CHIEF COMPLAINT: 

PRESENT ILLNESS: The is a 67 year old male who
presented with a  three day history of abdominal pain with
nausea and vomiting.  The patient presented to the emergency
department and had not had a bowel movement in one day but
had been passing gas.

MEDICAL HISTORY: Significant for coronary artery
disease, status post an myocardial infarction, hypertension,
hypercholesterolemia, head trauma with right hemiparesis.

MEDICATION ON ADMISSION: 

ALLERGIES: There are no known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection),Accidental puncture or laceration during a procedure, not elsewhere classified,Unspecified septicemia,Severe sepsis,Acute respiratory failure,Unspecified peritonitis,Cardiac complications, not elsewhere classified
Intestinal adhes w obstr,Accidental op laceration,Septicemia NOS,Severe sepsis,Acute respiratry failure,Peritonitis NOS,Surg compl-heart
Admission Date: [**2147-4-9**]        Discharge Date: [**2147-5-31**]

Date of Birth:  [**2079-9-8**]        Sex:  M

Service:  [**Last Name (un) **]


HISTORY OF PRESENT ILLNESS:  The is a 67 year old male who
presented with a  three day history of abdominal pain with
nausea and vomiting.  The patient presented to the emergency
department and had not had a bowel movement in one day but
had been passing gas.

PAST MEDICAL HISTORY:  Significant for coronary artery
disease, status post an myocardial infarction, hypertension,
hypercholesterolemia, head trauma with right hemiparesis.

PAST SURGICAL HISTORY:  Includes a cardiac catheterization
with stents to the LAD and diagonal in [**2144**].

MEDICATIONS:  Included aspirin, Lipitor, hydrochlorothiazide,
Lopressor and Nitrostat.

ALLERGIES:  There are no known drug allergies.

PHYSICAL EXAMINATION:  Vital signs:  Temperature of 97.4,
pulse 55, blood pressure 90/60, respirations 18, saturation
100 percent.  Patient was awake and alert.  His chest was
clear.  Heart was regular rate and rhythm.  Abdomen was soft
with some epigastric tenderness with normal bowel sounds.  No
peritoneal signs.  Extremities were warm.  Rectal was guaiac
negative without any masses.

PERTINENT LABORATORY TESTS:  White count was 14, hematocrit
was 53, platelets 99.  Sodium 136, potassium 4.2, chloride
98, bicarb 25, BUN 31, creatinine 1.4, glucose 111.  Liver
function tests:  AST 16, ALT 23, alkaline phosphatase 84,
total bilirubin 1.0, amylase 63, lipase 25.  Abdominal x-rays
showed dilated loops of small bowel.  Abdominal CT scan
revealed small bowel obstruction with dilated proximal small
bowel and decompressed distal small bowel.

Patient was admitted to the surgical service and was treated
for small bowel obstruction with nasogastric tube, n.p.o. and
intravenous fluids.

HOSPITAL COURSE:  The patient was observed on the surgical
service and failed to resolve the small bowel obstruction and
on [**2147-4-11**] patient underwent a diagnostic laparoscopy,
laparoscopic lysis of adhesions with exploratory laparotomy
and wash out for enterotomy and repair of enterotomy.
Postoperative course after the procedure on [**2149-4-10**] was
significant for respiratory failure and sepsis.  The patient
required reintubation and vasopressors.  Postoperative day
number three the patient underwent re-exploration for
abdominal compartment syndrome with abdominal wash out and
closure of the abdominal wall with Aqua mesh on [**2147-4-14**].  On
[**2147-4-27**] patient underwent exploratory laparotomy, removal
of Vicryl mesh, lysis of  adhesions and ventral hernia repair
with component separation and Aqua mesh overlay.  The
postoperative course during the period was significant for
ARDS, pneumonia and sepsis.  The patient required support
with mechanical ventilation and was treated with broad
spectrum antibiotics.  The sources of sepsis included
abdominal as well as pulmonary.  Abdominal sepsis was
controlled with antibiotic and the serial washouts as
previously described.  Patient's sputum culture was positive
for methicillin resistant staph aureus as well as Klebsiella
which were treated with antibiotics.  The patient also had a
blood culture which was positive for yeast and was treated
with fluconazole during the postoperative period.  The
Intensive Care Unit course was prolonged and was further
characterized by renal failure as well as cholestasis and
liver failure secondary to sepsis.  The patient required
hemodialysis and was followed by the renal service and the
hepatology service was consulted and complete evaluation with
ultrasound as well as MRCT confirmed that there was no
biliary ductal obstruction and no other significant liver
lesions and the liver failure was likely secondary to sepsis.
Hepatitis profile also was negative for any active hepatitis.
The patient continued with low grade sepsis and respiratory
failure.  Tracheostomy was performed on [**2147-5-3**].

In the weeks before discharge the patient's issues included
staph aureus methicillin resistant arterial line infection as
well as Klebsiella pneumonia for which the patient is
completing a course of levofloxacin and Vancomycin.  The
following is a summary of the condition at discharge with
relevance to previous history.

1. Neurologic:  The patient is awake, Spanish speaking and is
   intermittently following commands.  Patient has no
   significant active neurologic issues.

1. Pulmonary:  The patient is on the ventilator supported by
   18 depressed port and 5.0 PEEP with 40 percent FIO2 with a
   tracheostomy.

1. Cardiac:  The patient had a history of intermittent atrial
   fibrillation and was briefly on amiodarone.  However, has
   been in sinus rhythm without problems of tachyarrhythmia
   recently.

1. Gastrointestinal:  The patient is being supported
   nutritionally by tube feeds Nephro at 35 cc an hour.  The
   abdominal wound is open.  It was recently debrided four
   days prior to discharge of all necrotic and purulent
   tissue and is being treated with a  wet to dry dressing
   B.I.D  The patient has elevated liver function tests with
   elevated AST, ALT, bilirubin and alkaline phosphatase as
   well as mild coagulopathy which is likely due to liver
   injury from sepsis.  Again MRCP as well as ultrasound
   showed no evidence of biliary ductal obstruction and
   hepatology consult suggested treatment with Actigall and
   no further work up was necessary.

1. Renal:  Patient is on hemodialysis Monday, Wednesday and
   Friday.

1. Hematology:  The patient has had some evidence of anemia
   likely related to the renal failure and is on Epogen.
   However, there is no evidence of any active bleeding
   issues.  Patient is also on subcutaneous heparin for
   prophylaxis.

1. Infectious disease:  The patient is now completing a
   course for treatment of the methicillin resistant staph
   aureus arterial line infection as well as Klebsiella
   pneumonia.  Patient on day of discharge, [**2147-5-31**] will be
   day five of 14 of Vancomycin and 11 of 14 of Levofloxacin.

1. Endocrine:  Patient has not had problems with elevated
   blood sugar.


DISPOSITION:  The patient is in the Intensive Care Unit and
with plans for transfer to rehabilitation.

DISCHARGE STATUS:  Fair.

DISCHARGE DIAGNOSES:
1. Small bowel obstruction.
2. Status post laparoscopic lysis of adhesions, exploratory
   laparotomy and enterotomy repair on [**2147-4-11**].
3. Status post re-exploration, abdominal wash out and
   abdominal wall closure with Aqua mesh on [**2147-4-14**].
4. Patient is status post exploratory laparotomy, removal of
   Aqua mesh, lysis of adhesions, abdominal wash out and
   ventral hernia component separation on [**2147-4-27**].
5. ARDS.
6. Acute renal failure.
7. Atrial fibrillation.
8. Cholestasis, hyperbilirubinemia.
9. Methicillin resistant staph aureus and Klebsiella
   pneumonia.
10.      Methicillin resistant staph aureus line sepsis.
11.      Status post tracheostomy [**2147-5-3**].
12.      Coronary artery disease, status post myocardial
   infarction.
13.      Hypertension.
14.      Hypercholesterolemia.
15.      History of head trauma with right hemiparesis.


DISCHARGE MEDICATIONS:
1. Actigall 300 per feeding tube t.i.d.
2. Calcium 667 mg per nasogastric tube t.i.d.
3. Vancomycin 1 gram intravenous p.r.n. Vancomycin level less
   than 15, checked q day.
4. Levofloxacin 250 mg intravenous q 48.
5. Heparin subcutaneous q 8.
6. Desitin topical p.r.n.
7. Epogen 5,000 units intravenous every hemodialysis.
8. Nystatin 5 cc P.O.  p.r.n.
9. Lopressor 2.5 mg intravenous q 8 p.r.n.
10.      Lansoprazole 30 mg per nasogastric q.d.
11.      Versed 1 mg intravenous q 4 p.r.n.
12.      Hydromorphone 0.5 to 2 mg intravenous q 2 to 3
   p.r.n.
13.      Insulin sliding scale.
14.      Artificial tears p.r.n.
15.      Albuterol 1 to 2 puffs inhaler q 6 p.r.n.
16.      Lacrilube ointment p.r.n.


FOLLOW UP PLANS:  Patient will follow up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]



                        [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**MD Number(2) 11162**]

Dictated By:[**Name8 (MD) 26127**]
MEDQUIST36
D:  [**2147-5-30**] 16:06:55
T:  [**2147-5-30**] 17:45:56
Job#:  [**Job Number 26128**]


Name:  [**Known lastname 4492**], [**Known firstname **]               Unit No:  [**Numeric Identifier 4493**]

Admission Date: [**2147-4-9**]        Discharge Date: [**2147-6-7**]

Date of Birth:  [**2079-9-8**]        Sex:  M

Service:  [**Last Name (un) **]


ADDENDUM:  This is an Addendum to the dictation for an
admission from [**2147-4-9**] to [**2147-6-7**].  The previous
dictation ended on [**2147-5-31**].

The patient was scheduled to go to rehabilitation, but his
discharge to rehabilitation was delayed because of rising
liver function tests.  His nasogastric tube was replaced, and
he was tube feeding well at the time at goal, and he was
passing stool as well.



                        [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**MD Number(2) 4494**]

Dictated By:[**Dictator Info 4495**]
MEDQUIST36
D:  [**2147-7-11**] 17:08:13
T:  [**2147-7-11**] 17:20:03
Job#:  [**Job Number **]


Name:  [**Known lastname 4492**], [**Known firstname **]               Unit No:  [**Numeric Identifier 4493**]

Admission Date: [**2147-4-9**]        Discharge Date: [**2147-6-7**]

Date of Birth:  [**2079-9-8**]        Sex:  M

Service:  [**Last Name (un) **]


ADDENDUM:  The previous discharge summary ended on [**2147-5-31**].

The patient was scheduled to go to rehabilitation on
[**2147-5-31**], however, his discharge rehabilitation was delayed
because of rising liver function tests.  His nasogastric tube
was placed and tube feeds were increasing to goal at that
time.  He was also passing stool.  He was getting
hemodialysis at that time, but was unable to tolerate ultra-
filtration due to hypotension.  So assuming his difficulty
breathing was not due to congestive heart failure.  He was
continued on ventilation as he had been on until [**2147-6-5**], at
which time he was placed on a Trach mask and his respiratory
status was improving.  He continued to get his dialysis while
his INR and liver function tests were watched.  He was
treated with Vitamin K for his elevated INR.  On [**2147-6-6**],
his major issues included respiratory failure, responsive to
antibiotics and the antibiotic regimen he was given.
Cholestatic jaundice felt to be secondary to his sepsis.
Acute tubular necrosis leading to chronic renal failure.  He
was receiving hemodialysis Monday, Wednesday and Friday for
his end stage renal disease and he continued to receive
Vancomycin for his sepsis.  He was stable on his laboratories
that followed pending disposition to rehabilitation facility.
The patient remained hemodynamically stable and progressed
clinically.  He had no new issues or problems.  As of
[**2147-6-7**], as his liver function tests trended down, his INR
was trending down as well, and he was on a Trach mask, he was
able to be discharged to [**Hospital6 2501**]
facility on [**2147-6-7**], in stable condition.





                        [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**MD Number(2) 4494**]

Dictated By:[**Last Name (NamePattern1) 4507**]
MEDQUIST36
D:  [**2147-7-11**] 17:25:33
T:  [**2147-7-11**] 18:17:19
Job#:  [**Job Number 4508**]
{'Intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection),Accidental puncture or laceration during a procedure, not elsewhere classified,Unspecified septicemia,Severe sepsis,Acute respiratory failure,Unspecified peritonitis,Cardiac complications, not elsewhere classified'}


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: The is a 67 year old male who
presented with a  three day history of abdominal pain with
nausea and vomiting.  The patient presented to the emergency
department and had not had a bowel movement in one day but
had been passing gas.

MEDICAL HISTORY: Significant for coronary artery
disease, status post an myocardial infarction, hypertension,
hypercholesterolemia, head trauma with right hemiparesis.

MEDICATION ON ADMISSION: 

ALLERGIES: There are no known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection),Accidental puncture or laceration during a procedure, not elsewhere classified,Unspecified septicemia,Severe sepsis,Acute respiratory failure,Unspecified peritonitis,Cardiac complications, not elsewhere classified'}
