CHIEF COMPLAINT: Small bowel obstruction.

PRESENT ILLNESS: This is a [**Age over 90 **]-year-old female in
fairly consistent health who was seen in the Emergency Room
by the General Surgery service on [**2169-7-23**].  On physical
exam at that time this patient had been complaining of
nausea, vomiting, and abdominal distention and pain.  She had
not moved her bowels in a number of days.

MEDICAL HISTORY: Significant for aortic stenosis,
hypertension, atrial fibrillation, constipation,
gastroesophageal reflux disease.

MEDICATION ON ADMISSION: 

ALLERGIES: Erythromycin and Amoxicillin both give a rash.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: She is do not resuscitate, do not intubate.
She lives alone.  Her son [**Name (NI) **] [**Name (NI) **] is her health
care proxy.  His phone number is [**Telephone/Fax (1) 102739**].  Her
granddaughter is [**Name (NI) **] [**Name (NI) 102740**] [**Telephone/Fax (1) 102741**].
Intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection),Urinary tract infection, site not specified,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Atrial fibrillation,Iron deficiency anemia secondary to blood loss (chronic),Congestive heart failure, unspecified,Unspecified pleural effusion
Intestinal adhes w obstr,Urin tract infection NOS,Food/vomit pneumonitis,Acute respiratry failure,Atrial fibrillation,Chr blood loss anemia,CHF NOS,Pleural effusion NOS
Admission Date:  [**2169-7-23**]     Discharge Date:  [**2169-8-4**]


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

HISTORY OF PRESENT ILLNESS:  This is a [**Age over 90 **]-year-old female in
fairly consistent health who was seen in the Emergency Room
by the General Surgery service on [**2169-7-23**].  On physical
exam at that time this patient had been complaining of
nausea, vomiting, and abdominal distention and pain.  She had
not moved her bowels in a number of days.

CT scan was obtained in the Emergency Room.  This revealed a
small bowel obstruction with the transition point in the
right lower quadrant.  There is a small amount of free fluid
within the pelvis and along the inferior pole of the liver.
There was no evidence of bowel ischemia at that time.

The patient was then consented for exploratory laparotomy.
This was discussed with her primary care physician and with
her family extensively before the surgery was undertaken.
Consent was taken from all necessary parties.

PAST MEDICAL HISTORY:  Significant for aortic stenosis,
hypertension, atrial fibrillation, constipation,
gastroesophageal reflux disease.

PAST SURGICAL HISTORY:  Significant for an appendectomy at a
young age.



                          [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.  [**MD Number(1) 19318**]

Dictated By:[**Last Name (STitle) 102744**]

MEDQUIST36

D:  [**2169-8-15**]  13:07
T:  [**2169-8-16**]  14:45
JOB#:  [**Job Number 102745**]


Admission Date:  [**2169-7-23**]       Discharge Date:  [**2169-8-4**]


Service:  GENERAL SURGERY

CHIEF COMPLAINT:  Small bowel obstruction.

HISTORY OF PRESENT ILLNESS:  The patient is a [**Age over 90 **] year-old
female who presented to the [**Hospital1 188**] Emergency Department after one day of crampy abdominal
pain with no bowel movements for three days and obstipated
for three days.  She tolerated her lunch today and on
previous days, but quickly became nauseated and vomited
approximately eight times afterward.  She had no complaints
of dysuria or bleeding from rectum.  No complaints of chest
pain or shortness of breath.  Three days prior to admission
she took some Milk of Magnesia for constipation and had some
watery stools.

PAST MEDICAL HISTORY:
1.  Paget's disease of the bone.
2.  Hypertension.
3.  Cataracts.
4.  Cervical spondylosis.
5.  Supraventricular tachycardia.
6.  Diverticulitis.
7.  History of lower gastrointestinal bleed.
8.  Legally blind.
9.  Hard of hearing.
10.  Osteoporosis.
11.  Prior fracture of the spinal.
12.  Left femur fracture [**2165**].
13.  History of sundowning.
14.  History of constipation.
15.  History of abdominal pain.
16.  Anxiety.
17.  Depression.
18.  Arthritis.

PAST SURGICAL HISTORY:
1.  [**2160**] she had a subtotal colectomy for bleeding
diverticulosis.
2.  Open cholecystectomy.

MEDICATIONS AT HOME:
1.  Diltiazem.
2.  Folate.
3.  Hydrochlorothiazide.
4.  Potassium.
5.  Fosamax.
6.  Ativan.
7.  Remeron.
8.  Colace as needed.
9.  Senna as needed.

ALLERGIES:  Erythromycin and Amoxicillin both give a rash.

SOCIAL HISTORY:  She is do not resuscitate, do not intubate.
She lives alone.  Her son [**Name (NI) **] [**Name (NI) **] is her health
care proxy.  His phone number is [**Telephone/Fax (1) 102739**].  Her
granddaughter is [**Name (NI) **] [**Name (NI) 102740**] [**Telephone/Fax (1) 102741**].

PHYSICAL EXAMINATION ON PRESENTATION:  She was afebrile 97.1.
Pulse 81.  Blood pressure 152/70.  Respiratory rate 17.  O2
sat 98%.  She is in no acute distress.  Alert, awake and
oriented times three.  She has a nasogastric tube in place to
low continuous suction.  Her lungs were clear to auscultation
bilaterally.  She was mildly kyphotic.  Cardiovascular
regular rate and rhythm with a loud murmur.  Abdomen she has
a well healed scar in the lower mid abdomen.  She was soft
distended, tympanitic, tender in the left lower quadrant to
deep palpation.  No rebound or guarding.  Rectal was guaiac
negative with no masses by the Emergency Department staff.
Extremities showed no edema.

CT scan on admission showed contrast to the proximal jejunum
with a transition point in the right lower quadrant.  There
is a small amount of free fluid within the pelvis and also
along the inferior pole of the liver.  There is no evidence
of bowel ischemia.  The abdominal x-ray showed an opacity of
gas in the rectum.

LABORATORY:  White blood cell count 11.3, hematocrit 40.8,
platelets 168, 91% neutrophils.  Her chem 7 sodium 128,
potassium 3.9, chloride 90, bicarb 25, BUN 12, creatinine
0.7, glucose 155.  Liver function tests ALT 11, AST 21,
alkaline phosphatase 131, total bili 0.6, amylase 55.
Urinalysis did show evidence of a urinary tract infection and
urine culture from admission ended up showing alpha
streptococcus growing in her urine.  Her electrocardiogram
was unchanged from prior electrocardiograms.

HOSPITAL COURSE:  This patient has early small bowel
obstruction.  She was consented and taken to the Operating
Room for an exploratory laparotomy.  After she was consented
and she was about to undergo surgery she underwent the
exploratory laparotomy by Dr. [**First Name (STitle) 2819**] with the assistance of Dr.
[**Last Name (STitle) **].  Please refer to the previously dictated operative
note by Dr. [**First Name (STitle) 2819**].  In short they did an exploratory
laparotomy with lysis of adhesions.  They also did an
appendectomy as well as repair of multiple serosal injuries.
There surgical findings were dense adhesions throughout the
abdomen with a transition point proximal to the appendix in
the terminal ileum.  Postoperatively, the patient was sent to
the Intensive Care Unit where cardiology evaluated her and
she was started on a Diltiazem drip and ruled out for a
myocardial infarction.  In addition, her atrial fibrillation
during this part of her Intensive Care Unit stay, she was
rate controlled with a Diltiazem drip.  In addition she
received full doses for hypovolemia as well as she was
transfused for chronic blood loss anemia.  After improvement
after several days she was transferred out to the floor on
postoperative day two where she stayed for one day and then
until on postoperative day three she experienced several
episodes of respiratory distress where she was noted to be
tachypneic with decreasing oxygen saturation on both room air
and face mask.  Later on postoperative day three she was
transferred back to the Intensive Care Unit where she was
intubated.

Chest films at this time showed marked fluid overload at
stake with bilateral pleural effusions and signs of
congestive heart failure.  She was diuresed over the next few
days.  Several sputum cultures during this time revealed the
presence of yeast as well as gram negative rods within her
sputum.  She was started on antibiotics for presumed
aspiration pneumonia.  On postoperative day six the patient
self extubated herself and was not reintubated due to her
DNR/DNI status and also the fact that she seemed to be
tolerating oxygenation via face mask.  On postoperative day
[**2092-7-15**] the patient was started on enteral feedings,
which she tolerated without nausea, vomiting, aspiratory
symptoms or abdominal pain.  At this time her family and Dr.
[**First Name (STitle) 2819**] and the Intensive Care Unit team discussed the patient's
code status and as of discharge the patient is currently do
not resuscitate, do not perform shocks or chest compressions
on her.  This is the latest order in terms of that.  However,
she is to be intubated for respiratory failure.  This,
however, should be confirmed by her family as to her current
status.

On postoperative day eleven the patient was receiving tube
feeds to goal and her total parenteral nutrition was
discontinued.  She was screened and accepted at [**Hospital6 102742**] Facility.  She was discharged in stable condition to
that facility in the afternoon on that day.

PHYSICAL EXAMINATION ON DISCHARGE:  Afebrile.  Pulse 93.
Blood pressure 174/74.  Respirations 28.  96% on room air.
She was tolerating enteral tube feeds with good urine output.
 She was minimally responsive.  She had decreased breath
sounds bilaterally with cackles.  Her abdomen was soft,
nondistended.  The wound was clean, dry and intact and her
extremities showed no edema.

DISCHARGE DIAGNOSES:
1.  Status post exploratory laparotomy.
2.  Status post appendectomy.
3.  Status post lysis of adhesions.
4.  Status post repair of serosal injuries times five.
5.  Hypovolemia requiring fluid resuscitation.
6.  Hypomagnesia.
7.  Hypocalcemia.
8.  Chronic blood loss anemia requiring multiple
transfusions.
9.  Congestive heart failure fluid overload.
10.  Respiratory distress.
11.  Pulmonary edema.
12.  Hypoalimentation.
13.  Urinary tract infection.
14.  Aspiration pneumonia.

DISCHARGE MEDICATIONS:
1.  Zosyn 2.25 mg intravenous q 6 for four more days.
2.  Diltiazem 60 mg po four times a day.
3.  Pepcid 20 mg po twice a day.
4.  Dulcolax 10 mg prn once a day as needed for constipation.
5.  Albuterol nebulizer q 6 prn.
6.  Combivent four puffs q 4 hours.
7.  Hydrochlorothiazide 25 mg po three times a week.
8.  Potassium chloride 20 milliequivalents po three times a
week.

DISCHARGE INSTRUCTIONS:  She needs physical therapy for
activity.  She also has a Foley that should be placed to
gravity and she has a central line that should remain in
place as long as she is receiving Zosyn antibiotics.  This
should be discontinued after the antibiotics are discontinued
in four days.  She should have a follow up with Dr. [**First Name (STitle) 2819**] in
two weeks.






                            [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.  [**MD Number(1) 19318**]

Dictated By:[**Last Name (NamePattern1) 30555**]
MEDQUIST36

D:  [**2169-8-11**]  10:53
T:  [**2169-8-11**]  11:05
JOB#:  [**Job Number 102743**]
{'Intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection),Urinary tract infection, site not specified,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Atrial fibrillation,Iron deficiency anemia secondary to blood loss (chronic),Congestive heart failure, unspecified,Unspecified pleural effusion'}


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: Small bowel obstruction.

PRESENT ILLNESS: This is a [**Age over 90 **]-year-old female in
fairly consistent health who was seen in the Emergency Room
by the General Surgery service on [**2169-7-23**].  On physical
exam at that time this patient had been complaining of
nausea, vomiting, and abdominal distention and pain.  She had
not moved her bowels in a number of days.

MEDICAL HISTORY: Significant for aortic stenosis,
hypertension, atrial fibrillation, constipation,
gastroesophageal reflux disease.

MEDICATION ON ADMISSION: 

ALLERGIES: Erythromycin and Amoxicillin both give a rash.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: She is do not resuscitate, do not intubate.
She lives alone.  Her son [**Name (NI) **] [**Name (NI) **] is her health
care proxy.  His phone number is [**Telephone/Fax (1) 102739**].  Her
granddaughter is [**Name (NI) **] [**Name (NI) 102740**] [**Telephone/Fax (1) 102741**]. 

### Response:
{'Intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection),Urinary tract infection, site not specified,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Atrial fibrillation,Iron deficiency anemia secondary to blood loss (chronic),Congestive heart failure, unspecified,Unspecified pleural effusion'}
