CHIEF COMPLAINT: menorrhagia, endometriosis, chronic pelvic pain

PRESENT ILLNESS: 28 year old G5P1041 with a history of severe pelvic pain with
laparoscopy-proven endometriosis, metromenorrhagia, and severe
constipation who presents for
preoperative visit.

MEDICAL HISTORY: GynHx:
Long history of endometriosis and pelvic pain.
Currently on OCPs.  On continuous hormones for many years with
irregular menses.
Menarche age 11. Reports no "normal menses"; LMP
H/o abnormal paps, s/p colposcopy. Last Pap negative  [**2122-12-3**].
Endometrial biopsy negative [**2122-12-10**]
Denies STIs, PID, or [**Last Name (un) **].
Currently sexually active with one male partner although
infrequent intercourse due to pain.

MEDICATION ON ADMISSION: Epinephrine, medroxyprogesterone, omeprazole, polyethylene
glycol, bisacodyl, cetirizine, colace, percocet

ALLERGIES: Penicillins / Aspirin / Latex / shrimp

PHYSICAL EXAM: 

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Originally from [**Country 13622**] Republic. Has worked as hairdresser
for several years. No t/e/d.
Endometriosis of uterus,Iatrogenic pulmonary embolism and infarction,Allergic purpura,Excessive or frequent menstruation,Unspecified symptom associated with female genital organs,Constipation, unspecified,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Other non-narcotic analgesics causing adverse effects in therapeutic use,Other alteration of consciousness,Other musculoskeletal symptoms referable to limbs
Uterine endometriosis,Iatrogen pulm emb/infarc,Allergic purpura,Excessive menstruation,Fem genital symptoms NOS,Constipation NOS,Migrne unsp wo ntrc mgrn,Adv eff non-narc analgsc,Other alter consciousnes,Muscskel sympt limb NEC
Admission Date:  [**2123-3-18**]              Discharge Date:   [**2123-3-22**]

Date of Birth:  [**2094-11-19**]             Sex:   F

Service: OBSTETRICS/GYNECOLOGY

Allergies:
Penicillins / Aspirin / Latex / shrimp

Attending:[**Doctor First Name 6716**]
Chief Complaint:
menorrhagia, endometriosis, chronic pelvic pain

Major Surgical or Invasive Procedure:
1. total laparascopic hysterectomy
2. cystoscopy

History of Present Illness:
28 year old G5P1041 with a history of severe pelvic pain with
laparoscopy-proven endometriosis, metromenorrhagia, and severe
constipation who presents for
preoperative visit.

This patient has failed medical treatments: depo-provera, COCPs,
progestin-only OCPs, Mirena, with moderate-severe side effects
with each.  She  did get some relief from laparoscopy with
excision of endo x4, for 2-6 months each time.  Previous
operative reports from the [**Country 13622**] republic classified her
endometriosis as Stage 2.

The patient has severe pain when menstruating but always has
some
pain at baseline. She has never had normal menses and has
required narcotic medications for pain relief. She has need
excessive amounts of tylenol for pain relief.  SHe is currently
also using Vicodin at bedtime as well as Gabapentin. She also
has
chronic constipation with some discomfort in bowel movements.
She
uses a bowel prep twice a week as well as an enema, fiber
supplements and stool softeners.  There are also plans for bio
feedback.

Past Medical History:
GynHx:
Long history of endometriosis and pelvic pain.
Currently on OCPs.  On continuous hormones for many years with
irregular menses.
Menarche age 11. Reports no "normal menses"; LMP
H/o abnormal paps, s/p colposcopy. Last Pap negative  [**2122-12-3**].
Endometrial biopsy negative [**2122-12-10**]
Denies STIs, PID, or [**Last Name (un) **].
Currently sexually active with one male partner although
infrequent intercourse due to pain.

ObHx: G5P1041 (in previous notes, had reported G6P1)
SAB x4, some requiring D&C
SVD x1, term, c/b short cvx, pt declined cerclage

PMH:
- Endometriosis
- Constipation
- Hx DVT, s/p several months anticoagulation (per pt both
injected and po)

PSH:
Dx LSC x4, with LOA and ?fulguration/excision endometriosis,
most
recent [**3-/2122**]
LSC appy

Social History:
Originally from [**Country 13622**] Republic. Has worked as hairdresser
for several years. No t/e/d.


Family History:
non-contributory


Pertinent Results:
[**2123-3-18**] 07:02PM   WBC-10.5# RBC-4.02* HGB-11.6* HCT-34.8*
MCV-87 MCH-28.8 MCHC-33.3 RDW-15.3
[**2123-3-18**] 07:02PM   PLT COUNT-233

Radiology:
MR HEAD W/O CONTRAST Study Date of [**2123-3-20**] 2:41 AM
There is no focus of decreased diffusion to suggest an acute
infarct.
On the FLAIR sequence, there is very subtle increased signal
intensity
scattered adjacent to the cortex in the frontal and the parietal
lobes, for example, series 6, image 15. The significance of this
finding is uncertain.  It is unclear if these are artifactual or
related to recent anesthesia or other abnormality. A close
followup evaluation can be considered on a different MRI scanner
to assess stability/progression/resolution.
No focus of negative susceptibility is noted to suggest
hemorrhage.
Ventricles and extra-axial CSF spaces otherwise are
unremarkable. Small cavum septum pellucidum is noted along with
a prominent cavum velum interpositum. The major intracranial
arterial flow voids are noted on the T2-weighted images.
Mild mucosal thickening is noted in the ethmoid air cells. There
is a
retention cyst measuring approximately 2.2 x 1.6 cm in the left
maxillary
sinus/polyp.

MRV HEAD WITHOUT CONTRAST:
The major venous sinuses are patent.

IMPRESSION:
1. No focus of acute infarction.
2. Scattered subtle FLAIR hyperintense signal foci adjacent to
the sulci as described above are of equivocal significance.
Unclear if these are
artifactual or related to an abnormality. Interval close
followup evaluation can be considered on a different MRI scanner
from the present one to evaluate for any interval change.
3. Retention cyst/polyp in the left maxillary sinus.

CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2123-3-19**]
8:28 AM
FINDINGS: Moderate respiratory motion artifacts that limit the
quality of the CT examination. There are filling heterogeneities
in the intermediate right pulmonary artery, towards the medial
part of the vessel (3, 48) and in a left lower lobe segmental
artery (3, 45). In addition, smaller hypodense attenuation
heterogeneities are seen in both the right and left lower lobes,
at the level of segmental arteries.
Bilaterally, relatively extensive areas of dependent
atelectasis, but on the left, an additional peripheral
wedge-shaped opacity is seen (3, 65). A second right-sided
wedge-shaped opacity is seen at the level of the right lower
lobe apex (3, 43).
The heart is of overall borderline size, but the right heart is
not enlarged, and there is no bulging of the septum. No evidence
of pleural effusions.
Because of the high likelihood of acute pulmonary embolism, the
referring
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 34602**], was paged for notification at the time
of dictation, 9:22 a.m., on [**2123-3-19**].

IMPRESSION: High likelihood of right rather central and left
lower lobe
peripheral pulmonary embolism. There are bilateral wedge-shaped
parenchymal opacities that support this diagnosis.
Moderate bilateral dependent atelectasis. No right heart
enlargement, no
bulging of the intraventricular septum. Free air in the right
upper quadrant after abdominal surgery.

Brief Hospital Course:
28 year old F G5P1041 with h/o severe pelvic pain with
laparoscopy-proven endometriosis, metromenorrhagia, and severe
constipation, h/o DVT s/p short course of anticoagulation and
spontaneous abortion x 5 (details unclear, negative
hypercoagulable workup per report) transferred to ICU for
unresponsiveness, now resolved, and new dx of PE, all on POD 1.
She was transferred back to the floor on POD 2 and discharged on
POD 4.  Her hospital course is organized by systems below.

# unresponsiveness/ sedating medication overdose on POD 1:
likely secondary to multiple sedating medications, including
high doses of opiates received overnight prior to transfer.
Improved with one dose of IV Narcan 0.5mg, although transient.
Patient transferred to unit and with time improved without
further intervention.  We initially held sedating medications
for now, including Ativan.  We attempted pain control with
Toradol and PO Tylenol, but this was inadequate so low dose IV
Dilaudid was started (after a trial of oxycodone without
sedition).  Toradol was discontinued due to questionable
allergic reaction including vasculitic lesion on the right lower
extremity.  After transfer to the floor on POD 2, her pain was
well-controlled with vicodin and she had no further somnolence.

# PE: on POD 1 she complained of chest pain and had persistent
tachycardia to 130s-140s. bilateral PE noted on CTA chest [**3-19**],
likely was contributing to tachycardia and new O2 requirement.
Pt with h/o DVT and multiple spontaneous abortions, it is
possible she has an underlying clotting disorder however testing
in the past has been unremarkable and is unlikely to be helpful
now.  Patient was started on Lovenox 60 mg sc BID, will need
lifelong anticoagulation with Coumadin.  discharged to home with
VNA and lovenox, to make appiontment with [**Hospital 3052**].

# tachycardia: likely [**3-4**] PE and hypovolemia, as tachycardia
improved with IV fluids

# Vasculitic lesion: question temporal relationship to Toradol
administration.  Derm was consulted due to concern of the
lesions, question vasculitis given history of abortions and PE.
Biopsy is pending, no further interventions.

# s/p lap hysterectomy: pt complaining of pain, but tolerated
surgery.  pain controlled with vicodin prior to discharge.

# lower extremity weakness/numbness: likely [**3-4**] epidural
catheter, which persisted a day into the ICU course.  Neurology
was consulted and expressed concern about the possibility of a
venous sinus thrombosis given that the patient also has
left-sided headache. MRI/MRV was unremarkable.  Neurology also
recommended MRI t and l spine to r/o epidural bleed, but
unlikely, weakness likely functional.  L-spine MRI and
weakness/numbness spontaneously improved.  She was seen by PT
and by POD 4 (day of discharge) was ambulating independantly
with no ongoing deficit.

The patient was discharged to home in good condition on POD 4.

Medications on Admission:
Epinephrine, medroxyprogesterone, omeprazole, polyethylene
glycol, bisacodyl, cetirizine, colace, percocet


Discharge Medications:
1. Vicodin 5-500 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
2. Lovenox 60 mg/0.6 mL Syringe Sig: One (1) syringe
Subcutaneous twice a day.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
endometriosis/pelvic pain, menorrhagia
pulmonary emboli


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


Discharge Instructions:
Dear Ms. [**Known lastname 74133**],
You were admitted for laparoscopic hysterectomy for heavy
bleeding and pelvic pain.  Your post-operative course was
complicated by bilateral pulmonary emboli (lung clots), and a
stay in the ICU.  For this, you will need lifelong
anticoagulation (blood thinners).  For now, you will inject
lovenox twice daily and will be transitioned to oral coumadin.
You will need to call the [**Hospital 18**] [**Hospital3 **] on
Tuesday do set up an appointment ([**Telephone/Fax (1) 10413**]).  They will help
you start the coumadin and arrange for blood draws to monitor
your dose.

Also, you had leg numbness and weakess that was possibly related
to the epidural and slowly resolved. You were seen by neurology
and physical therapy both of which thought you were improving
and safe to be discharged on your own.

General instructions:
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Do not combine narcotic and sedative medications or alcohol
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs
* No strenuous activity until your post-op appointment
* Nothing in the vagina (no tampons, no douching, no sex) for 3
months
* no heavy lifting of objects >10lbs for 6 weeks.
* You may eat a regular diet

Incision care:
* You may shower and allow soapy water to run over incision; no
scrubbing of incision. No bath tubs for 6 weeks.
* If you have steri-strips, leave them on. They will fall off on
their own or be removed during your followup visit.

To reach medical records to get the records from this
hospitalization sent to your doctor at home, call [**Telephone/Fax (1) 2806**].


Call your doctor for:
* fever > 100.4
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* redness or drainage from incision
* nausea/vomiting where you are unable to keep down fluids/food
or your medication


Followup Instructions:
ob/gyn
1) call the [**Hospital 18**] [**Hospital3 **] first thing on Tuesday
at [**Telephone/Fax (1) 10413**]. Tell them that you had bilateral pulmonary
emboli and were discharged on lovenox and need lifetime
anticoagulation.  They can call [**Telephone/Fax (1) 2664**] with any questions
but you need an appointment as soon as possible.

2) Follow-up with Dr. [**First Name4 (NamePattern1) 11320**] [**Last Name (NamePattern1) 34602**] on [**2123-4-7**] at 4pm.

3) Follow-up with your primary care provider within one week of
discharge.


                             [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 6721**]
{'Endometriosis of uterus,Iatrogenic pulmonary embolism and infarction,Allergic purpura,Excessive or frequent menstruation,Unspecified symptom associated with female genital organs,Constipation, unspecified,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Other non-narcotic analgesics causing adverse effects in therapeutic use,Other alteration of consciousness,Other musculoskeletal symptoms referable to limbs'}


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: menorrhagia, endometriosis, chronic pelvic pain

PRESENT ILLNESS: 28 year old G5P1041 with a history of severe pelvic pain with
laparoscopy-proven endometriosis, metromenorrhagia, and severe
constipation who presents for
preoperative visit.

MEDICAL HISTORY: GynHx:
Long history of endometriosis and pelvic pain.
Currently on OCPs.  On continuous hormones for many years with
irregular menses.
Menarche age 11. Reports no "normal menses"; LMP
H/o abnormal paps, s/p colposcopy. Last Pap negative  [**2122-12-3**].
Endometrial biopsy negative [**2122-12-10**]
Denies STIs, PID, or [**Last Name (un) **].
Currently sexually active with one male partner although
infrequent intercourse due to pain.

MEDICATION ON ADMISSION: Epinephrine, medroxyprogesterone, omeprazole, polyethylene
glycol, bisacodyl, cetirizine, colace, percocet

ALLERGIES: Penicillins / Aspirin / Latex / shrimp

PHYSICAL EXAM: 

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Originally from [**Country 13622**] Republic. Has worked as hairdresser
for several years. No t/e/d. 

### Response:
{'Endometriosis of uterus,Iatrogenic pulmonary embolism and infarction,Allergic purpura,Excessive or frequent menstruation,Unspecified symptom associated with female genital organs,Constipation, unspecified,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Other non-narcotic analgesics causing adverse effects in therapeutic use,Other alteration of consciousness,Other musculoskeletal symptoms referable to limbs'}
