CHIEF COMPLAINT: Morbid obesity

PRESENT ILLNESS: [**Known firstname **] has class III morbid obesity with weight 290.1 lbs,
height 71 inches and BMI 40.5. His previous weight loss efforts
[**Street Address(1) 32919**] visits, Slim-Fast, HMR, and Weight Watchers.
He has not taken prescription weight loss medications or used
over-the-counter ephedra-containing appetite suppressants/herbal
supplements. He stated he developed significant [**Last Name 4977**] problem
at age 27 and cites as factors contributing to his excess weight
large portions, genetics, too many carbohydrates and saturated
fats and lack of exercise. He does walk 30-60 minutes several
times a week. He denied history of eating disorders or
depression.

MEDICAL HISTORY: Past Medical History:
1.  Hypertension.
2.  Type 2 diabetes with hemoglobin A1c of 8.2.
3.  Dyslipidemia with elevated triglycerides.
4.  Obstructive sleep apnea, on CPAP.
5.  History of penile candidiasis.
6.  Fatty liver by ultrasound.

MEDICATION ON ADMISSION: Acarbose 100 mg TID
Diltiazem 240 mg ER daily
Folic acid 1000 mg daily
Gemfibrizol 600 mg [**Hospital1 **]
Glargine 40 units [**Hospital1 **]
Insulin aspart sliding scale
Lisinopril 40 mg q am, 20 mg q pm
Simvastatin 40 mg daily
Omega 3 6,000 mg daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: VS: 97.9 91 137/65 20 98 RA

FAMILY HISTORY: Father deceased at age 45 with diabetes, hyperlipidemia, and
obesity.  Mother living, age 69, with arthritis.  Brother
living, age 39, with asthma. Grandfather deceased at age 65 of a
stroke and diabetes.

SOCIAL HISTORY: He denies tobacco or recreational drug use, has alcohol on
social occasions and drinks both caffeinated and carbonated
beverages.
Morbid obesity,Paroxysmal ventricular tachycardia,Body Mass Index 40.0-44.9, adult,Other chronic nonalcoholic liver disease,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Laparoscopic surgical procedure converted to open procedure,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Obstructive sleep apnea (adult)(pediatric)
Morbid obesity,Parox ventric tachycard,BMI 40.0-44.9, adult,Chronic liver dis NEC,DMII wo cmp uncntrld,Lap surg convert to open,Hyperlipidemia NEC/NOS,Hypertension NOS,Obstructive sleep apnea
Admission Date:  [**2195-5-4**]              Discharge Date:   [**2195-5-10**]

Date of Birth:  [**2150-6-8**]             Sex:   M

Service: SURGERY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Morbid obesity

Major Surgical or Invasive Procedure:
[**2195-5-4**]:
1. Laparoscopic converted to open Roux-en-Y gastric bypass.
2. Resection of small intestine with anastomosis.


History of Present Illness:
[**Known firstname **] has class III morbid obesity with weight 290.1 lbs,
height 71 inches and BMI 40.5. His previous weight loss efforts
[**Street Address(1) 32919**] visits, Slim-Fast, HMR, and Weight Watchers.
He has not taken prescription weight loss medications or used
over-the-counter ephedra-containing appetite suppressants/herbal
supplements. He stated he developed significant [**Last Name 4977**] problem
at age 27 and cites as factors contributing to his excess weight
large portions, genetics, too many carbohydrates and saturated
fats and lack of exercise. He does walk 30-60 minutes several
times a week. He denied history of eating disorders or
depression.


Past Medical History:
Past Medical History:
1.  Hypertension.
2.  Type 2 diabetes with hemoglobin A1c of 8.2.
3.  Dyslipidemia with elevated triglycerides.
4.  Obstructive sleep apnea, on CPAP.
5.  History of penile candidiasis.
6.  Fatty liver by ultrasound.

Past surgical history includes a ventral hernia repair in [**2184**]
by
Dr. [**Last Name (STitle) **] at which time he placed a [**Doctor Last Name 4726**]-Tex mesh.


Social History:
He denies tobacco or recreational drug use, has alcohol on
social occasions and drinks both caffeinated and carbonated
beverages.


Family History:
Father deceased at age 45 with diabetes, hyperlipidemia, and
obesity.  Mother living, age 69, with arthritis.  Brother
living, age 39, with asthma. Grandfather deceased at age 65 of a
stroke and diabetes.


Physical Exam:
VS: 97.9 91 137/65 20 98 RA

Constitutional: comfortable, NAD
Neuro: EOMI
Cardiac: RRR, no M/R/G, clear S1, S2
Lungs: CTAB
Abdomen: obese, soft, non-tender to palpation
Wounds: no erythema or drainage, incision well-healed
Ext: no unilateral swelling or peripheral edema

Pertinent Results:
[**2195-5-4**] 12:38PM   WBC-13.3*# RBC-4.79 HGB-14.6 HCT-39.8* MCV-83
MCH-30.4 MCHC-36.6* RDW-15.4
[**2195-5-4**] 12:38PM   GLUCOSE-339* UREA N-20 CREAT-1.5* SODIUM-138
POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-24 ANION GAP-16

CXR [**2195-5-6**]: There is interval development of mild vascular
congestion but no overt pulmonary edema. The lung volumes are
low. Bibasilar opacities, left more than right are most likely
consistent with areas of atelectasis. Left and right
costophrenic sulci were not included in this field of view, thus
smaller or larger pleural effusion cannot be excluded. There is
no pneumothorax.



Brief Hospital Course:
The patient presented to pre-op on [**2195-5-4**]. Pt was evaluated by
anaesthesia, and his blood sugars were significantly elevated
preoperatively.  He was taken to the operating room for
laparoscopic gastric bypass, which was converted to an open
gastric bypass.  Pt was extubated, taken to the PACU until
stable, then transferred to the [**Hospital1 **] for observation.

Neuro: The patient was alert and oriented throughout her
hospitalization; pain was initially managed with a PCA and then
transitioned to oral Roxicet once tolerating a stage 2 diet.
CV: Patient was in sinus tachycardia postoperatively.  On POD#1,
pt went into new-onset atrial fibrillation with rapid
ventricular rate and was transferred to the ICU.  Cardioversion
with amiodarone was first attempted and, after this failed, he
was electrically cardioverted on POD#2.  He returned to [**Location 213**]
sinus rhythm following cardioversion, and remained in normal
sinus rhythm for the remainder of his hospital stay.  He
remained in sinus tachycardia for the remainder of his stay,
which was initially managed with IV lopressor but this was
discontinued.  His heart rate remained 90-110 in normal sinus
rhythm on diltiazem.  He was switched from extended release to a
normal diltiazem formulary given the fact that he will need to
crush this medication. His HCTZ remains held perioperatively,
and his lisinopril dose was decreased to 20 daily, which can be
increased if necessary at his postoperative PCP [**Name Initial (PRE) **].  He did
have intermittent bursts of ventricular tachycardia. Cardiology
recommended optimization of electrolytes, and this resolved. We
have recommended close follow-up for his cardiac issues.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: He was initially kept NPO until an upper GI study was
performed on post-operative day 1 and was negative for a leak,
Therefore, his diet was advanced to a bariatric stage 1 diet,
which was advanced sequentially to stage 3, and well tolerated.
Patient's intake and output were closely monitored.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Endo: The patient was initially placed on an IV insulin drip
postoperatively for blood sugars >250.  After his blood sugars
returned to [**Location 213**], he was placed on Lantus plus a sliding
scale, which was closely managed by the [**Last Name (un) **] team.  He is
being discharged on Lantus, metformin, and an insulin sliding
scale, and will have close follow-up with [**Last Name (un) **] diabetes as an
outpatient.
Prophylaxis: The patient received subcutaneous heparin and [**Last Name (un) **]
dyne boots were used during this stay; she was encouraged to get
up and ambulate as early as possible.

At the time of discharge, the patient was doing well, afebrile
with stable vital signs.  The patient was tolerating a stage 3
diet, ambulating, voiding without assistance, and pain was well
controlled.  His drain was removed and staples left in place.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.

The cardiology service recommended restarting his home dose of
diltiazem, and restarting lisinopril at a lower dose of 20 daily
instead of 20 twice daily.  They also recommended restarting
hydrochlorothiazide.  The patient was instructed to follow up
with his PCP for [**Name Initial (PRE) **] blood pressure check and, at that time, his
lisinopril dose may be increased to his preoperative dose as
needed.  His hydrochlorothiazide may also be restarted at that
time.  He should be continued on the usual formulary for
diltiazem, rather than the extended release version, given the
fact that he will be crushing this medication.


Medications on Admission:
Acarbose 100 mg TID
Diltiazem 240 mg ER daily
Folic acid 1000 mg daily
Gemfibrizol 600 mg [**Hospital1 **]
Glargine 40 units [**Hospital1 **]
Insulin aspart sliding scale
Lisinopril 40 mg q am, 20 mg q pm
Simvastatin 40 mg daily
Omega 3 6,000 mg daily

Discharge Medications:
1. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for Pain.
Disp:*300 ML(s)* Refills:*0*
2. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. ranitidine HCl 15 mg/mL Syrup Sig: Ten (10) mL PO BID (2
times a day).
Disp:*600 mL* Refills:*2*
4. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day) as needed for Constipation.
Disp:*300 mL* Refills:*1*
5. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

6. multivitamin,tx-minerals     Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
8. Insulin sliding Scale
insulin sliding scale: as attached
9. Lantus 100 unit/mL Solution Sig: Seventeen (17) units
Subcutaneous at bedtime: hold for blood sugar < 130.


Discharge Disposition:
Home

Discharge Diagnosis:
1. Diabetes mellitus type 2.
2. Morbid obesity.
3. Hyperlipidemia.
4. Hypertension.
5. Atrial fibrillation


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
Discharge Instructions: Please call your surgeon or return to
the emergency department if you develop a fever greater than
101.5, chest pain, shortness of breath, severe abdominal pain,
pain unrelieved by your pain medication, severe nausea or
vomiting, severe abdominal bloating, inability to eat or drink,
foul smelling or colorful drainage from your incisions, redness
or swelling around your incisions, or any other symptoms which
are concerning to you.

You had a rapid heart rate, atrial flutter, during this
hospitalization which responded to electrical cardioversion. You
also intermittently had short bursts of a rhythm called
ventricular tachycardia, which resolved with optimization of
your electrolytes. You should have close follow-up with your PCP
who will determine whether you should continue to see a
cardiologist as an outpatient.  Your blood sugar was also
difficult to control throughout this hospitalization. With the
help of the [**Last Name (un) **] diabetes team, we have optimized your blood
sugar control, but you should continue to work with your primary
care physician to better manage your diabetes.

DO NOT TAKE THE EXTENDED RELEASE VERSION OF DILTIAZEM OR ANY
OTHER MEDICATION. CRUSHING AND TAKING THIS MEDICATION CAN BE
VERY DANGEROUS AND POTENTIALLY LETHAL. We have prescribed the
standard diltiazem formulary. You should continue with this.

Diet: Stay on Stage III diet until your follow up appointment.
Do not self advance diet, do not drink out of a straw or chew
gum.

Medication Instructions:
Resume your home medications, CRUSH ALL PILLS.
You will be starting some new medications:
1.  You are being discharged on medications to treat the pain
from your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
2. You should begin taking a chewable complete multivitamin with
minerals. No gummy vitamins.
3. You will be taking Zantac liquid 150 mg twice daily for one
month. This medicine prevents gastric reflux.
4. You will be taking Actigall 300 mg twice daily for 6 months.
This medicine prevents you from having problems with your
gallbladder.
5. You should take a stool softener, Colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
6. You must not use NSAIDS (non-steroidal anti-inflammatory
drugs) Examples are Ibuprofen, Motrin, Aleve, Nuprin and
Naproxen. These agents will cause bleeding and ulcers in your
digestive system.

Activity:
No heavy lifting of items [**9-26**] pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.

Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.


Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RD Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2195-5-21**] 3:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], MD Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2195-5-21**] 3:45

We have scheduled a follow-up appointment with your PCP, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 2903**], on [**2195-5-22**] at 12:15pm.

You have a follow-up appointment with endocrinology at [**Last Name (un) **]
with Dr. [**Last Name (STitle) 32920**] on [**2195-5-12**] at 9am.  The phone number is
[**Telephone/Fax (1) 32921**].

It is also recommended that you schedule an appointment to see a
cardiologist at [**Hospital1 18**] after discharge.  Please call [**Telephone/Fax (1) 62**]
to schedule an appointment.
{'Morbid obesity,Paroxysmal ventricular tachycardia,Body Mass Index 40.0-44.9, adult,Other chronic nonalcoholic liver disease,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Laparoscopic surgical procedure converted to open procedure,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Obstructive sleep apnea (adult)(pediatric)'}


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: Morbid obesity

PRESENT ILLNESS: [**Known firstname **] has class III morbid obesity with weight 290.1 lbs,
height 71 inches and BMI 40.5. His previous weight loss efforts
[**Street Address(1) 32919**] visits, Slim-Fast, HMR, and Weight Watchers.
He has not taken prescription weight loss medications or used
over-the-counter ephedra-containing appetite suppressants/herbal
supplements. He stated he developed significant [**Last Name 4977**] problem
at age 27 and cites as factors contributing to his excess weight
large portions, genetics, too many carbohydrates and saturated
fats and lack of exercise. He does walk 30-60 minutes several
times a week. He denied history of eating disorders or
depression.

MEDICAL HISTORY: Past Medical History:
1.  Hypertension.
2.  Type 2 diabetes with hemoglobin A1c of 8.2.
3.  Dyslipidemia with elevated triglycerides.
4.  Obstructive sleep apnea, on CPAP.
5.  History of penile candidiasis.
6.  Fatty liver by ultrasound.

MEDICATION ON ADMISSION: Acarbose 100 mg TID
Diltiazem 240 mg ER daily
Folic acid 1000 mg daily
Gemfibrizol 600 mg [**Hospital1 **]
Glargine 40 units [**Hospital1 **]
Insulin aspart sliding scale
Lisinopril 40 mg q am, 20 mg q pm
Simvastatin 40 mg daily
Omega 3 6,000 mg daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: VS: 97.9 91 137/65 20 98 RA

FAMILY HISTORY: Father deceased at age 45 with diabetes, hyperlipidemia, and
obesity.  Mother living, age 69, with arthritis.  Brother
living, age 39, with asthma. Grandfather deceased at age 65 of a
stroke and diabetes.

SOCIAL HISTORY: He denies tobacco or recreational drug use, has alcohol on
social occasions and drinks both caffeinated and carbonated
beverages. 

### Response:
{'Morbid obesity,Paroxysmal ventricular tachycardia,Body Mass Index 40.0-44.9, adult,Other chronic nonalcoholic liver disease,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Laparoscopic surgical procedure converted to open procedure,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Obstructive sleep apnea (adult)(pediatric)'}
