CHIEF COMPLAINT: Abdominal Pain

PRESENT ILLNESS: This is a 44 year old male who was transfered from [**Location (un) 5503**]
in an emergent condition. He had a 12 hour history of abdominal
pain precipitated by urinating
at 2:30 on the night prior to this operation. He went to his
local emergency room and was found to have free air and evidence
of a perforated viscus, with oral contrast extravasation on his
CAT scan. His prior medical history was
consistent with a Roux-en-Y gastrojejunostomy for morbid
obesity, performed laparoscopically 5 years ago in [**State 3908**].
Since then, he has lost 200 pounds and has decreased many of its
comorbidities. He has had a history of hard drinking in the past
and had been drinking until a few weeks ago.

MEDICAL HISTORY: Hypothyroid
Depression

MEDICATION ON ADMISSION: levoryl 0.025, oxycontin 40", K dur, aldactone 100", miralax 17
gm, wellbutrin 150', valium 10q8

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: 99.8, HR 150, SBP 80-90, 99% 2L
Gen: Writhing in pain
Head: EOMI, PERRL
Chest: CTAB
CV: Tachy RR
GI: + tenderness diffusely, + rebound, + peritoneal signs, +
distension, + dullness inferiorly to percussion
Skin: +2 edema LE

FAMILY HISTORY: Mother died from stroke at young age and history of alcohol
abuse
Father had urethral cancer and history of alcohol abuse.

SOCIAL HISTORY: Smoking: 80 pack yr hx
ETOH: [**3-17**] alcoholic drinks/day for 20 yrs.
Poor nutrition
Unspecified peritonitis,Chronic or unspecified gastrojejunal ulcer with perforation, without mention of obstruction,Cirrhosis of liver without mention of alcohol,Other specified disorders of peritoneum,Unspecified acquired hypothyroidism,Intestinal bypass or anastomosis status
Peritonitis NOS,Chr marginal ulc w perf,Cirrhosis of liver NOS,Peritoneal disorder NEC,Hypothyroidism NOS,Intestinal bypass status
Admission Date:  [**2141-8-26**]              Discharge Date:   [**2141-9-5**]

Date of Birth:  [**2097-5-1**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Abdominal Pain

Major Surgical or Invasive Procedure:
Exploratory Laporatomy
Liver Wedge Biopsy
J tube placement
Resection of Gastrojejunostomy Anastomosis
New Gastrojejunostomy Formation


History of Present Illness:
This is a 44 year old male who was transfered from [**Location (un) 5503**]
in an emergent condition. He had a 12 hour history of abdominal
pain precipitated by urinating
at 2:30 on the night prior to this operation. He went to his
local emergency room and was found to have free air and evidence
of a perforated viscus, with oral contrast extravasation on his
CAT scan. His prior medical history was
consistent with a Roux-en-Y gastrojejunostomy for morbid
obesity, performed laparoscopically 5 years ago in [**State 3908**].
Since then, he has lost 200 pounds and has decreased many of its
comorbidities. He has had a history of hard drinking in the past
and had been drinking until a few weeks ago.

He was recently admitted to the hospital following his recent
unemployment. He was found to have evidence of the liver
decompensation, as well as renal insufficiency. He was treated
for these and released from the hospital for a few
days prior to the current presentation of rigid abdominal pain
last night.

He was found to have florid peritonitis upon meeting him here at
the [**Hospital1 18**]. He was pretty well resuscitated from a volume status
and his mental status was completely intact. He required an
emergency operation to repair a perforated viscus.

Past Medical History:
Hypothyroid
Depression

Past Surgical Hx:
Gastric Bypass 5 years ago lost approximately 200lbs
Cholecystectomy
Shoulder Surgery x 4
Left Knee hematoma evacuation after motorcylce accident

Social History:
Smoking: 80 pack yr hx
ETOH: [**3-17**] alcoholic drinks/day for 20 yrs.
Poor nutrition

Family History:
Mother died from stroke at young age and history of alcohol
abuse
Father had urethral cancer and history of alcohol abuse.

Physical Exam:
VS: 99.8, HR 150, SBP 80-90, 99% 2L
Gen: Writhing in pain
Head: EOMI, PERRL
Chest: CTAB
CV: Tachy RR
GI: + tenderness diffusely, + rebound, + peritoneal signs, +
distension, + dullness inferiorly to percussion
Skin: +2 edema LE

Pertinent Results:
Pathology Examination

Name Birthdate    Age     Sex Pathology #     [**Hospital1 18**] [**Known lastname 69811**],[**Known firstname **] P.       [**2097-5-1**]    44 Male      [**-7/2767**]
[**Numeric Identifier 69812**]
Report to:   DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by:   DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/et



SPECIMEN SUBMITTED:  LIVER BX & GASTRO-JEJUNAL PERFORATION SITE.

Procedure date     Tissue received     Report Date    Diagnosed
by
[**2141-8-26**] [**2141-8-28**] [**2141-9-1**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 18795**]/cma??????

DIAGNOSIS

I.  Liver, wedge biopsy (A):

1.  Marked steatosis, predominantly large droplet type,
involving virtually 100% of hepatocytes.

2.  Moderate, predominantly mononuclear cell, inflammation in
portal tracts and fibrous septa, with bile duct proliferation.

3.  Intracytoplasmic hyaline seen, without lobular neutrophils.

4.  Trichrome stain demonstrates nodule formation consistent
with cirrhosis.

5.  Iron stain shows increased iron in Kupffer cells and
hepatocytes.  The findings are consistent with toxic metabolic
liver injury, with   progression to cirrhosis.

II.  Resection of gastroenteric anastomosis (B-K):

1.  Transmural perforation of the small bowel with acute
inflammatory exudate, granulation tissue, and early fibrosis.

2.  The remaining small bowel is unremarkable.  No features of
enteritis are identified.

3.  Resection margins (small bowel and proximal stomach):  No
diagnostic abnormalities recognized.

CHEST (PORTABLE AP)  [**2141-8-27**] 7:43 AM

CHEST (PORTABLE AP)

Reason: position of ett after repositioning?

[**Hospital 93**] MEDICAL CONDITION:
44 year old man s/p exploratory laparotomy s/p intra-operative
right IJ CVL placement and removal and subsequent
intra-operative left IJ central line placement
REASON FOR THIS EXAMINATION:
position of ett after repositioning?
HISTORY: Check ET tube placement.

CHEST, SINGLE AP PORTABLE SUPINE VIEW.

An ET tube is present -- the tip lies above the level of the
clavicles, 9.5 cm above the carina, somewhat high. A left IJ
central line is present, tip overlying distal portion of the
left innominate vessel. An NG tube is present, tip beneath
diaphragm extending off film.

There is upper zone redistribution and diffuse vascular
blurring, consistent with CHF, similar to, but slightly worse
than, on [**2141-8-26**]. There is increased hazy opacity at the left
base with new partial obscuration of the left hemidiaphragm. No
gross effusion is identified on either side.

Old healed right-sided rib fractures noted. At the periphery of
these films, under penetrated and therefore faintly seen, or
right upper quadrant clips, skin staples, and some form of
catheter drain over the upper abdomen from an inferior approach.

IMPRESSION :

1. Mild CHF, slightly worse compared with one day earlier. New
patchy opacity left base -- question atelectasis or early
infiltrate.

2. ET tube remains above the level of the clavicles and
attempted repositioning should be considered. Left IJ line as
described.

UGI SGL W/ SBFT  [**2141-9-1**] 10:30 AM

UGI SGL W/ SBFT

Reason: Want to make sure that his new Gastrojejunostomy
anastomosis

[**Hospital 93**] MEDICAL CONDITION:
44 year old man POD# 7 s/p resection and formation of perforated
gastrojejunostomy after a gastric bypass in [**2136**]
REASON FOR THIS EXAMINATION:
Please use Gastrograffin. Want to make sure that his new
Gastrojejunostomy anastomosis site is patent and that it is not
obstructed.
INDICATION: 44-year-old gentleman postop day 7 status post
revision of a gastric bypass done in [**2136**] with reformation of
gastrojejunostomy. Patient referred to evaluate
gastrojejunostomy anastomosis.

TECHNIQUE: Upper GI study. Study done using Conray. This is a
very limited study due to patient sedated on Dilaudid PCA and
Ativan prior to arrival.

FINDINGS: Conray was administered to the patient while in a
semi-upright position. Contrast passes freely through the
esophagus into the stomach. There is evidence of free reflux
with slow clearance. The stomach fills with contrast and empties
into the small bowel without difficulty. Contrast flows
antegrade and retrograde into the Roux limb of the gastric
bypass. There is no evidence of extravasation of contrast.
Gastrojejunostomy anastomosis site is patent without evidence of
leak. In the obtained images there are dilated loops of small
bowel which may represent an ileus.

IMPRESSION:
1. Gastrojejunostomy anastomosis is intact without evidence of
leak. There is no evidence of obstruction.

2. Dilated loops of small bowel concerning for ileus.

3. Limited exam due to patient sedation from narcotics and
benzodiazepine.


Brief Hospital Course:
He was admitted to [**Hospital1 18**] on [**2141-8-26**] to Dr. [**Last Name (STitle) **] for
perforated viscus.  The CT from Outside hospital showed free air
with contrast extravasation, and ascites. The ascites is most
likely due to cirrhosis of the liver. He was resuscitated with 4
liters and was emergently taken to the OR for an exploratory
laparotomy. He then went to the SICU post-operatively sedated
and intubated. He continued to receive fluids post-op for low
urine output. He had a PCA for pain control. He was switched to
Percocet when he was taking PO's.

GI/Abd:
He was markedly distended with a dressing in place. He had a
J-tube to gravity. His NGT was patent and draining small amounts
of bilious drainage. He was started on J tube feedings POD 2 and
slowly advanced to his goal rate. The NGT was self D/C'd POD 4.
He was tolerating a clear diet and was advanced to a regular
diet on POD 8. The [**Doctor Last Name 406**] drain, which was putting out about
1700cc daily was D/C'd POD 8, so that the fluids would be
reabsorbed.

He had +4 pitting edema to the lower extremities and had massive
scrotal swelling. His Albumin was 1.4. Most of the fluid was
third space and would gradually improve when his nutrition and
Albumin improved. Lasix was ordered for diuresis, with moderate
effect.
An UGI was performed on [**2141-9-1**] and showed the anastomosis is
intact without evidence of a leak.
His abdominal incision with staples was clean, dry, and intact.
The edges were well approximated and there was no redness. The
staples will remain in place until his follow-up appointment.
His [**Doctor Last Name 406**] tube and drain were D/C'd POD 8 and a U-stitch was
placed.

CV:
IV fluids were ordered for tachycardia and hypotension with a
good response.

Resp:
He was weaned off the vent POD 2 and doing well. He was
instructed to continue deep breathing and incentive spirometry.

ID:
He was started on Fluconazole, Zosyn, Flagyl, and Vanco. He
continued with the antibiotics until discharge.

Physical Therapy: The patient was deconditioned and had trouble
ambulating due to the large amount of edema. Physical Therapy
worked with him several times and deemed him safe to go home
with home PT.

He was started back on his home medications and discharged in
good condition.

Medications on Admission:
levoryl 0.025, oxycontin 40", K dur, aldactone 100", miralax 17
gm, wellbutrin 150', valium 10q8

Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever, pain.
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*qs Tablet(s)* Refills:*2*
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*qs Tablet(s)* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Spironolactone 25 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
7. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO QAM (once a day (in the morning)).
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for 3 weeks.
Disp:*35 Tablet(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
southcaost home care services

Discharge Diagnosis:
Perforated Gastrojejunostomy


Discharge Condition:
Good


Discharge Instructions:
* Increasing pain
* Fever (>101.5 F) or Vomiting
* Inability to pass gas or stool
* Other symptoms concerning to you

Please take all your medications as ordered
Continue to walk several times every day.
You may shower and wash incision with soap and water. Pat dry.
No tub baths or swimming
No heavy lifting >10 lbs for 6 weeks.

Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 2 weeks. Call [**Telephone/Fax (1) 1231**]
for an appointment.
Please follow-up with your PCP for continued pain management.



Completed by:[**2141-9-5**]
{'Unspecified peritonitis,Chronic or unspecified gastrojejunal ulcer with perforation, without mention of obstruction,Cirrhosis of liver without mention of alcohol,Other specified disorders of peritoneum,Unspecified acquired hypothyroidism,Intestinal bypass or anastomosis status'}


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: This is a 44 year old male who was transfered from [**Location (un) 5503**]
in an emergent condition. He had a 12 hour history of abdominal
pain precipitated by urinating
at 2:30 on the night prior to this operation. He went to his
local emergency room and was found to have free air and evidence
of a perforated viscus, with oral contrast extravasation on his
CAT scan. His prior medical history was
consistent with a Roux-en-Y gastrojejunostomy for morbid
obesity, performed laparoscopically 5 years ago in [**State 3908**].
Since then, he has lost 200 pounds and has decreased many of its
comorbidities. He has had a history of hard drinking in the past
and had been drinking until a few weeks ago.

MEDICAL HISTORY: Hypothyroid
Depression

MEDICATION ON ADMISSION: levoryl 0.025, oxycontin 40", K dur, aldactone 100", miralax 17
gm, wellbutrin 150', valium 10q8

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: 99.8, HR 150, SBP 80-90, 99% 2L
Gen: Writhing in pain
Head: EOMI, PERRL
Chest: CTAB
CV: Tachy RR
GI: + tenderness diffusely, + rebound, + peritoneal signs, +
distension, + dullness inferiorly to percussion
Skin: +2 edema LE

FAMILY HISTORY: Mother died from stroke at young age and history of alcohol
abuse
Father had urethral cancer and history of alcohol abuse.

SOCIAL HISTORY: Smoking: 80 pack yr hx
ETOH: [**3-17**] alcoholic drinks/day for 20 yrs.
Poor nutrition 

### Response:
{'Unspecified peritonitis,Chronic or unspecified gastrojejunal ulcer with perforation, without mention of obstruction,Cirrhosis of liver without mention of alcohol,Other specified disorders of peritoneum,Unspecified acquired hypothyroidism,Intestinal bypass or anastomosis status'}
