CHIEF COMPLAINT: Abdominal pain

PRESENT ILLNESS: The patient is a 68 y/o male who presented to an outside
hospital on [**2175-11-12**] for lower abdominal pain.  The abdominal
pain started the day prior to presentation and has worsened in
severity.  He denies fever, chills, nausea/vomiting, or a change
in bowel habits.  He was evaluated at the outside hospital where
a CT scan showed sigmoid diverticulitis, adjacent stranding, and
a small amount of free air.  He is referred to [**Hospital1 18**] for
management of his comorbidities.

MEDICAL HISTORY: 1. CAD - MI, PTCA in [**2170**], deccreased EF
2. CVA - left monocular blindness
3. COPD on home O2
4. Chronic renal insufficiency
5. Renal cell carcinoma s/p nephrectomy
6. sleep apnea
7. diverticulitis
8. iliac stent

MEDICATION ON ADMISSION: Plavix
Norvasc
ASA
Tricor
Toprol
Lipitor
Amitriptyline
Prednisone

ALLERGIES: Codeine / Iodine

PHYSICAL EXAM: T 98.0  P 88  BP 132/85  R 26  SaO2 95% 5L nc
Gen - mild discomfort, non-toxic appearing
Lungs  - decreased in bases bilaterally
Heart - Regular rate and rhythm, no murmurs rubs or gallops
ABD - very distended, tender to palpation in lower quadrants, no
rebound or guarding
Ext - no lower extremity edema

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Patient smokes a pack per day of cigarettes.
Diverticulitis of colon (without mention of hemorrhage),Peritonitis (acute) generalized,Abscess of intestine,Cardiac arrest,Chronic airway obstruction, not elsewhere classified,Chronic kidney disease, unspecified,Intestinal infection due to Clostridium difficile,Other complications due to other vascular device, implant, and graft,Disruption of internal operation (surgical) wound,Congestive heart failure, unspecified,Peritoneal adhesions (postoperative) (postinfection),Morbid obesity,Tobacco use disorder,Percutaneous transluminal coronary angioplasty status,Profound impairment, one eye, impairment level not further specified,Late effects of cerebrovascular disease, disturbances of vision,Personal history of malignant neoplasm of kidney,Acquired absence of kidney,Long-term (current) use of steroids,Other specified disorders of pancreatic internal secretion,Adrenal cortical steroids causing adverse effects in therapeutic use,Incisional hernia without mention of obstruction or gangrene
Dvrtcli colon w/o hmrhg,Peritonitis (acute) gen,Intestinal abscess,Cardiac arrest,Chr airway obstruct NEC,Chronic kidney dis NOS,Int inf clstrdium dfcile,Comp-oth vasc dev/graft,Disrup internal op wound,CHF NOS,Peritoneal adhesions,Morbid obesity,Tobacco use disorder,Status-post ptca,Blindness, one eye,Disturbances of vision,Hx of kidney malignancy,Acquired absence kidney,Long-term use steroids,Pancreatic disorder NEC,Adv eff corticosteroids,Incisional hernia
Admission Date:  [**2175-11-12**]              Discharge Date:   [**2175-12-1**]

Date of Birth:  [**2107-3-28**]             Sex:   M

Service: SURGERY

Allergies:
Codeine / Iodine

Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
Abdominal pain

Major Surgical or Invasive Procedure:
[**11-12**] Laparotomy, lysis of adhesions, sigmoid colectomy and
transverse loop colostomy.
[**11-21**] Endotracheal intubation, cardio-pulmonary resuscitation


History of Present Illness:
The patient is a 68 y/o male who presented to an outside
hospital on [**2175-11-12**] for lower abdominal pain.  The abdominal
pain started the day prior to presentation and has worsened in
severity.  He denies fever, chills, nausea/vomiting, or a change
in bowel habits.  He was evaluated at the outside hospital where
a CT scan showed sigmoid diverticulitis, adjacent stranding, and
a small amount of free air.  He is referred to [**Hospital1 18**] for
management of his comorbidities.

Past Medical History:
1. CAD - MI, PTCA in [**2170**], deccreased EF
2. CVA - left monocular blindness
3. COPD on home O2
4. Chronic renal insufficiency
5. Renal cell carcinoma s/p nephrectomy
6. sleep apnea
7. diverticulitis
8. iliac stent


Social History:
Patient smokes a pack per day of cigarettes.

Family History:
Non-contributory

Physical Exam:
T 98.0  P 88  BP 132/85  R 26  SaO2 95% 5L nc
Gen - mild discomfort, non-toxic appearing
Lungs  - decreased in bases bilaterally
Heart - Regular rate and rhythm, no murmurs rubs or gallops
ABD - very distended, tender to palpation in lower quadrants, no
rebound or guarding
Ext - no lower extremity edema


Pertinent Results:
[**2175-11-12**] 08:42PM BLOOD WBC-23.4* RBC-4.13* Hgb-12.4* Hct-37.3*
MCV-90 MCH-30.2 MCHC-33.4 RDW-15.3 Plt Ct-337
[**2175-11-12**] 08:42PM BLOOD Neuts-90* Bands-4 Lymphs-3* Monos-2 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-1*
[**2175-11-12**] 08:42PM BLOOD Glucose-224* UreaN-72* Creat-2.4* Na-140
K-4.2 Cl-99 HCO3-28 AnGap-17
[**2175-11-12**] 08:42PM BLOOD ALT-15 AST-11 CK(CPK)-26* AlkPhos-58
Amylase-53 TotBili-0.5
[**2175-11-12**] 08:42PM BLOOD Lipase-30
[**2175-11-12**] 08:42PM BLOOD Albumin-3.2* Calcium-8.3* Phos-5.6*
Mg-2.1

[**2175-11-13**] 8:57 pm SWAB     Site: ABDOMEN

                            **FINAL REPORT [**2175-11-18**]**

   GRAM STAIN (Final [**2175-11-14**]):
      2+   (1-5 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      1+    (<1 per 1000X FIELD):   GRAM NEGATIVE ROD(S).
      SMEAR REVIEWED; RESULTS CONFIRMED.

   WOUND CULTURE (Final [**2175-11-17**]):
      THIS IS A CORRECTED REPORT [**2175-11-16**].
      PROBABLE ENTEROCOCCUS.    MODERATE GROWTH.
      PROBABLE ENTEROCOCCUS.    SPARSE GROWTH.  2ND MORPHOLOGY.
      STAPH AUREUS COAG +.    SPARSE GROWTH.
         Oxacillin RESISTANT Staphylococci MUST be reported as
also
         RESISTANT to other penicillins, cephalosporins,
carbacephems,
         carbapenems, and beta-lactamase inhibitor combinations.

         Rifampin should not be used alone for therapy.
      PSEUDOMONAS AERUGINOSA.    SPARSE GROWTH.
      [**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION.    SPARSE
GROWTH.
         PREVIOUSLY REPORTED AS MOLD ([**2175-11-15**]).
         REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] R.N CC6 [**2175-11-16**] 1PM.
      BACILLUS SPECIES; NOT ANTHRACIS.    SPARSE GROWTH.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |          PSEUDOMONAS AERUGINOSA
                             |          |
CEFEPIME--------------              <=1 S
CEFTAZIDIME-----------                2 S
CIPROFLOXACIN---------           <=0.25 S
CLINDAMYCIN-----------   =>8 R
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S      <=1 S
IMIPENEM--------------             =>16 R
LEVOFLOXACIN----------   =>8 R
MEROPENEM-------------                2 S
OXACILLIN-------------   =>4 R
PENICILLIN------------ =>0.5 R
PIPERACILLIN----------              <=4 S
PIPERACILLIN/TAZO-----              <=4 S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------   <=1 S
TOBRAMYCIN------------              <=1 S
VANCOMYCIN------------   <=1 S

   ANAEROBIC CULTURE (Final [**2175-11-18**]):    NO ANAEROBES ISOLATED.

[**2175-11-20**] 3:21 pm STOOL     CONSISTENCY: NOT APPLICABLE
      Source: Stool.

                            **FINAL REPORT [**2175-11-21**]**

   CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2175-11-21**]):
      REPORTED BY PHONE TO M. MAL [**2175-11-21**] @8:07 AM.
      CLOSTRIDIUM DIFFICILE.
         FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
         Reference Range:  Negative.
         A positive result in a recently treated patient is of
uncertain
         significance unless the patient is currently
symptomatic
         (relapse).

Operative report [**11-12**]:
Perforated sigmoid diverticulitis
with intraabdominal contamination.
PROCEDURE PERFORMED:  Laparotomy, lysis of adhesions, sigmoid
colectomy and transverse loop colostomy.

CT scan [**11-21**]:
IMPRESSION:
1. No evidence of pulmonary embolism. Please note that
evaluation of small branches in lower lobes are somewhat limited
due to quantum mottle and atelectasis.
2. Severe centrilobular emphysema with peribronchial opacities,
pulmonary edema, and bilateral small effusion and atelectasis.
Enlarged main pulmonary artery.
3. Probable tracheobronchomalacia.
4. Mediastinal lymphadenopathy, which can be reactive.
5. Multiple small hypodense lesions in the liver, too small to
characterize.
6. Gallstones.
7. 1-cm right renal lesion, of indeterminate appearance on this
one-phase CT. Further characterization by dedicated MRI or CT
scan is recommended on non- urgent basis.
8. Changed appearance of the bowel in this patient with recent
sigmoidectomy.

Head CT scan [**11-21**]:
CONCLUSION:
No evidence of hemorrhage. No mass effect. Opacified ethmoid
sinus.

Chest X-Ray [**2175-11-27**]:
FINDINGS: Since the prior study, the patient has been extubated
and there is a right CVL with the tip in the SVC and no PTX.
There is no focal consolidation; the left CP angle is cutoff
from view. There is continued demonstration of right pleural
thickening, unchanged from the previous study. Pulmonary
vascular markings are within normal limits. Previously seen area
of increased density in left upper lung zone is not seen on the
current film.
IMPRESSION: No radiographic explanation for the patient's
dyspnea

EKG [**2175-11-27**]:
Baseline artifact
Sinus rhythm
Probable left atrial abnormality
Right bundle branch block
Consider prior inferolateral myocardial infarct
Since previous tracing of [**2175-11-22**], no significant change
Intervals Axes
Rate PR QRS QT/QTc P QRS T
62 172 136 464/468.71 -1 47 11

Right upper extremity ultrasound [**2175-11-27**]:
MPRESSION: Negative right upper extremity DVT study.

Discharge Labs:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2175-11-29**] 06:14AM    8.9 3.15* 9.6* 27.6* 88 30.6 34.9 15.4
282
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT) [**Name (NI) 36549**]
[**2175-11-29**] 06:14AM          282
Chemistry
  RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2175-11-30**] 04:45AM    138* 20 1.5* 137 4.1 100 32 9
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2175-11-30**] 04:45AM          8.0* 2.5* 1.9




Brief Hospital Course:
The patient was deemed a poor surgical candidate given his co
morbidities and the initial plan was to admit him to the SICU
for monitoring and to treat his diverticulitis with IV
antibiotics of ampicillin, ciprofloxacin, and Flagyl, and bowel
rest.  [**Last Name (un) **]-rectal surgery was consulted to provide
recommendations on management and concurred with the decision to
manage the patient non-operatively.  Serial exams were performed
on the patient and he continued not to display any peritoneal
signs.  On hospital day #2, conservative management was
continued.  However, the patient's abdomen became firmly
distended and became larger throughout the course of the day.  A
CT scan was obtained which showed enlarging air and fluid
collection in the central abdomen abutting a region of sigmoid
colon with multiple diverticula.  This finding was significantly
larger compared to the CT scan at the outside hospital.  In the
context of significantly increasing pneumoperitoneum, the
patient likely had a perforated sigmoid diverticulitis with
associated phlegmon or abscess.  Given the new findings, it was
decided to take the patient to the OR for a laparotomy, lysis of
adhesions, sigmoid colectomy and transverse loop colostomy.  The
fascia was closed with interrupted sutures and the umbilicus was
loosely
approximated with staples and the abdominal wound was packed.

After the surgery, the patient was transferred back to the SICU
intubated and in stable condition.  The patient was able to be
weaned off the vent and was extubated on post-op day 1.  Given
the patient's history of COPD, aggressive pulmonary toilet was
initiated to help improved the patient's respiratory status.
The patient received IV hydrocortisone for his COPD and this was
eventually tapered and switched to Prednisone when the patient
was tolerating POs.  The patient was doing well post-operatively
and was able to be transferred to the floor on post-op day 3.
However overnight, the patient became agitated and went into
rapid atrial fibrillation and was transferred back into the SICU
where he was started on an amiodarone drip for a his rapid afib.
 The patient was able to revert back to sinus rhythm on his own
and amiodarone was switched over to the PO form.  The patient's
IV antibiotics were switched to Vancomycin and Zosyn given the
sensitivities on his wound culture.  Flagyl was also started for
clostridium difficile colitis.  The patient continued to do well
and was transferred back to the floor on post-op day 6.  The
patient was tolerating a regular diet and was able to ambulate
in the hallways with Physical Therapy.

On [**2175-11-22**], the patient was set to go to rehab.  However,
patient stated that in the morning he felt funny for [**9-14**]
seconds with an "electric" feeling throughout his body and felt
a little lightheaded.  He pushed the call button for help and
pitched forward and the nursing aide helped lower him to the
floor and a code was called.  Code team promptly arrived and the
patient was ventilated well via a bag-valve mask.  The patient
was found to be in PEA and ACLS protocol was initiated.  CPR was
started and the patient was given atropine and epinephrine as
well as bicarbonate and calcium.  The patient was intubated
without difficulty with good chest rise and bilateral breath
sounds.  The patient eventually regained a pulse and maintained
a SBP in the 120s.  The patient was transferred to the ICU.  The
patient had a CT angiogram which showed no pulmonary embolus.  A
head CT scan showed no evidence of hemorrhage or mass effect.
In the ICU, he was noted to have one episode of non-sustained
junctional rhythm, though review of the telemetry strip prior to
code was negative for any arrhythmias.  Cardiac enzymes were
cycled which were negative.  He was transfused 2 units of packed
RBCs for a Hct of 22.4.  The patient was able to be weaned from
the vent and extubated the following day.  Cardiology was
consulted and they suggested that a vaso-vagal response could
have been the cause of the patient's code.  Prior to the patient
coding, the cap on his central line had fallen off and the
current working diagnosis is that this gave the patient an air
embolus.  The patient remained stable and was transferred to the
floor on [**2175-11-24**].

On the floor the patient remained on telemetry for monitoring
and remained normotensive and good rate control with oral
Metoprolol and Amiodarone.  The patient was edematous from the
IV fluids he received during his resuscitation and received IV
Lasix.  Due to the patient's edema, the fascia from the
abdominal wound pulled apart with bowel exposed.  Xeroform was
placed over the exposed bowel and a VAC dressing was placed on
the patient's abdominal wound with continuous suction. He
remained afebrile with no leukocytosis and was to complete his
course of Flagyl on [**12-3**], and low dose Prednisone on [**12-25**].  The
patient was discharged to rehab on [**12-1**], in stable condition
tolerating a regular diet, his colostomy was functioning well,
and  with his pain well controlled on oral Dilaudid. He was to
receive continued physical therapy as recommended to increase
his gait and functional mobility.

Medications on Admission:
Plavix
Norvasc
ASA
Tricor
Toprol
Lipitor
Amitriptyline
Prednisone

Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
3. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
5. Nicotine 7 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 2 days: Last dose pm [**12-3**].
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 24 doses: Last dose [**2175-12-25**].
11. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): Hold for HR < 69
Hold for SBP < 120.
13. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4
to 6 hours) as needed for pain: Be sure to give 1 hour prior to
VAC dressing changes.
14. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed): To groin area.
15. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
16. Insulin Sliding Scale  Sig: Regular Insulin Sliding Scale
QACHS: Insulin SC Sliding Scale Q6H
Regular  Insulin

0-60 mg/dL  [**11-28**] amp D50
61-120 mg/dL   0   Units
121-140 mg/dL   3   Units
141-160 mg/dL   5   Units
161-180 mg/dL   7   Units
181-200 mg/dL   9   Units
201-220 mg/dL   11  Units
221-240 mg/dL   13  Units
241-260 mg/dL  15   Units
261-280 mg/dL  17   Units
281-300 mg/dL  19   Units
301-320 mg/dL  21   Units
321-340 mg/dL  23   Units
341-360 mg/dL  25   Units
> 360 mg/dL  Notify M.D.
.
17. Glargine Insulin  Sig: Ten (10) units  at bedtime: Give in
addition to Regular Insulin Sliding Scale.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]

Discharge Diagnosis:
Perforated diverticulitis requiring [**Doctor Last Name 3379**] pouch and
transverse colostomy
Abdominal wound with incisional hernia
Atrial fibrillation
Air embolus
Clostridium Difficile
CAD
HTN
Chronic renal failure
CHF
COPD requiring Steroids
Steroid induced DM


Discharge Condition:
Stable


Discharge Instructions:
Notify MD or return to the emergency department if you
experience:

*Increased or persistent pain not relieved by pain medication
*Fever > 101.5
*Nausea, vomiting, or increased abdominal distention
*Increased or decreased ostomy outputs over 24 hours
*Change in color or appearance of stoma
*Shortness of breath or chest pain
*Changes in appearance of abdominal wound or drainage from VAC

Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 1120**] in [**11-28**] weeks, call [**Telephone/Fax (1) 160**] for an
appointment

Follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] upon discharge from the
hospital, call [**Telephone/Fax (1) 56850**] for an appointment



Completed by:[**2175-12-1**]
{'Diverticulitis of colon (without mention of hemorrhage),Peritonitis (acute) generalized,Abscess of intestine,Cardiac arrest,Chronic airway obstruction, not elsewhere classified,Chronic kidney disease, unspecified,Intestinal infection due to Clostridium difficile,Other complications due to other vascular device, implant, and graft,Disruption of internal operation (surgical) wound,Congestive heart failure, unspecified,Peritoneal adhesions (postoperative) (postinfection),Morbid obesity,Tobacco use disorder,Percutaneous transluminal coronary angioplasty status,Profound impairment, one eye, impairment level not further specified,Late effects of cerebrovascular disease, disturbances of vision,Personal history of malignant neoplasm of kidney,Acquired absence of kidney,Long-term (current) use of steroids,Other specified disorders of pancreatic internal secretion,Adrenal cortical steroids causing adverse effects in therapeutic use,Incisional hernia without mention of obstruction or gangrene'}


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: The patient is a 68 y/o male who presented to an outside
hospital on [**2175-11-12**] for lower abdominal pain.  The abdominal
pain started the day prior to presentation and has worsened in
severity.  He denies fever, chills, nausea/vomiting, or a change
in bowel habits.  He was evaluated at the outside hospital where
a CT scan showed sigmoid diverticulitis, adjacent stranding, and
a small amount of free air.  He is referred to [**Hospital1 18**] for
management of his comorbidities.

MEDICAL HISTORY: 1. CAD - MI, PTCA in [**2170**], deccreased EF
2. CVA - left monocular blindness
3. COPD on home O2
4. Chronic renal insufficiency
5. Renal cell carcinoma s/p nephrectomy
6. sleep apnea
7. diverticulitis
8. iliac stent

MEDICATION ON ADMISSION: Plavix
Norvasc
ASA
Tricor
Toprol
Lipitor
Amitriptyline
Prednisone

ALLERGIES: Codeine / Iodine

PHYSICAL EXAM: T 98.0  P 88  BP 132/85  R 26  SaO2 95% 5L nc
Gen - mild discomfort, non-toxic appearing
Lungs  - decreased in bases bilaterally
Heart - Regular rate and rhythm, no murmurs rubs or gallops
ABD - very distended, tender to palpation in lower quadrants, no
rebound or guarding
Ext - no lower extremity edema

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Patient smokes a pack per day of cigarettes. 

### Response:
{'Diverticulitis of colon (without mention of hemorrhage),Peritonitis (acute) generalized,Abscess of intestine,Cardiac arrest,Chronic airway obstruction, not elsewhere classified,Chronic kidney disease, unspecified,Intestinal infection due to Clostridium difficile,Other complications due to other vascular device, implant, and graft,Disruption of internal operation (surgical) wound,Congestive heart failure, unspecified,Peritoneal adhesions (postoperative) (postinfection),Morbid obesity,Tobacco use disorder,Percutaneous transluminal coronary angioplasty status,Profound impairment, one eye, impairment level not further specified,Late effects of cerebrovascular disease, disturbances of vision,Personal history of malignant neoplasm of kidney,Acquired absence of kidney,Long-term (current) use of steroids,Other specified disorders of pancreatic internal secretion,Adrenal cortical steroids causing adverse effects in therapeutic use,Incisional hernia without mention of obstruction or gangrene'}
