CHIEF COMPLAINT: 

PRESENT ILLNESS: 

MEDICAL HISTORY: Pedestrian struck by motor vehicle on
[**2144-11-12**], subsequent hospital course was as follows.  Status
post exploratory laparotomy with a splenectomy and
diaphragmatic rupture repair.  The patient had a right
internal capsule and right frontal lobe intracranial bleed.
On [**2144-11-13**], he went to the operating room for external
fixation of his left tib-fib fracture.  Subsequently he was
noted to have a right MCA embolic stroke with a patent
foramen ovale.  He had an IVC filter placed.  On [**2144-11-19**],
he went back to the operating room and had an ORIF performed
of his left tib-fib fracture.  On [**2144-11-21**], status post
exploratory laparotomy, appendectomy for perforated
gangrenous appendicitis, status post tracheostomy, status
post percutaneous cholecystostomy on [**2144-11-27**], secondary to
acalculous cholecystitis, an episode of rapid atrial
fibrillation, and underwent a left lung decortication on
[**2145-1-1**].

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Pneumonia due to Pseudomonas,Unspecified septicemia,Calculus of gallbladder with other cholecystitis, without mention of obstruction,Closed fracture of unspecified part of fibula with tibia,Tracheostomy status
Pseudomonal pneumonia,Septicemia NOS,Cholelith w cholecys NEC,Fx tibia w fibula NOS-cl,Tracheostomy status
Admission Date:  [**2144-12-21**]     Discharge Date:  [**2145-1-18**]

Date of Birth:   [**2087-11-11**]     Sex:  M

Service:

The patient is a 57-year-old man who is well known to the
Trauma Service, status post pedestrian struck by motor
vehicle on [**2144-11-12**] with a subsequent prolonged hospital
stay.  The patient was discharged to rehab on [**2144-12-18**].  On
the evening of [**2144-12-20**], his percutaneous cholecystostomy
tube was inadvertently removed.  Subsequently, he had
complaints of abdominal pain and the patient was transferred
to [**Hospital1 18**] for evaluation.  In the E.R., he had complaints of
diffuse abdominal pain, nausea and vomiting, also with
complaints of difficulty breathing.  In the E.R., he had an
episode of emesis, which was witnessed, with aspiration of
gastric contents.

PAST MEDICAL HISTORY:  Pedestrian struck by motor vehicle on
[**2144-11-12**], subsequent hospital course was as follows.  Status
post exploratory laparotomy with a splenectomy and
diaphragmatic rupture repair.  The patient had a right
internal capsule and right frontal lobe intracranial bleed.
On [**2144-11-13**], he went to the operating room for external
fixation of his left tib-fib fracture.  Subsequently he was
noted to have a right MCA embolic stroke with a patent
foramen ovale.  He had an IVC filter placed.  On [**2144-11-19**],
he went back to the operating room and had an ORIF performed
of his left tib-fib fracture.  On [**2144-11-21**], status post
exploratory laparotomy, appendectomy for perforated
gangrenous appendicitis, status post tracheostomy, status
post percutaneous cholecystostomy on [**2144-11-27**], secondary to
acalculous cholecystitis, an episode of rapid atrial
fibrillation, and underwent a left lung decortication on
[**2145-1-1**].

MEDICATIONS ON THIS ADMISSION:
1.  Aspirin 325 mg q.day.
2.  Subcu heparin 5,000 units b.i.d.
3.  Flomax 0.4 mg q.day.
4.  Tylenol p.r.n.
5.  Colace 100 mg b.i.d.
6.  Percocet p.r.n.

ALLERGIES:  No known drug allergies.

PHYSICAL EXAMINATION:  Temperature was 103.0??????, heart rate
110, blood pressure 110/palp, 150/80, breathing between 24 to
50, 90% saturation.  GENERAL:  He was alert and oriented
times three, appropriate.  HEENT:  Pupils were equally round
and reactive bilaterally.  Extraocular movements intact.
Oropharynx was clear.  C-collar was placed.  CARDIOVASCULAR:
Regular rate and rhythm.  CHEST:  Decreased breath sounds at
the left base, otherwise fine crackles bilaterally.  No
wheezes.  ABDOMEN:  Non-distended, diffusely tender with
guarding except at left upper quadrant where it was negative.
Negative drainage from cholecystostomy tube site.  RECTAL:
Negative mass.  Guaiac negative.  EXTREMITIES:  2+ DP pulses
bilaterally, minimal edema.

LABORATORY:  Hematocrit 45.7, white count 20.4, platelet
count 985.  Chem-7:  Sodium 137, potassium 5.4, chloride 106,
bicarb 24, BUN 19, creatinine 0.5, glucose 83, calcium 10.6,
magnesium 2.5, phosphorus 6.5, albumin 3.5, AST 110, ALT 60,
total bilirubin 1, amylase 103, lipase 43, alkaline
phosphatase 423.

Chest x-ray at that time showed feeding tube in proximal
esophagus.  Left lower lobe collapse.  No free air in the
abdomen.

At that time, the patient was aggressively resuscitated,
placed on broad-spectrum antibiotics, vancomycin and Zosyn.
The patient had ABGs on the day of admission which revealed
pH 7.33, pCO2 25, pO2 75, bicarb 25, -1 base excess.  At that
time, CT of abdomen and chest were performed, showing slight
decrease in size of the loculated left pleural effusion,
persistent collapse of the left lower lobe, and posteroapical
segment of the left lower lobe, also small amount of
perihepatic fluid as well as fluid in bilateral pericolic
gutters and the pelvis, which could represent a bile leak
consequent to the forceful extraction of the cholecystostomy
tube, with minimal right mesenteric stranding which may be
related to postsurgical changes.  An area of high attenuation
in the region of the right UV junction, small, partially
obstructing stone cannot be excluded.  A right subclavian
line was placed on the day of admission.

Given the nature of his peritoneal signs and the degree of
septic physiology, it was elected to take him to the
operating room for an exploratory laparotomy.
Cholecystectomy and right upper quadrant drains were placed.
Estimated blood loss was 500 cc.  The patient was taken to
the PACU in guarded condition.  See operative note for
further detail.  A CT surgery consult was obtained on post-op
day #1 to evaluate the multiple rib fractures in proximity to
the heart.  Thoracic team bronchoscoped the patient and found
thick yellow-green plug in left upper lobe and left lower
lobe trifurcation, which was sent for cultures and Gram
stain.  Otherwise, their recommendation was to bronchoscope
again, also chest PT, but no concern for the rib fractures.
On post-op day #2, [**2144-12-23**], the patient continued to be
afebrile and required moderate amounts of fluids.  His white
blood cell count continued to increase up to 26.

It was, therefore, decided to take him back to the operating
room to re-explore and wash out his abdomen to rule out any
other septic focus.  Again, bile peritonitis (post-op
diagnosis), no other focus for infection.  Wash-out was
performed.  Blood loss was 100 cc and no complications.  The
patient was taken to the PACU in fair condition.  See
operative note for further details.  Postoperatively, the
patient remained febrile.  On [**2144-11-23**] another bronchoscopy
was performed, which found copious thick secretions on the
left.  Chest x-ray was also done on [**2144-11-23**], which showed
improvement on the right side with little change on the left.
On [**2144-11-24**], the patient's vitals had improved to T-max
99.1??????, heart rate 88, blood pressure 117/64, respiratory rate
10, satting 98%.  He was on CPAP, PEEP of 10, pressure
support of 15.  At that point, in terms of cultures, blood
cultures had not grown anything.  Sputum had grown Staph.
aureus.  The urine culture is still pending and peritoneal
culture has just started growing MRSA.  Also Klebsiella was
growing from the [**2144-12-22**], therefore both Zosyn and
vancomycin were continued.

The patient was getting TPN for nutrition thus far through
the hospital course.  He was started on tube feeds on
[**2144-12-27**], which were increased slowly.  Tube feeds were at
goal of 110 on [**2144-12-30**].  At that point, TPN was DC'd.

The patient's respiratory status was a major issue.  The
patient continued to have a lot of secretions which made
weaning from the ventilator difficult.  The patient failed
many trach mask trials.  On [**2144-12-30**], the patient was on
trach O2, tolerated this well with a blood gas of 7.44, 42,
88, 29, base excess of 3.

As of [**2145-1-1**], the patient's neurologic status revealed he
was awake, alert, continued to have weakness on his left arm
and leg.  Plan was to continue to treat his intermittent
agitation with Ativan.

Cardiovascularly, he is on 50 mg of Lopressor b.i.d. for his
previous history of MI.  Currently, he had pulse in the 80s
and BP of 110 systolic.  Respiratory-wise, he continued to
have ongoing problems with secretions.  They did not appear
to look like tube feeds, but thick yellow secretions.  Chest
x-ray from [**2144-12-29**] showed much improved aeration in the
left lobe.  Blood gases showed good oxygenation.  Planned to
continue pulmonary toilet, which will necessitate the ICU
stay, so he does not develop significant mucus plugs that
will compromise his respiratory status.

GI:  The patient's abdomen is soft, wound is clean.  The
patient has normal bowel function.  At this point, the plan
is to continue tube feeds and to discontinue Protonix.

I.D.:  He is still on Zosyn and vancomycin covering his
Klebsiella pneumonia and Staph. pneumonia and peritoneal
culture that grew out Staph.  Plan is to continue Zosyn and
vancomycin until white counts are normal and he is afebrile
for 24 hours.  Antibiotics were DC'd on [**2145-1-3**] after a
12-day course of vancomycin and 13-day course of Zosyn.

Speech and swallow evaluation was obtained on [**2144-12-30**].
Consult said patient was not considered safe for p.o. intake,
consider a PEG for long-term tube feeds.  Because the patient
had problems with aspiration left lower lobe pneumonia
necessitating tracheostomy, and due to the fact that he
developed a right hemispheric stroke, the PEG procedure was
performed for long-term tube feeds.  After the PEG placement,
the patient developed progressive worsening abdominal pain,
tenderness, and tachycardia, unable to really control pain
despite multiple doses of fentanyl.  Abdomen was diffusely
tender to light palpation.  Hematocrit was 29.9.  Foley
catheter was placed, showed no urine output.  Episodic
decreased BPs to 80/palp, responsive to crystalloid bolus,
left subclavian Cordis and right radial lines placed.  CVP
was low.  Multiple liters of crystalloid were administered
without any urine output.  Systolic blood pressure was
maintained at 110 range.  With deteriorating clinical status,
concern for visceral injury at the PEG placement site and
questionable injury to transverse colon, possible bleeding at
PEG site.  Repeat crit was 27.2.  The patient was started
back on Zosyn empirically.  CT scan revealed tapering of the
colon up to and away from site of PEG, question of
penetration tenting, large hematoma at left upper quadrant,
displacement of left colon medially, and free fluid in the
pelvis.

The patient was taken back to the O.R. for exploration.  At
that point, he had evacuation of his hematoma and removal and
replacement of the gastrostomy tube.  The patient received
three units of packed red blood cells, two units of FFP, and
one unit of platelets.  Estimated blood loss was 500 cc.
I.V. fluids 2500 cc, urine out 175 cc.  Findings included a
large amount of clot, abdomen without active bleeding or
particular site identified, PEG passing through pericolonic
tissue, not through colon itself.  The patient was taken to
the SICU in stable condition.  Post-op crit was 34.  The
patient was restarted on TPN and tube feedings were held.  At
that time, sputum culture on [**2144-12-29**] continued to grow
MRSA and Gram-negative rods, presumably Klebsiella.  The
collar was removed on [**2144-12-30**] after an 8-week course.
Tube feeds were restarted on [**2145-1-8**] after the patient had
a bowel movement on [**2145-1-7**].  Blood culture on [**2145-1-7**]
showed Gram-negative rods, so Cipro was added to Zosyn for
coverage.  Enterobacter, Ceftaz, Bactrim, piperacillin, was
growing out from [**2145-1-7**] blood culture.  Zosyn was
discontinued at that time and gentamicin was started.

The patient was transferred to the floor on  [**2145-1-13**] after
finishing a 7-day antibiotic course of gentamicin and
ciprofloxacin.  At that time, the patient was afebrile and
had a white count of 15, was stable.  His tube feeds were at
goal at 90 cc of Impact with fiber.  His secretions had
improved and his trach-mask.  The patient is on the floor
remaining afebrile with stable white count.  Nutrition was
asked to re-evaluate patient caloric needs.  The patient's
tube feeds were changed to ____________________  at
full-strength, 7 cc an hour.

At the time of discharge, the patient was doing well, taking
medications including:

1.  Oxazepam 15 mg p.o. q.h.s. p.r.n. per G-tube.
2.  Colace 100 mg p.o. b.i.d.
3.  Aspirin 325 mg per PEG.
4.  Roxicet 5 - 10 ml p.o. q.4-6h. p.r.n.
5.  Heparin 5,000 units subcu b.i.d.
6.  Mupirocin nasal ointment 2% b.i.d.
7.  Bisacodyl 10 mg q.h.s. p.r.n.
8.  Lopressor 50 mg p.o. b.i.d.
9.  Insulin, sliding scale.
10.  Tylenol 650 mg p.o. q.4-6 hours.
11.  Albuterol 6 puffs q.4h.

The patient has a 7.0 trach with inner cannula.  The patient
is to follow up with Dr. [**Last Name (STitle) **].  He is being discharged on
[**2145-1-18**] to rehab.




                          [**Name6 (MD) 19851**] [**Name8 (MD) 19852**], M.D.  [**MD Number(1) 19853**]

Dictated By:[**Last Name (NamePattern1) 7241**]

MEDQUIST36
rp12/09/[**2144**]
D:  [**2145-1-16**]  17:00
T:  [**2145-1-16**]  17:34
JOB#:  [**Job Number 44178**]


Name:  [**Known lastname 2441**], [**Known firstname 7978**]                     Unit No:  [**Numeric Identifier 7979**]

Admission Date:  [**2144-12-21**]     Discharge Date:  [**2145-1-21**]

Date of Birth:   [**2087-11-11**]     Sex:  M

Service:

For the continued abdominal pain, the patient had an
abdominal computerized tomography scan with oral and
intravenous contrast on [**2145-1-18**] which showed a 5 cm
left infrarenal fluid collection which was subsequently
drained on [**2145-1-19**] which was computerized
tomography-guided, approximately 40 cc of hematogenous
material was aspirated and no drain was placed.  The aspirate
was sent to the laboratory for gram stain and culture.  Gram
stain showed 1+ polys, no organisms and on culture there had
been no growth to date.  The patient also received a speech
and swallow evaluation on [**1-19**] and the patient had a
video swallow which was performed on [**1-20**] which showed
no evidence of aspiration and an essentially normal study.
Therefore, the patient was advanced to a regular diet as
tolerated.  His white blood cell count on [**2145-1-10**]
was 12.4.  The patient is being discharged to rehabilitation
on [**2145-1-21**] on the medications listed previously and
will be decreased as his p.o. intake increases.




                          [**Name6 (MD) 7930**] [**Name8 (MD) 7931**], M.D.  [**MD Number(1) 7932**]

Dictated By:[**Last Name (NamePattern1) 5567**]

MEDQUIST36

D:  [**2145-1-20**]  17:44
T:  [**2145-1-20**]  18:52
JOB#:  [**Job Number 8358**]
{'Pneumonia due to Pseudomonas,Unspecified septicemia,Calculus of gallbladder with other cholecystitis, without mention of obstruction,Closed fracture of unspecified part of fibula with tibia,Tracheostomy status'}


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: 

PRESENT ILLNESS: 

MEDICAL HISTORY: Pedestrian struck by motor vehicle on
[**2144-11-12**], subsequent hospital course was as follows.  Status
post exploratory laparotomy with a splenectomy and
diaphragmatic rupture repair.  The patient had a right
internal capsule and right frontal lobe intracranial bleed.
On [**2144-11-13**], he went to the operating room for external
fixation of his left tib-fib fracture.  Subsequently he was
noted to have a right MCA embolic stroke with a patent
foramen ovale.  He had an IVC filter placed.  On [**2144-11-19**],
he went back to the operating room and had an ORIF performed
of his left tib-fib fracture.  On [**2144-11-21**], status post
exploratory laparotomy, appendectomy for perforated
gangrenous appendicitis, status post tracheostomy, status
post percutaneous cholecystostomy on [**2144-11-27**], secondary to
acalculous cholecystitis, an episode of rapid atrial
fibrillation, and underwent a left lung decortication on
[**2145-1-1**].

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Pneumonia due to Pseudomonas,Unspecified septicemia,Calculus of gallbladder with other cholecystitis, without mention of obstruction,Closed fracture of unspecified part of fibula with tibia,Tracheostomy status'}
