CHIEF COMPLAINT: GERD

PRESENT ILLNESS: The patient is a 41 year old female with a history og GERD who
underwent a plication procedure with Dr. [**Last Name (STitle) 57257**] approximately
5 months prior to admission.  She had some relief for one month,
but then developed serious symptoms of heartburn along with
choking and coughing.  A follow-up endoscopy showed that the
Plicator had probably loosened.  No hiatal hernia was evident.
A 24 hour pH probe was positive for reflux.Her symptom have
presisted despite medical management.  No nausea, vomiting or
dysphagia.

MEDICAL HISTORY: GERD s/p endoscopic fundoplication [**5-/2174**]
Asthma
Sinusitis

MEDICATION ON ADMISSION: [**Last Name (LF) **], [**First Name3 (LF) 130**], accolate, mucinex, OCP

ALLERGIES: Bactrim / Penicillins / Aspirin / Oxycodone

PHYSICAL EXAM: NAD
CTA b/l
RRR, S12, no murmurs
soft, NT/ND, no masses
AxOx3

FAMILY HISTORY: N/A

SOCIAL HISTORY: married, lives with husband, no tobacco, no ETOH, no
recreational drugs
Esophageal reflux,Accidental puncture or laceration during a procedure, not elsewhere classified,Empyema without mention of fistula,Cardiac complications, not elsewhere classified,Other specified cardiac dysrhythmias,Pulmonary collapse,Dehydration,Anemia, unspecified,Asthma, unspecified type, unspecified,Unspecified sinusitis (chronic)
Esophageal reflux,Accidental op laceration,Empyema w/o fistula,Surg compl-heart,Cardiac dysrhythmias NEC,Pulmonary collapse,Dehydration,Anemia NOS,Asthma NOS,Chronic sinusitis NOS
Admission Date:  [**2175-3-8**]              Discharge Date:   [**2175-3-27**]

Date of Birth:  [**2133-11-10**]             Sex:   F

Service: SURGERY

Allergies:
Bactrim / Penicillins / Aspirin / Oxycodone

Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
GERD

Major Surgical or Invasive Procedure:
Laproscopic Nissen fundoplication; Esophagoscopy, left
thoracoscopy with partial decortication of lung, limited left
thoracotomy with repair of diaphragmatic defect, exploratory
laparotomy with omental flap and wide drainage


History of Present Illness:
The patient is a 41 year old female with a history og GERD who
underwent a plication procedure with Dr. [**Last Name (STitle) 57257**] approximately
5 months prior to admission.  She had some relief for one month,
but then developed serious symptoms of heartburn along with
choking and coughing.  A follow-up endoscopy showed that the
Plicator had probably loosened.  No hiatal hernia was evident.
A 24 hour pH probe was positive for reflux.Her symptom have
presisted despite medical management.  No nausea, vomiting or
dysphagia.

Past Medical History:
GERD s/p endoscopic fundoplication [**5-/2174**]
Asthma
Sinusitis

Social History:
married, lives with husband, no tobacco, no ETOH, no
recreational drugs


Family History:
N/A

Physical Exam:
NAD
CTA b/l
RRR, S12, no murmurs
soft, NT/ND, no masses
AxOx3

Pertinent Results:
[**2175-3-10**] 10:50AM BLOOD WBC-16.7*# RBC-4.21 Hgb-13.5 Hct-39.7
MCV-94 MCH-32.1* MCHC-34.0 RDW-13.4 Plt Ct-241
[**2175-3-10**] 10:50AM BLOOD Glucose-126* UreaN-6 Creat-0.6 Na-139
K-3.8 Cl-103 HCO3-26 AnGap-14
[**2175-3-12**] 12:11AM BLOOD Type-ART Temp-38.4 Rates-16/ Tidal V-550
PEEP-5 FiO2-50 pO2-129* pCO2-38 pH-7.42 calHCO3-25 Base XS-0
Intubat-INTUBATED Vent-CONTROLLED
[**2175-3-14**] 03:53AM BLOOD Type-ART Temp-36.2 pO2-103 pCO2-39
pH-7.44 calHCO3-27 Base XS-1

Brief Hospital Course:
The patient was admitted on [**2175-3-8**] for a laproscopic Nissen
fundoplication by Dr. [**Last Name (STitle) **].  Please see operative note for
details.  The procedure went well, however there was extensive
scarring anf a gastrotomy was inadvertently created and repaired
primarily.  She was extubated and stable in the PACU.
Perioperaitve ceftazidime and flagyl were administered.  Her HG
tube and Foley were discontinued on POD1.  On POD2, she was
complaining of a lot of nonspecific pain.  She was advanced to a
regular diet and given vicodin for pain.  Due to her persistent
pain, the pain service saw and evaluated her.  They performed
trigger point injections at the bedsise (these had worked for
her in the past), along with Valium and a lidoderm patch.  On
POD3, she continued to have left sided chest pain.  An upper GI
study demonstrated a small distal esophageal vs GE junction leak
and a chest X-ray shoed a large left pleural effusion.  A CT
scan showed that the left pleural collection was loculated with
air, suggesting a leak into the left chest from an esophageal
perforation. Later that day, she had an esophagoscopy, left
thoracoscopy with partial decortication of lung, limited left
thoracotomy with repair of diaphragmatic
defect, and an exploratory laparotomy with omental flap and wide
drainage.  Dr. [**Last Name (STitle) 952**] of the thoracic surgery service performed
most of the operation.  Please see operative note for details.
She was transferrded to the ICU post-operatively with 2 chest
tubes, a J-tube and a JP drain.  She was sedated on propofol
fentanyl drips.   On POD 4,1, her ventaillator and propofol were
weaned.  Vancomycin, Zosyn, and Flagyl were started empirically
for her pleural fluid collection. She was tachycardic to the
130's and had a temperature of 101.1.  Her tachycardia was
thought to be due to pain and her fever was expected given her
course.  Fluid boluses did not decrease her tachycardia.  Later
that day, her antibiotic coverage was changed to Levoquin,
Vancomycin, Fluconazole, and Flagyl.  On POD 5,2, her propofol
and Fluconazole were discontinued. She was extubated and tube
feeds were slowly advanced.  Her chest tubes were set to
waterseal.  On POD 7,4 her apical chest tube was discontinued.
She was transferred tot he floor.  Her NG tube was continued and
she was still NPO. Her other chest tube was set to waterseal.
She had a small air leak, but a chest X-ray showed no
pneumothorax.  On POD 8,5 her Foley was removed.  On POD 9,6 she
had an UGI demonstrated a persistent small leak just superior to
the prior Nissen fundoplication, not significantly changed
compared to the prior study, and the passage of contrast through
GE junction was smooth.  Her NG tube was discontinued becasue it
was producing very little.  She was kept NPO on IV antibiotics
and the chest tube was left in place.  On POD 11,8 a chest X-ray
showed a continued small loculated hydropneumothorax associated
with atelectasis in the left lung base.  Her WBC was 16.7
although she was afebrile.  She was passing flatus.  On POD
13,10 her WBC was 14.9.  A CT scan shwed a linear small area of
oral contrast extravasation just above the wrap of the Nissen
fundoplication connecting to a small pocket of air just below
the diaphragm, consistent with a small leak.  There was also an
interval reduction in size of left-sided hydropneumothorax and a
split pleura sign surrounding left effusion, suggestive of a
complex exudative effusion such as empyema.  Later that day she
had an ultrasound guided pleural fluid aspiration of 2cc of
serosanguinous fluid that did not grow anything on culture.  In
addition, a CT of her sinuses was normal (she has chronic
sinusitis and was complaining of symptoms).  An ENT consult was
obtained but they signed off because there was nothing to do.
On POD 16,13 she tolerated a clear liquid diet.  Her WBC had
normalized.  On POD 17,14 she was doing well with a regular
diet.  She was afebrile with a nromal WBC.  Her staples were
removed and her tube feeds were stopped.  Her PICC line was
removed.  On POD 18,15 her JP drain was removed and antibiotics
were srtopped.  On POD 19,16 she was experiencing some reflux
symptoms, which was to be expected.  later that day she felt
better and decided she was ready to go home.

Medications on Admission:
[**Last Name (LF) **], [**First Name3 (LF) 130**], accolate, mucinex, OCP

Discharge Medications:
1. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for 2 weeks.
Disp:*25 Tablet(s)* Refills:*0*
2. Zafirlukast 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation for 2 weeks.
Disp:*30 Capsule(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
GERD


Discharge Condition:
Good


Discharge Instructions:
Please call or come to the ED with any fevers > 101, increased
pain, nausea, vomiting, or redness around your incision.

Please do not eat crackers, chips, or doughy foods.

You may eat a regular diet.  You may shower.

Please resume all of your home medications.

Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**], [**Name Initial (NameIs) **].D. Date/Time:[**2175-3-23**] 3:30

Please call Dr.[**Name (NI) 1482**] office to shcedule a follow-up
appointment in [**11-25**] days ([**Telephone/Fax (1) 1483**].



Completed by:[**2175-3-27**]

Unit No:  [**Numeric Identifier 57258**]
Admission Date: [**2175-3-8**]
Discharge Date: [**2175-3-27**]
Date of Birth:  [**2133-11-10**]
Sex:  F
Service:  [**Last Name (un) **]


ADDENDUM:
Addition to the discharge summary should include.

ADDITION TO DISCHARGE DIAGNOSES:  These included:
1.  Postoperative leak.
2.  Respiratory failure.



                        [**First Name11 (Name Pattern1) 333**] [**Last Name (NamePattern4) 366**], [**MD Number(1) 367**]

Dictated By:[**Last Name (NamePattern4) 24987**]
MEDQUIST36
D:  [**2175-4-18**] 09:03:17
T:  [**2175-4-18**] 11:22:01
Job#:  [**Job Number 57259**]
{'Esophageal reflux,Accidental puncture or laceration during a procedure, not elsewhere classified,Empyema without mention of fistula,Cardiac complications, not elsewhere classified,Other specified cardiac dysrhythmias,Pulmonary collapse,Dehydration,Anemia, unspecified,Asthma, unspecified type, unspecified,Unspecified sinusitis (chronic)'}


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: GERD

PRESENT ILLNESS: The patient is a 41 year old female with a history og GERD who
underwent a plication procedure with Dr. [**Last Name (STitle) 57257**] approximately
5 months prior to admission.  She had some relief for one month,
but then developed serious symptoms of heartburn along with
choking and coughing.  A follow-up endoscopy showed that the
Plicator had probably loosened.  No hiatal hernia was evident.
A 24 hour pH probe was positive for reflux.Her symptom have
presisted despite medical management.  No nausea, vomiting or
dysphagia.

MEDICAL HISTORY: GERD s/p endoscopic fundoplication [**5-/2174**]
Asthma
Sinusitis

MEDICATION ON ADMISSION: [**Last Name (LF) **], [**First Name3 (LF) 130**], accolate, mucinex, OCP

ALLERGIES: Bactrim / Penicillins / Aspirin / Oxycodone

PHYSICAL EXAM: NAD
CTA b/l
RRR, S12, no murmurs
soft, NT/ND, no masses
AxOx3

FAMILY HISTORY: N/A

SOCIAL HISTORY: married, lives with husband, no tobacco, no ETOH, no
recreational drugs 

### Response:
{'Esophageal reflux,Accidental puncture or laceration during a procedure, not elsewhere classified,Empyema without mention of fistula,Cardiac complications, not elsewhere classified,Other specified cardiac dysrhythmias,Pulmonary collapse,Dehydration,Anemia, unspecified,Asthma, unspecified type, unspecified,Unspecified sinusitis (chronic)'}
