CHIEF COMPLAINT: super obesity (BMI=66)

PRESENT ILLNESS: 53 year-old man with a history of obesity, BMI of 66. He was
initially evaluated for gastric restrictive surgery through the
[**Hospital 18**] [**Hospital 33018**] clinic on [**10-7**] and [**2132-11-10**] with
follow-up visits in the Weight Winners Program on 7 visits from
[**11-27**] to [**2133-2-6**]. His initial presentation weight
was 495.9 lbs on [**2132-10-7**], height of 73.75 inches and BMI of
64.2. [**Known firstname 62002**] was evaluated in the surgical clinic on [**2133-2-18**] at
weight of 476.4 lbs and BMI of 61.7. He was approved for the
Roux-en-Y gastric bypass procedure and scheduled for surgery,
however during Pre-op Admission Testing he was noted to be in
new-onset atrial fibrillation with hypertension. Surgery was
cancelled and he was followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73**] of
Cardiology for management of his blood pressure and evaluation
of atrial fibrillation, for which he was placed on Coumadin. He
returned to PAT on [**2133-8-11**] with surgery date set for [**2133-8-18**]. At
this time it was noted that he had developed a left lower
extremity cellulitis
with a history of recurrent cellulitis, which had been treated
with IV antibiotics daily at [**Hospital3 2358**]. Surgery was again
postponed until the cellulitis resolved. Prior to scheduled
surgery, [**Known firstname 62002**] was followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 62003**] and
dietitian [**First Name4 (NamePattern1) 1356**] [**Last Name (NamePattern1) **], RD for dietary counseling and initiation
of Xenical prior to surgery. He was admitted on [**2134-7-5**] to
undergo open Roux-en-Y gastric bypass.

MEDICAL HISTORY: PMH:
Hypertension
Hyperlipidemia
Atrial fibrillation, on coumadin
Obstructive Sleep Apnea (on CPAP of 10 with 2 liters of
oxygen)Lower extremity venous stasis with recurrent cellulitis
Osteoarthritis of back and lower extremity joints

MEDICATION ON ADMISSION: Atenolol 100mg po daily
HCTZ 25mg po daily
Coumadin 5mg po qhs
Lisinopril 20mg po daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Gen: No acute distress.
HEENT: Sclerae were anicteric, conjunctiva clear, pupils equal,
round and
reactive to light, mucous membranes moist, oropharynx without
exudates
Neck: Trachea midline. Neck supple with no adenopathy
Pulm: Occasional expiratory wheeze, otherwise clear to
auscultation bilaterally.
CV: Irregular rhythm, regular rate, normal S1 and S2, no
murmurs/rubs/gallops
Abd: Soft, non-tender, obese, with normal bowel sounds. Open
areas of abdominal wound on superior and inferior aspects, with
wound VAC in place.
Ext: +1 edema, lower extremities, bilaterally. No joint swelling
Neuro: no focal deficits

FAMILY HISTORY: Family history is noted for father deceased age 68 of MI and
obesity and mother deceased age 72 from stroke. His son
underwent [**Name2 (NI) 33554**] gastric bypass for morbid obesity through
[**Hospital1 18**] Program in [**2132**].

SOCIAL HISTORY: He is married living with his wife. [**Name (NI) **] has a business involved
in medical transportation. He is former Olympic-style wrestler
in the old Soviet [**Hospital1 1281**]. He was former one pack cigarettes daily
stopping in [**9-/2131**], no recreational drugs, occasional alcohol
on weekends.
Morbid obesity,Disruption of internal operation (surgical) wound,Pneumonia, organism unspecified,Chronic cholecystitis,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Atrial fibrillation,Backache, unspecified,Diverticulosis of colon (without mention of hemorrhage),Personal history of tobacco use
Morbid obesity,Disrup internal op wound,Pneumonia, organism NOS,Chronic cholecystitis,Hypertension NOS,Hyperlipidemia NEC/NOS,Atrial fibrillation,Backache NOS,Dvrtclo colon w/o hmrhg,History of tobacco use
Admission Date:  [**2134-7-5**]              Discharge Date:   [**2134-7-24**]

Date of Birth:  [**2081-1-2**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 301**]
Chief Complaint:
super obesity (BMI=66)

Major Surgical or Invasive Procedure:
[**7-7**]: Open Roux-en-Y gastric bypass
[**7-16**]: Exploratory laparotomy, Cholecystectomy (open),
Debridement of fascial wound


History of Present Illness:
53 year-old man with a history of obesity, BMI of 66. He was
initially evaluated for gastric restrictive surgery through the
[**Hospital 18**] [**Hospital 33018**] clinic on [**10-7**] and [**2132-11-10**] with
follow-up visits in the Weight Winners Program on 7 visits from
[**11-27**] to [**2133-2-6**]. His initial presentation weight
was 495.9 lbs on [**2132-10-7**], height of 73.75 inches and BMI of
64.2. [**Known firstname 62002**] was evaluated in the surgical clinic on [**2133-2-18**] at
weight of 476.4 lbs and BMI of 61.7. He was approved for the
Roux-en-Y gastric bypass procedure and scheduled for surgery,
however during Pre-op Admission Testing he was noted to be in
new-onset atrial fibrillation with hypertension. Surgery was
cancelled and he was followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73**] of
Cardiology for management of his blood pressure and evaluation
of atrial fibrillation, for which he was placed on Coumadin. He
returned to PAT on [**2133-8-11**] with surgery date set for [**2133-8-18**]. At
this time it was noted that he had developed a left lower
extremity cellulitis
with a history of recurrent cellulitis, which had been treated
with IV antibiotics daily at [**Hospital3 2358**]. Surgery was again
postponed until the cellulitis resolved. Prior to scheduled
surgery, [**Known firstname 62002**] was followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 62003**] and
dietitian [**First Name4 (NamePattern1) 1356**] [**Last Name (NamePattern1) **], RD for dietary counseling and initiation
of Xenical prior to surgery. He was admitted on [**2134-7-5**] to
undergo open Roux-en-Y gastric bypass.

Past Medical History:
PMH:
Hypertension
Hyperlipidemia
Atrial fibrillation, on coumadin
Obstructive Sleep Apnea (on CPAP of 10 with 2 liters of
oxygen)Lower extremity venous stasis with recurrent cellulitis
Osteoarthritis of back and lower extremity joints

Social History:
He is married living with his wife. [**Name (NI) **] has a business involved
in medical transportation. He is former Olympic-style wrestler
in the old Soviet [**Hospital1 1281**]. He was former one pack cigarettes daily
stopping in [**9-/2131**], no recreational drugs, occasional alcohol
on weekends.

Family History:
Family history is noted for father deceased age 68 of MI and
obesity and mother deceased age 72 from stroke. His son
underwent [**Name2 (NI) 33554**] gastric bypass for morbid obesity through
[**Hospital1 18**] Program in [**2132**].

Physical Exam:
Gen: No acute distress.
HEENT: Sclerae were anicteric, conjunctiva clear, pupils equal,
round and
reactive to light, mucous membranes moist, oropharynx without
exudates
Neck: Trachea midline. Neck supple with no adenopathy
Pulm: Occasional expiratory wheeze, otherwise clear to
auscultation bilaterally.
CV: Irregular rhythm, regular rate, normal S1 and S2, no
murmurs/rubs/gallops
Abd: Soft, non-tender, obese, with normal bowel sounds. Open
areas of abdominal wound on superior and inferior aspects, with
wound VAC in place.
Ext: +1 edema, lower extremities, bilaterally. No joint swelling
Neuro: no focal deficits

Pertinent Results:
[**2134-7-5**] 01:00PM   PT-13.7* PTT-25.4 INR(PT)-1.2*
[**2134-7-5**] 10:00PM   CALCIUM-8.6 PHOSPHATE-4.2# MAGNESIUM-1.7
[**2134-7-5**] 10:00PM   POTASSIUM-4.5
[**2134-7-5**] 11:04PM   WBC-14.9*# RBC-4.89 HGB-15.7 HCT-44.6 MCV-91
MCH-32.1* MCHC-35.2* RDW-14.3
[**2134-7-5**] 11:04PM   PLT COUNT-189

[**7-6**] CXR: The lung volumes are significantly decreased with the
bibasilar
linear opacitiessis.  The bilateral perihilar vessel crowdness
most likely related to poor inspiration effort but underlying
pulmonary edema cannot be excluded.
[**7-7**] CXR: Question early developing opacity in the lingular
segment
[**7-8**] CXR: Worsening left lower lobe/lingular consolidation
suggesting developing infection, pulmonary engorgement
[**7-9**] CXR: Left lower lobe opacities have improved consistent
with improving atelectasis
[**7-9**] US-guided PICC placement: Uncomplicated ultrasound-guided
single lumen PICC line placement via the right cephalic venous
approach.  Final internal length is 47 cm, with the tip
positioned in the SVC
[**7-11**] Pathology (gallbladder): Chronic cholecystitis, Hyperplasia
of cholecystic duct lymph node, No calculi in this specimen
[**7-11**] CXR: Low lung volumes, left basilar opacity noted on the
prior examination has resolved in the interim.  The lungs are
grossly clear.  There is some perihilar fullness of the
pulmonary bronchovasculature.
[**7-11**] Ultrasound of gallbladder: No evidence of gallstone or
pericholecystic fluid or edema identified in the visualized
portion of the gallbladder. Fatty liver.
[**7-11**] Doppler U/S of LE: Normal flow, compressibility, and
augmentations are seen in both common femoral, superficial
femoral, and popliteal veins.  No evidence of DVT.
[**7-11**] CXR: Cardiac size is slightly increased accompanied by
increasing vascular engorgement and perihilar haziness, likely
due to worsening edema from volume overload. Small bilateral
pleural effusions.
[**7-11**] ECG: Atrial fibrillation. Possible prior anterior
myocardial infarction based on Q waves in leads V1-V3. Compared
to prior tracing of [**2134-6-21**] ventricular response rate has
increased.
[**7-12**] CXR: No obvious infiltrate or failure, possible small areas
of left
lower lobe atelectasis not excluded.

Brief Hospital Course:
Admitted on [**2134-7-5**] and underwent open Roux-en-Y gastric bypass.
He tolerated the procedure well with no complications. While in
the PACU the patient went into rapid AFib, became hypertensive
(200/100) with heartrate in the 100s. He was subsequently placed
on nitro gtt and lopressor gtt, SBP titrated to 150 systolic.
Vital signs were otherwise stable. He denied chest pain and
shortness of breath. He was placed on dilaudid PCA for pain
management, in addition to thoracic epidural which was placed by
anesthesia in the OR. On POD2, NG tube removed, and patient
started on Stage I bariatric diet following negative Methylene
blue test. Around mid-day on POD2, patient began tachycardic (HR
140s) with O2 sats 87% on room air and was transferred to SICU
for hemodynamic monitoring, heartrate control, and respiratory
monitoring. He received Lopressor 10mg IV with stabilization of
blood pressure and rate control (HR 110s in AFib). He was placed
on 4L oxygen via nasal cannula with improvement in oxygen
saturation to 95%. CXR revealed linear atelectasis in the right
perihilar and left retrocardiac regions, with increased opacity
in the lingular segment, suspicious for developing infiltrate.
No effusion or pneumothorax, although mild tortuosity of the
thoracic aorta. He was placed NPO with IVF at 100cc/hr.
Overnight, heartrate was maintained 99-135 in AFib with
labetolol and lopressor IV. Blood pressure stabilized in
120-150s systolic. On POD3, the patient developed a low grade
temperature, for which blood and urine cultures were sent, and
prophylactic vancomycin and cefepime were started for suspected
pneumonia. He was placed on Stage I diet and coumadin was
re-started for prophylactic AFib management. On POD4, he was
transitioned to Stage II diet, which he tolerated well. On POD5,
he was transferred from the SICU to [**Hospital Ward Name 121**] 9. AFib was stabilized
with heartrate in the 70s-90s on po diltiazem and lopressor. He
was tolerating Stage II diet, with maintainence fluids at
100cc/hr. On POD6, patient developed right sided abdominal pain,
temperature to 101.4, rigors, shortness of breath, and
tachycardia (AFib) to 120-130s. He was immediately transferred
to the SICU. At this time, he was also noted to have wound
erythema, which prompted opening the wound at bedside, with
resulting purulent, brown, foul-smelling fluid expelled. Patient
was unable to undergo CT scan due to weight = 519 pounds. He
received a RUQ ultrasound to evaluate the gallbladder and a
doppler ultrasound of the lower extremities to rule out DVT.
Findings revealed no evidence of gallstone or pericholecystic
fluid or edema identified in the visualized portion of the
gallbladder, and normal flow, compressibility, and augmentations
in both common femoral, superficial femoral, and popliteal
veins, with no evidence of DVT. He was subsequently taken to the
operating room for exploration to washout wound and rule out
possible leak. Intraoperatively, exploratory laparotomy, open
cholecystectomy, and debridement of fascial wound were performed
with no leak found. He was brought back to the SICU
post-operatively intubated and sedated. He was resuscitated,
placed on zosyn and hemodynamics were closely monitored. On
POD7/1, the patient was weaned off propofol and subsequently
extubated with accompanying NG tube removal. Wound cultures
revealed gram negative rods (E.Coli and Enterococcus), for which
zosyn was continued. On POD8/2, temperature was 100.5 and wound
appeared erythematous at the staple line, with serous drainage
at superior and inferior edges. The wound was opened around
these seromas and packed with wet-dry gauze. In addition to
zosyn, vancomycin was added for wound erythema. He was placed on
Stage I diet, and transitioned to Stage II as tolerated. The
patient continued to be in AFib with heartrates in 100-150s. He
was maintained on diltiazem, lopressor, and eventually esmolol
gtt with improvement in HR to 70-90s. On POD [**7-26**] he was
transitioned to Stage III diet. Antibiotics were continued and
aggressive pulmonary toilet was encouraged. Diuresis with Lasix
IV was administered, as appropriate. On POD [**8-26**], the patient's
foley was discontinued and wound erythema was noted to decrease.
On POD [**9-27**], the patient was transferred from SICU to [**Hospital Ward Name 121**] 9 on
telemetry, remained in AFib well-controlled on po diltiazem and
lopressor. On POD [**10-28**] until 15/9, the patient remained on Stage
III diet which he tolerated well, ambulated with the assistance
of physical therapists and nurses, urinated without difficulty,
and reported adequate pain control. He received dressing changes
3x per day with wet-dry gauze in superior and inferior portions
of open wound, covered with dry gauze. JP drain output
progressively decreased, quality was serosanginous. He was
started on his home medications (Lisinopril, Atenolol,
Multivitamin, HCTZ, Coumadin), which he tolerated well. Labs
were checked daily and electrolytes were repleted as
appropriate. Atenolol was changed to Metoprolol 75mg po TID for
elevated heart rate (100s), which since decreased to 80s. A
wound VAC was placed on POD 18/12. Home nursing was arranged
prior to discharge to assist with VAC changes every 3 days and
evaluate for physical therapy. Coumadin was 7.5 mg po daily on
discharge. He will followup with Dr [**Last Name (STitle) 73**] and Dr [**Last Name (STitle) 13983**], in
addition to Dr [**Last Name (STitle) **] following discharge.


Medications on Admission:
Atenolol 100mg po daily
HCTZ 25mg po daily
Coumadin 5mg po qhs
Lisinopril 20mg po daily

Discharge Medications:
1. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): crush medication.
Disp:*30 Tablet(s)* Refills:*2*
2. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day).
Disp:*600 mL* Refills:*2*
3. Zantac 15 mg/mL Syrup Sig: Ten (10) mL PO twice a day.
Disp:*250 150* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed.
Disp:*250 ML(s)* Refills:*1*
5. Coumadin 7.5 mg Tablet Sig: One (1) Tablet PO once a day:
Have INR checked on Monday.
Disp:*30 Tablet(s)* Refills:*0*
6. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Disp:*250 Tablet(s)* Refills:*2*
7. Multivitamins     Tablet, Chewable Sig: One (1) Cap PO DAILY
(Daily).
Disp:*30 caplets* Refills:*2*
8. Outpatient Lab Work
INR, PTT, PT on [**8-1**], [**7-30**]
Follow up with Dr. [**Last Name (STitle) 73**] and Dr. [**Last Name (STitle) 13983**] concerning your INR
and coumadin dosing


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
1. Super obesity with BMI of 62
2. Obstructive sleep apnea
3. Hypertension
4. Atrial fibrillation, chronic
5. Chronic back pain
6. Wound and intradominal abscesses
7. Wound dehiscence
8. Cholecystitis s/p cholecystectomy


Discharge Condition:
Stable


Discharge Instructions:
Please call your surgeon or return to the emergency department
if you develop a fever greater than 101.5, chest pain, shortness
of
breath, severe abdominal pain, pain unrelieved by your pain
medication, severe nausea or vomiting, severe abdominal
bloating, inability to eat or drink, foul smelling or colorful
drainage from your incisions, redness or swelling around your
incisions, or any other symptoms which are concerning to you.

Diet:
Stay in Stage III diet until your follow up appointment. Do not
self advance diet, do not drink out of a straw or chew gum.

Medication Instructions:
Resume your home medications, CRUSH ALL PILLS.
You will be starting some new medications:
1.  You will be given a prescription for pain medication, which
may make you drowsy. Do not drive while taking pain medication.
2. You should begin taking a Flintstones chewable complete
ultivitamin. No gummy vitamins.
3. You will be taking Zantac liquid 150 mg twice daily for one
month. This medicine prevents gastric reflux.
4. You should take a stool softener, Colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.

Activity:
No heavy lifting of items [**9-6**] pounds for 6 weeks. You may
resume moderate exercise at your discretion, no abdominal
exercises.

Wound Care:
You may shower, no tub baths or swimming. Home nursing will
perform dressing changes daily.

Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 304**], MD Phone:[**Telephone/Fax (1) 305**] Date/Time:[**2134-7-28**] 3:15
[**Doctor Last Name **] [**Doctor Last Name 28352**], RD,LDN Phone:[**Telephone/Fax (1) 305**] Date/Time:[**2134-7-28**] 3:30
{'Morbid obesity,Disruption of internal operation (surgical) wound,Pneumonia, organism unspecified,Chronic cholecystitis,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Atrial fibrillation,Backache, unspecified,Diverticulosis of colon (without mention of hemorrhage),Personal history of tobacco use'}


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: super obesity (BMI=66)

PRESENT ILLNESS: 53 year-old man with a history of obesity, BMI of 66. He was
initially evaluated for gastric restrictive surgery through the
[**Hospital 18**] [**Hospital 33018**] clinic on [**10-7**] and [**2132-11-10**] with
follow-up visits in the Weight Winners Program on 7 visits from
[**11-27**] to [**2133-2-6**]. His initial presentation weight
was 495.9 lbs on [**2132-10-7**], height of 73.75 inches and BMI of
64.2. [**Known firstname 62002**] was evaluated in the surgical clinic on [**2133-2-18**] at
weight of 476.4 lbs and BMI of 61.7. He was approved for the
Roux-en-Y gastric bypass procedure and scheduled for surgery,
however during Pre-op Admission Testing he was noted to be in
new-onset atrial fibrillation with hypertension. Surgery was
cancelled and he was followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73**] of
Cardiology for management of his blood pressure and evaluation
of atrial fibrillation, for which he was placed on Coumadin. He
returned to PAT on [**2133-8-11**] with surgery date set for [**2133-8-18**]. At
this time it was noted that he had developed a left lower
extremity cellulitis
with a history of recurrent cellulitis, which had been treated
with IV antibiotics daily at [**Hospital3 2358**]. Surgery was again
postponed until the cellulitis resolved. Prior to scheduled
surgery, [**Known firstname 62002**] was followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 62003**] and
dietitian [**First Name4 (NamePattern1) 1356**] [**Last Name (NamePattern1) **], RD for dietary counseling and initiation
of Xenical prior to surgery. He was admitted on [**2134-7-5**] to
undergo open Roux-en-Y gastric bypass.

MEDICAL HISTORY: PMH:
Hypertension
Hyperlipidemia
Atrial fibrillation, on coumadin
Obstructive Sleep Apnea (on CPAP of 10 with 2 liters of
oxygen)Lower extremity venous stasis with recurrent cellulitis
Osteoarthritis of back and lower extremity joints

MEDICATION ON ADMISSION: Atenolol 100mg po daily
HCTZ 25mg po daily
Coumadin 5mg po qhs
Lisinopril 20mg po daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Gen: No acute distress.
HEENT: Sclerae were anicteric, conjunctiva clear, pupils equal,
round and
reactive to light, mucous membranes moist, oropharynx without
exudates
Neck: Trachea midline. Neck supple with no adenopathy
Pulm: Occasional expiratory wheeze, otherwise clear to
auscultation bilaterally.
CV: Irregular rhythm, regular rate, normal S1 and S2, no
murmurs/rubs/gallops
Abd: Soft, non-tender, obese, with normal bowel sounds. Open
areas of abdominal wound on superior and inferior aspects, with
wound VAC in place.
Ext: +1 edema, lower extremities, bilaterally. No joint swelling
Neuro: no focal deficits

FAMILY HISTORY: Family history is noted for father deceased age 68 of MI and
obesity and mother deceased age 72 from stroke. His son
underwent [**Name2 (NI) 33554**] gastric bypass for morbid obesity through
[**Hospital1 18**] Program in [**2132**].

SOCIAL HISTORY: He is married living with his wife. [**Name (NI) **] has a business involved
in medical transportation. He is former Olympic-style wrestler
in the old Soviet [**Hospital1 1281**]. He was former one pack cigarettes daily
stopping in [**9-/2131**], no recreational drugs, occasional alcohol
on weekends. 

### Response:
{'Morbid obesity,Disruption of internal operation (surgical) wound,Pneumonia, organism unspecified,Chronic cholecystitis,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Atrial fibrillation,Backache, unspecified,Diverticulosis of colon (without mention of hemorrhage),Personal history of tobacco use'}
