CHIEF COMPLAINT: abdominal pain

PRESENT ILLNESS: 55F with hx of Crohn's disease s/p total abdominal colectomy
with ileorectal anastomosis in [**2107**] presents with severe
abdominal pain for 1.5 days. Patient experienced sudden onset of
abdominal pain after dinner on [**2111-9-22**] and several episodes of
vomiting. She has not been passing flatus or having bowel
movements for at least 2 days. She has never had symptoms like
this before. Since her colectomy, her UC has not been active and
she has been completely off steroids.

MEDICAL HISTORY: UC, osteoporosis (2 steroids), knee OA, kyphosis and compression
fractures, ovarian cysts, Notalgia paraesthetica on back, HTN,
hyperlipid, GERD, anxiety/depression, CBP

MEDICATION ON ADMISSION: Calcium-Vit D, pantoprazole 40', reclast 5 yearly, simvastatin
10', immodium, sucralfate 1', MV, folic acid 1, flonase prn

ALLERGIES: Erythromycin Base / Mercaptopurine / Canasa / Clindamycin Hcl

PHYSICAL EXAM: Temp 98.8   HR 120   BP 143/98   RR 18   RA O2 sat 99%
Gen: Appears uncomfortable, distressed
CV:RRR
Resp: CTAB
Abd: distended, very tender in RLQ to percussion and palpation.
+rebound and guarding. Umbilical hernia palpable.
Ext: Warm, well perfused

FAMILY HISTORY: non contributory

SOCIAL HISTORY: Lives in group home due to mental illness, denies tobacco,
alcohol, and illicit drug use
Hernia of other specified sites, with gangrene,Hyposmolality and/or hyponatremia,Other postoperative infection,Cellulitis and abscess of trunk,Unspecified essential hypertension,Arthropathy, unspecified, site unspecified,Anxiety state, unspecified,Other and unspecified hyperlipidemia,Esophageal reflux,Acquired absence of intestine (large) (small),Other osteoporosis,Adrenal cortical steroids causing adverse effects in therapeutic use,Kyphosis (acquired) (postural),Removal of other organ (partial) (total) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation
Hernia, site NEC w gangr,Hyposmolality,Other postop infection,Cellulitis of trunk,Hypertension NOS,Arthropathy NOS-unspec,Anxiety state NOS,Hyperlipidemia NEC/NOS,Esophageal reflux,Acquire absnce intestine,Osteoporosis NEC,Adv eff corticosteroids,Kyphosis NOS,Abn reac-organ rem NEC
Admission Date:  [**2111-9-24**]              Discharge Date:   [**2111-9-28**]

Date of Birth:  [**2056-6-6**]             Sex:   F

Service: SURGERY

Allergies:
Erythromycin Base / Mercaptopurine / Canasa / Clindamycin Hcl

Attending:[**First Name3 (LF) 3200**]
Chief Complaint:
abdominal pain

Major Surgical or Invasive Procedure:
[**2111-9-24**]
1. Exploratory laparotomy.
2. Lysis of adhesions.
3. Small-bowel resection.
4. Repair of internal hernia.
5. Primary anastomosis.


History of Present Illness:
55F with hx of Crohn's disease s/p total abdominal colectomy
with ileorectal anastomosis in [**2107**] presents with severe
abdominal pain for 1.5 days. Patient experienced sudden onset of
abdominal pain after dinner on [**2111-9-22**] and several episodes of
vomiting. She has not been passing flatus or having bowel
movements for at least 2 days. She has never had symptoms like
this before. Since her colectomy, her UC has not been active and
she has been completely off steroids.

On arrival in the ED around 1 pm (per patient), patient was
tachycardic to 120s and complaining of RLQ pain. Her HR came
down
to low 100s with 2L of fluid. Her pain worsened while in the ED
over a period of 10 hours. Surgery was consulted at 10:45 pm for
CT findings of SBO with a transition point. An NGT was placed at
that time with 400 cc of CT contrast effluent. A foley was
placed
with clear, yellow, urine. On exam, she complained of severe RLQ
pain, though her nausea had largely resolved. Stat repeat labs
were sent.


Past Medical History:
UC, osteoporosis (2 steroids), knee OA, kyphosis and compression
fractures, ovarian cysts, Notalgia paraesthetica on back, HTN,
hyperlipid, GERD, anxiety/depression, CBP

Social History:
Lives in group home due to mental illness, denies tobacco,
alcohol, and illicit drug use


Family History:
non contributory

Physical Exam:
Temp 98.8   HR 120   BP 143/98   RR 18   RA O2 sat 99%
Gen: Appears uncomfortable, distressed
CV:RRR
Resp: CTAB
Abd: distended, very tender in RLQ to percussion and palpation.
+rebound and guarding. Umbilical hernia palpable.
Ext: Warm, well perfused


Pertinent Results:
[**2111-9-23**] 01:50PM   WBC-22.5*# RBC-5.14 HGB-15.4 HCT-47.0 MCV-92
MCH-29.9 MCHC-32.7 RDW-12.5
[**2111-9-23**] 01:50PM   NEUTS-86.6* LYMPHS-8.8* MONOS-3.5 EOS-0.9
BASOS-0.3
[**2111-9-23**] 01:50PM   PLT COUNT-391
[**2111-9-23**] 01:50PM   ALT(SGPT)-27 AST(SGOT)-52* ALK PHOS-73 TOT
BILI-0.5
[**2111-9-23**] 01:50PM   LIPASE-28
[**2111-9-23**] 01:50PM   GLUCOSE-110* UREA N-11 CREAT-0.8 SODIUM-139
POTASSIUM-4.7 CHLORIDE-96 TOTAL CO2-27 ANION GAP-21*
[**2111-9-23**] 07:35PM   LACTATE-1.7

[**2111-9-23**] CT Abd/pelvis ;
1. Status post total colectomy. Abnormal fecalized loop of small
bowel in
the right lower quadrant with adjacent fluid and fat stranding
raising concern  for a small bowel obstruction, with closed loop
obstruction not excluded. A repeat study of the pelvis after
oral contrast administration could better evaluate this finding.

2. 3 cm left adnexal cyst can be further evaluated on nonurgent
pelvic
ultrasound.
3. Stable spinal degenerative changes.
4. Stable ventral hernias containing a small amount of fat and a
small loop of nonobstructed bowel.

[**2111-9-23**] CT pelvis :
Small bowel obstruction with a mildly dilated small bowel loop
in
the right lower quadrant with fecalized material and a
transition point.
Adjacent fat stranding and a small amount of fluid.

[**2111-9-28**] PA & Lat CXR :
There is severe scoliosis with wedge-shaped thoracic vertebra,
leading to extreme asymmetry of the thoracic rib cage and wall.
In addition, irregular rib margins and inhomogeneous bony
structures are seen bilaterally. There is moderate-to-severe
cardiomegaly with signs of mild pulmonary edema.
In addition, moderate bilateral pleural effusions with areas of
subsequent
atelectasis are seen. No evidence of pneumonia in the well
ventilated lung
areas. No pneumothorax.


Brief Hospital Course:
The patient was taken to the OR on [**9-24**] for emergent exlap. She
was found to have some ischemic small bowel which was resected
and primary anastomosis was performed. Please see operative
report for further details. Postoperatively, the patient was
managed in the ICU. Her pain was well controlled with Dilaudid
PCA. She was kept NPO/IVF with NGT in place. She had persistent
tachycardia on PO D1, but BP was stable and urine output was
strong. She did receive additional fluid boluses and IV
Lopressor was started, which helped control her tachycardia. On
[**9-25**], the patient's NGT was removed because output was minimal.
The patient was overall doing well and she was transferred to
the floor.

Following transfer to the Surgical floor she continued to do
well.  Her tachycardia resolved after full fluid resuscitation
and her Lopressor was discontinued.  Her diet was slowly
advanced after full bowel function was attained and she
tolerated it well without nausea or vomiting.  Her abdominal
incision had some mild erythema which resolved on its own and
was healing well.  Her oxygen saturations were in the low 90% on
room air.  A chest xray was done which showed bilateral small
effusions and atelectasis.  She also has severe kyphosis which
contributes to her pulmonary deficits. She is able to cough and
deep breath along with use her incentive spirometer.

Prior to discharge, electrolytes were checked and she was found
to have a potassium of 2.8 and a phosphorus of 1.0.  She
received 40 meq of Potassium Chloride and 1 packet of
Neutra-Phos prior to leaving and she will continue Neutra-Phos
TID for 3 days as well as take an additional dose of Potassium
40 meq tonight. After an uneventful recovery she was discharged
to home on [**2111-9-28**] and will follow up in the [**Hospital 2536**] Clinic in 2
weeks for staple removal.

Medications on Admission:
Calcium-Vit D, pantoprazole 40', reclast 5 yearly, simvastatin
10', immodium, sucralfate 1', MV, folic acid 1, flonase prn


Discharge Medications:
1. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal once a day as needed for allergy symptoms.
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
4. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every four (4) hours as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Calcium 600 + D(3) 600 mg(1,500mg) -400 unit Tablet Sig: One
(1) Tablet PO twice a day.
6. simvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. multivitamin     Tablet Sig: One (1) Tablet PO once a day.
8. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
9. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
Two (2) Tablet, ER Particles/Crystals PO once: take with dinner.
Disp:*2 Tablet, ER Particles/Crystals(s)* Refills:*2*
10. medication
Nutra-Phos
sig  1 packet PO TID for three days
Dispense 10 packets
No refills


Discharge Disposition:
Home

Discharge Diagnosis:
1. Intestinal obstruction.
2. Internal hernia.
3. Intestinal necrosis.


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


Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:

*You experience new chest pain, pressure, squeezing or
tightness.

*New or worsening cough, shortness of breath, or wheeze.

*If you are vomiting and cannot keep down fluids or your
medications.

*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.

*You see blood or dark/black material when you vomit or have a
bowel movement.

*You experience burning when you urinate, have blood in your
urine, or experience a discharge.

*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.

*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.

*Any change in your symptoms, or any new symptoms that concern
you.

Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.

Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-14**] lbs until you follow-up with your
surgeon.

Avoid driving or operating heavy machinery while taking pain
medications.

Incision Care:

*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.

*Avoid swimming and baths until your follow-up appointment.

*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.

*Your staples will be removed at your follow-up appointment.


Followup Instructions:
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment in 2 weeks for staple removal

Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name12 (NameIs) 1046**] Phone:[**Telephone/Fax (1) 1387**]
Date/Time:[**2111-10-8**] 12:30

Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 33176**], M.D. Phone:[**Telephone/Fax (1) 96976**]
Date/Time:[**2111-11-11**] 11:30

Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5447**], M.D. Date/Time:[**2111-12-22**] 10:10



Completed by:[**2111-9-28**]
{'Hernia of other specified sites, with gangrene,Hyposmolality and/or hyponatremia,Other postoperative infection,Cellulitis and abscess of trunk,Unspecified essential hypertension,Arthropathy, unspecified, site unspecified,Anxiety state, unspecified,Other and unspecified hyperlipidemia,Esophageal reflux,Acquired absence of intestine (large) (small),Other osteoporosis,Adrenal cortical steroids causing adverse effects in therapeutic use,Kyphosis (acquired) (postural),Removal of other organ (partial) (total) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation'}


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: abdominal pain

PRESENT ILLNESS: 55F with hx of Crohn's disease s/p total abdominal colectomy
with ileorectal anastomosis in [**2107**] presents with severe
abdominal pain for 1.5 days. Patient experienced sudden onset of
abdominal pain after dinner on [**2111-9-22**] and several episodes of
vomiting. She has not been passing flatus or having bowel
movements for at least 2 days. She has never had symptoms like
this before. Since her colectomy, her UC has not been active and
she has been completely off steroids.

MEDICAL HISTORY: UC, osteoporosis (2 steroids), knee OA, kyphosis and compression
fractures, ovarian cysts, Notalgia paraesthetica on back, HTN,
hyperlipid, GERD, anxiety/depression, CBP

MEDICATION ON ADMISSION: Calcium-Vit D, pantoprazole 40', reclast 5 yearly, simvastatin
10', immodium, sucralfate 1', MV, folic acid 1, flonase prn

ALLERGIES: Erythromycin Base / Mercaptopurine / Canasa / Clindamycin Hcl

PHYSICAL EXAM: Temp 98.8   HR 120   BP 143/98   RR 18   RA O2 sat 99%
Gen: Appears uncomfortable, distressed
CV:RRR
Resp: CTAB
Abd: distended, very tender in RLQ to percussion and palpation.
+rebound and guarding. Umbilical hernia palpable.
Ext: Warm, well perfused

FAMILY HISTORY: non contributory

SOCIAL HISTORY: Lives in group home due to mental illness, denies tobacco,
alcohol, and illicit drug use 

### Response:
{'Hernia of other specified sites, with gangrene,Hyposmolality and/or hyponatremia,Other postoperative infection,Cellulitis and abscess of trunk,Unspecified essential hypertension,Arthropathy, unspecified, site unspecified,Anxiety state, unspecified,Other and unspecified hyperlipidemia,Esophageal reflux,Acquired absence of intestine (large) (small),Other osteoporosis,Adrenal cortical steroids causing adverse effects in therapeutic use,Kyphosis (acquired) (postural),Removal of other organ (partial) (total) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation'}
