CHIEF COMPLAINT: Abdominal pain/Possible perforated diverticulum

PRESENT ILLNESS: The patient is a 68 year old male with a 38 year history of
Crohn's disease, coronary artery disease, previous small bowel
obstruction, and congestive heart failure, status post resection
of small bowel three times ([**2136**], [**2154**], [**2164**]) who presented from
[**Doctor Last Name 1495**] [**Hospital 107**] Medical center with abdominal pain.

MEDICAL HISTORY: 1.  Crohn's disease status post small bowel resections (see HPI)
2.  Coronory artery disease
3.  Status post exploratory laparotomy complicated by MI (in
past)
4.  Small bowel obstruction
5.  Congestive heart failure ([**7-24**] EF=39% with no reversable
defects

MEDICATION ON ADMISSION: Medications at home:  Immuran 50 mg [**Hospital1 **], Asacol 1200 [**Hospital1 **],
Prednisone 60 mg qd, Saltolol 80 mg [**Hospital1 **], Asprin 81 mg qd,
Lisinopril 5 mg qd, Digoxin 0.125 mg qd.

ALLERGIES: Oxycodone Hcl/Acetaminophen / Hydrocodone Bit/Acetaminophen

PHYSICAL EXAM: Temperature 98.6, Heart rate 76, Blood pressure 110/70,
Respiratory rate 20, oxygen saturation 99% on room air

FAMILY HISTORY: No history of crohn's disease

SOCIAL HISTORY: Retired, Married, no alcohol, no cigarettes
Diverticulosis of small intestine (without mention of hemorrhage),Infection and inflammatory reaction due to other vascular device, implant, and graft,Methicillin susceptible Staphylococcus aureus septicemia,Acute kidney failure, unspecified,Atrial fibrillation,Severe sepsis,Other and unspecified angina pectoris,Hyposmolality and/or hyponatremia,Congestive heart failure, unspecified
Dvrtclo sml int w/o hmrg,React-oth vasc dev/graft,Meth susc Staph aur sept,Acute kidney failure NOS,Atrial fibrillation,Severe sepsis,Angina pectoris NEC/NOS,Hyposmolality,CHF NOS
Admission Date:  [**2174-8-6**]              Discharge Date:   [**2174-9-8**]

Date of Birth:  [**2105-12-29**]             Sex:   M

Service: [**Doctor First Name 147**]

Allergies:
Oxycodone Hcl/Acetaminophen / Hydrocodone Bit/Acetaminophen

Attending:[**Doctor First Name 5188**]
Chief Complaint:
Abdominal pain/Possible perforated diverticulum

Major Surgical or Invasive Procedure:
1.  Exploratory laparatomy
2.  Small bowel resection

History of Present Illness:
The patient is a 68 year old male with a 38 year history of
Crohn's disease, coronary artery disease, previous small bowel
obstruction, and congestive heart failure, status post resection
of small bowel three times ([**2136**], [**2154**], [**2164**]) who presented from
[**Doctor Last Name 1495**] [**Hospital 107**] Medical center with abdominal pain.

He was in his usual state of health until approximately 2 months
ago, when he began having increased diarrheal episodes, with up
to 30 bowel movements in a 24 hour period.  This is compared to
his baseline for the last decade is [**5-26**] loose stools a day, but
overall has maintained a stable weight and lifestyle on 5-ASA,
Imuran, and prednisone maintenance.  He has had occasional
flares of cramps, partial small bowel obstructions treated with
IV fluids and increased doses of prednisone.  He also has had
complications involving recurrent perianal fistulas as well.

This resulted in him presenting to the outside institution for a
colonoscopy, and the results demonstrated some ileitis with no
colitis.  The the next day ([**2174-7-20**]), Three weeks prior to the
admission to this hospital, the patient experienced the acute
onset of abdominal pain.  A CT was suggestive of a potential
small bowel perforation.  He was kept NPO, started on TPN, and
was given antibiotics for 2 weeks, and he improved.  However, he
had persistent pain that was aggrevated by taking anything by
mouth.  He did have some fevers on presentation.

No nausea, vomiting, melena, hematochezia, hematemesis, recent
travel, new foods.  Otherwise review of systems was negative

Past Medical History:
1.  Crohn's disease status post small bowel resections (see HPI)
2.  Coronory artery disease
3.  Status post exploratory laparotomy complicated by MI (in
past)
4.  Small bowel obstruction
5.  Congestive heart failure ([**7-24**] EF=39% with no reversable
defects

Social History:
Retired, Married, no alcohol, no cigarettes

Family History:
No history of crohn's disease

Physical Exam:
Temperature 98.6, Heart rate 76, Blood pressure 110/70,
Respiratory rate 20, oxygen saturation 99% on room air

General: well nourished and well hydrated
Head and neck:  pupils equal round and reactive to light. neck
supple, trachea midline, no cervical lymphadenopathy
Chest: clear to auscultation bilaterally
Heart: regular rate and rhythm
Abdomen: obese, distended.  some focal tenderness in left upper
quadrant. No guarding or rebound tenderness
Extremities: no clubbing cyanosis or edema

Pertinent Results:
[**2174-8-6**] 11:09PM BLOOD WBC-9.5 RBC-3.77* Hgb-12.6* Hct-36.6*
MCV-97 MCH-33.5* MCHC-34.5 RDW-14.1 Plt Ct-99*
[**2174-8-6**] 11:09PM BLOOD PT-13.2 PTT-25.7 INR(PT)-1.4
[**2174-8-6**] 11:09PM BLOOD Glucose-106* UreaN-46* Creat-1.4* Na-131*
K-4.3 Cl-94* HCO3-27 AnGap-14
[**2174-8-6**] 11:09PM BLOOD ALT-37 AST-21 AlkPhos-65 Amylase-108*
TotBili-0.4
[**2174-8-6**] 11:09PM BLOOD Lipase-62*
[**2174-8-6**] 11:09PM BLOOD Albumin-2.5* Calcium-8.0* Phos-2.5*
Mg-2.1

[**2174-8-7**], [**2174-8-8**], [**2174-8-9**] Blood Cultures:
   AEROBIC BOTTLE (Final [**2174-8-10**]):
      STAPHYLOCOCCUS, COAGULASE NEGATIVE.

[**2174-8-9**]: Central line tip: Staphlococcus, coagulase negative

CT Abdomen and pelvis [**2174-8-8**]:
The visualized lung bases demonstrate tiny bilateral pleural
effusions and associated atelectatic changes. Allowing for
limitations of a noncontrast exam, the liver, spleen, pancreas,
adrenal glands, and kidneys appear grossly normal. Sludge and
stones are identified within the gallbladder, but no secondary
signs of cholecystitis are identified. Evauation of the bowel is
limited due to the presence of high- contrast barium material
and beam-hardening artifact. Allowing for this, there is a focal
loop of small bowel within the left hemiabdomen, likely mid
jejunum, which demonstrates wall thickening. At least two,
possibly three fluid collections are identified adjacent to this
loop of small bowel. This constellation of findings is most
compatible with active Crohn's disease. No free air is
identified. There are no discernible colonic abnormalities to
indicate the occurrence of perforation from recent colonoscopy.
These fluid collections measure approximately 5.6 x 4.1 and 6.3
x 2.2 cm. These are seemingly discrete collections, but they may
be contiguous by transmural extension. No other abnormal loops
of bowel are identified.

CT OF PELVIS WITHOUT IV CONTRAST: The urinary bladder is
collapsed due to the presence of a Foley catheter, limiting
evaluation. There is high-density contrast material within the
colon, as above, limiting evaluation. The sigmoid colon is
collapsed. No free fluid or air is identified.

IMPRESSION:

1. Focal wall thickening of a loop of mid jejunum with at least
two adjacent small fluid collections. These findings are most
compatible with active Crohn's disease in a patient with this
history.
2. Limited evaluation of colon demonstrates no evidence of
complications from recent colonoscopy.
3. Sludge and stone-containing gallbladder without evidence of
cholecystitis.
4. Tiny bilateral pleural effusions.


Brief Hospital Course:
The patient was admitted to the surgical service on [**2174-8-8**].  He
was kept NPO, was continued on his TPN, and had a CT scan.  He
was started on levofloxacin/flagyl.  He grew out coag negative
staph from in his blood cultures, and his central line was
pulled and he was started on vancomycin. The GI service thought
that this was not consistent with a crohn's flare, and they
suggested a rapid taper of his steroids.  He was stable until
the evening of hospital day number 2, when he had the acute
onset of Left lower quadrant abdominal pain.  The pain was
sharp, and his exam was concerning for some questionable
guarding in the left lower quadrant.  However, he did not have
any truly positive peritoneal signs.  His abdomen was more
distended than it had been. He got an upright chest and
abdominal xray that did not show any free air, but did show
dilated bowel loops.  An NG tube was placed, and he had serial
abdominal exams overnight.  His exam worsened, and he had clear
peritoneal signs in the left lower quadrant.  he also became
tachycardic to the 110s, and his urine output decreased.  A
decision was then made to take him to the operating room.  Gross
spillage of stool was noted on the exploratory laparotomy, and a
segment of small bowel was resected in the area of jejunal
diverticuli.  He was transfered to the intensive care unit,
intubated and required massive fluid resuscititation for his
septic picture. Patient remained in the T/SICU and transferred
to the floor after 5 days and monitored. The patient was
aggresvily diuresed and encouraged to take po. THe patient
continued to be diuresed and had wound changes done twice a day.
Patient was continued on TPN during his stay on the floor. On
[**8-28**], the patient became tachypneic and became
tachycardic. The patient was managed cardiovascularily
overnight, but spiked a tempature. The patient's line was
removed and pan cultured. The patient was transferred to the
unit the next day for closer management of his cardiac status.
The patient did well during the four days in the SICU and
returned again to the floor once cleared by cardiology. His
heart rate was controlled with 75 po tid. The patient had a
repeat episode of chest pain for approxiamtley for 2 hours on
the the 11th and and was evaluted by on surgery and cardiology.
Patient was started on heparin and and IV nitro dip and began to
cycle his enzymes. The patient ruled out for an myocardial
infarction and the nitro drip was discontinued. The patient
remained on the cardiac floor during the remaining part of his
inpatient stay. Psychiatry was consulted to evaluate the
patient's depressed mood and was started on remeron 7.5 and
ritalin as per psychiatry requiest. The patient was evalutated
by speech and swallow and had a video swallow gram performed
which illustrated a normal swallow function and the patient was
re-started on a house diet which he tolerated. The patient has
done well despite of his tumulotous course in the hospital and
is in good condition on discharge to the rehab center. The
patient's abdominal wound will still require dressing changes
[**Hospital1 **].

Medications on Admission:
Medications at home:  Immuran 50 mg [**Hospital1 **], Asacol 1200 [**Hospital1 **],
Prednisone 60 mg qd, Saltolol 80 mg [**Hospital1 **], Asprin 81 mg qd,
Lisinopril 5 mg qd, Digoxin 0.125 mg qd.

Meds on transfer: Cefoxitin 1 gram iv q6, Flagyl 500 mg IV TID,
Protonix 40 mg IV qd, TPN, and a methylprednisole drip at 2.4
mg/hour

Discharge Medications:
1. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO twice a day.
Disp:*180 Tablet(s)* Refills:*2*
2. Pantoprazole Sodium 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*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Disp:*270 Tablet(s)* Refills:*2*
5. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
6. Methylphenidate HCl 5 mg Tablet Sig: One (1) Tablet PO QAM
(once a day (in the morning)).
Disp:*30 Tablet(s)* Refills:*2*
7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Percocet 5-325 mg Tablet Sig: Two (2) Tablet PO every six (6)
hours for 20 days.
Disp:*160 Tablet(s)* Refills:*0*
9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day for
20 days.
Disp:*40 Capsule(s)* Refills:*0*


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 1293**] - [**Location (un) **]

Discharge Diagnosis:
x-lap and small bowel resection of mid-jejunal perforated
diverticulum with abdominal spillage [**2174-8-10**]


Discharge Condition:
Good

Discharge Instructions:
Please call if you have a fevers >100.5, chills, vomitting,
redness or drainage from the the wound.

Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 5182**] [**Telephone/Fax (1) 5189**] in [**2-22**] weeks


                             [**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 5190**]

Completed by:[**2174-9-8**]
{'Diverticulosis of small intestine (without mention of hemorrhage),Infection and inflammatory reaction due to other vascular device, implant, and graft,Methicillin susceptible Staphylococcus aureus septicemia,Acute kidney failure, unspecified,Atrial fibrillation,Severe sepsis,Other and unspecified angina pectoris,Hyposmolality and/or hyponatremia,Congestive heart failure, unspecified'}


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/Possible perforated diverticulum

PRESENT ILLNESS: The patient is a 68 year old male with a 38 year history of
Crohn's disease, coronary artery disease, previous small bowel
obstruction, and congestive heart failure, status post resection
of small bowel three times ([**2136**], [**2154**], [**2164**]) who presented from
[**Doctor Last Name 1495**] [**Hospital 107**] Medical center with abdominal pain.

MEDICAL HISTORY: 1.  Crohn's disease status post small bowel resections (see HPI)
2.  Coronory artery disease
3.  Status post exploratory laparotomy complicated by MI (in
past)
4.  Small bowel obstruction
5.  Congestive heart failure ([**7-24**] EF=39% with no reversable
defects

MEDICATION ON ADMISSION: Medications at home:  Immuran 50 mg [**Hospital1 **], Asacol 1200 [**Hospital1 **],
Prednisone 60 mg qd, Saltolol 80 mg [**Hospital1 **], Asprin 81 mg qd,
Lisinopril 5 mg qd, Digoxin 0.125 mg qd.

ALLERGIES: Oxycodone Hcl/Acetaminophen / Hydrocodone Bit/Acetaminophen

PHYSICAL EXAM: Temperature 98.6, Heart rate 76, Blood pressure 110/70,
Respiratory rate 20, oxygen saturation 99% on room air

FAMILY HISTORY: No history of crohn's disease

SOCIAL HISTORY: Retired, Married, no alcohol, no cigarettes 

### Response:
{'Diverticulosis of small intestine (without mention of hemorrhage),Infection and inflammatory reaction due to other vascular device, implant, and graft,Methicillin susceptible Staphylococcus aureus septicemia,Acute kidney failure, unspecified,Atrial fibrillation,Severe sepsis,Other and unspecified angina pectoris,Hyposmolality and/or hyponatremia,Congestive heart failure, unspecified'}
