status - FiO2 wean attempts continue but
required 70% FiO2

HD#7 - Lasix drip continues at 5/0/hr Continues on antibiotics,
no vent changes, MAP > 60, right a-line changed, difficulty
maintaining ostomy seal, sedation on versed maintained
intermittently

HD#8 - patient changed to APRV to maintain oxygenation with
improved ABG, able to wean FiO2 down to 50%, with PaO2 in the
low 100s.  In the evening - remained intubated on PSV 8/18,
bronched x 2 for copious, thick, yellow secretions.  Sedated on
propofol drip

HD#9 - patient weaned off all pressors, lungs appear stable
although CXR still demonstrates diffuse infiltrates.  BAL
demonstrates NGTD, Tube feeds increased to 45 with goal of 80 @
3/4 strength.  Antibiotics continue for aspiration pneumonia

HD#10 - white count decreasing with serial bronchs.  stoma
producing excellent stool output. CXR clearning. PT advanced to
goal tube feeds.

HD#11 - pt remaines intubated/sedated on PSV, diuresis continues
overnight, oxygenation improving with a PEEP of 2 in the AM

HD#12 - Patient was extubated, lungs sound clear, remained on
12L/min oxgyen and sat was 97%. Continued to increase Lopressor
to maintain rate and blood pressure. Patient continued to be
diuresis. Insulin requirements were increased based on the
fingersticks ranging from 148-164. Patient received a CT Scan of
the head per neurolog recommendation to evaluate for bleed,
which was negative.
HD13 - Neuro status continued to improve and patient is followed
by the neurology service.
HD16 - patient was transferred to the floor from ICU with 1:1
sitter in place to maintain patency of j-g tube and iv lines.
Neurology continued to follow with recommendations to hold tube
feedings 30minutes pre and post Parkinson's medications,
decrease troheyphenidyl to 1 mg for next 4 days and then d/c.
Patient was evaluated by speech and swallow for aspiration, they
recommended starting on thin liquids and puree diet. Screening
process started for rehab per physical therapy recommendations.
HD17 - Parkinson's: neurologically continues to improve and has
follows commands appropriately with purposeful movement,
hypophonia,  patient should contact primary neurology as an
outpatient (Dr. [**First Name (STitle) 7951**]. Continue to wean off Artane as planned.
Hemodynamically that patient has remained stable and afebrile.
Aspiration pneumonia - Patient has remained on 3liters via nasal
cannula and saturation maintaining sats of >94% and slightly
tachypnea with a rate of 26-29. Surgical incision has been
maintained via vac dressing system @ 125mmHg of suction.
Nutrition - patient's tube feeding started to be cycled for
16hours daily at a rate of 100cc/hr and he is tolerating liquid
oral intake. Ostomy - followed by ET nurses throughout
hospitalization, the stoma is located in the RLQ, size is 1 X 1
[**1-7**] inch, slightly protruding and red, the postion of the OS is
center. The mucocutanous junction is intact and the stool is
pasty brown. Patient was seen by the ET nurses on the day of
d/c. Skin - patient has a small right heel decubitus that has
been treated with [**Last Name (un) 16288**] vista and elevation, otherwise skin is
unremarkable. Patient was evaluated by physical therapy and felt
it was appropriate to d.c patient to a rehab facility.

Medications on Admission:
Sinemet 7 times a day
[**Last Name (un) 16285**] 2''3'
Trihexyphenidyl 1'
Zoloft75'
Lipitor20'
Vesicare5'
Patanol 2'
Dulcolax10'
Remeron 15'
Folplex 2.2'
Seroquel 25mg
Restasis
Protonix 40'
Florinef (new)

Discharge Medications:
1. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
DAILY Q0630 (): Crushed down G-tube  .
2. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
3. Trihexyphenidyl 2 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily)
for 4 days.
4. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours) as needed for fever.
5. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-1**]
Drops Ophthalmic Q2H (every 2 hours).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
9. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: Two
(2) Packet PO PRN (as needed) as needed for phos<3.0.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - MACU

Discharge Diagnosis:
Aspiration pneumonia, sigmoid volvulus


Discharge Condition:
stable, off ventilator and all drips/pressors, able to tolerate
liquid/puree diet s/p swallow eval, afebrile, hemodynamically
stable; feeding tube sites functional and otherwise without
problem


Discharge Instructions:
You, the patient, are to be discharged to an extended care
facility (rehabilitation) before returning home to your
residence.  You are to follow-up with Dr. [**Last Name (STitle) **] in his clinic
for a post-operative visit.  You are to also follow-up with your
outpatient primary care physician for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 16289**] follow-up
appointment.

Please return to the hospital (emergency room) for the
following:
* fevers > 101/5
* increasing abdominal pain
* pus from wound
* bleeding from wound
* blackening of ostomy site
* pus from any feeding tube site
* any concerns or problems regarding your health status

Followup Instructions:
You, the patient, are to be discharged to an extended care
facility (rehabilitation) before returning home to your
residence.  You are to follow-up with Dr. [**Last Name (STitle) **] in his clinic
for a post-operative visit.  You are to also follow-up with your
outpatient primary care physician for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 16289**] follow-up
appointment.



Completed by:[**2199-8-9**]
{'Unspecified vascular insufficiency of intestine,Volvulus,Perforation of intestine,Pneumonitis due to inhalation of food or vomitus,Paroxysmal ventricular tachycardia,Pressure ulcer, heel,Paralysis agitans,Unspecified essential hypertension,Pure hypercholesterolemia'}


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: Presented with 3 day history of constipation with flatus and
abdominal distention and pain.

PRESENT ILLNESS: 76 yo M with PMHx sig for Parkinson's and history of
constipation who presents with no stools for the past four days
and abdominal pain and distention for the past few days.  pain
was initially in the lower abdomen, became increasingly severe,
which caused the patient to come to the [**Hospital1 18**] ER.  KUB in the ER
demonstrated sigmoid volvulus - CT scan confirmed, and the
patient was admitted to the SICU for decompression.

MEDICAL HISTORY: Parkinson disease s/p deep brain stimulator placement
Hypertension
Hyperlipidimia

MEDICATION ON ADMISSION: Sinemet 7 times a day
[**Last Name (un) 16285**] 2''3'
Trihexyphenidyl 1'
Zoloft75'
Lipitor20'
Vesicare5'
Patanol 2'
Dulcolax10'
Remeron 15'
Folplex 2.2'
Seroquel 25mg
Restasis
Protonix 40'
Florinef (new)

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: 122/68 P 86 RR 29 96% on FIO2 50% (after aspiration in ED)

FAMILY HISTORY: non contributory

SOCIAL HISTORY: non contributory 

### Response:
{'Unspecified vascular insufficiency of intestine,Volvulus,Perforation of intestine,Pneumonitis due to inhalation of food or vomitus,Paroxysmal ventricular tachycardia,Pressure ulcer, heel,Paralysis agitans,Unspecified essential hypertension,Pure hypercholesterolemia'}
