CHIEF COMPLAINT: unremitting chest pain and abd pain out-of-proportion to exam

PRESENT ILLNESS: This was an 80-year-old man who
entered the hospital with a 1-day history of abdominal
discomfort. He had a known history of chronic bilateral chest
discomfort of which he also complained. He underwent an
initial CT scan of the abdomen which demonstrated a small
amount of free fluid, but no other obvious abnormality. It
was suggested that he had a larger amount of small intestine
than expected lateral to the ascending colon, potentially
suggestive of an internal hernia. The initial CT scan was
done without oral contrast. It had been performed in the
context of a CT angio of the chest to rule out aortic
dissection or embolus. His initial lactate was 1.1. A few
hours later while being observed, he complained of increased
pain. The lactate was found to be 4.8. A repeat CT scan with
contrast now showed an increased amount of free abdominal
fluid. He appeared to have an area of small bowel which was
somewhat dilated and thickened. Although his feeding vessels
were normal, the possibility of ischemic colitis, perhaps on
a mechanical basis such as a volvulus or internal hernia,
could not be discounted. Exploratory laparotomy was suggested
to the family and accepted by them.

MEDICAL HISTORY: headache, cerebellar CVA (ataxia), BPH, HTN, GERD, left foot
pain

MEDICATION ON ADMISSION: Protonix, enalapril 5, ASA 81, Cardura 4, Celexa 20, Lumigan
0.03% [**Hospital1 **], timolol 0.5% [**Hospital1 **]

ALLERGIES: No Known Allergies

PHYSICAL EXAM: NAD AOx3
CTA b/l
RRR
soft, mildly tender mildy distended hypoactive bowel sounds
no c/c/e

FAMILY HISTORY: 

SOCIAL HISTORY: 
Volvulus,Acute vascular insufficiency of intestine,Iatrogenic pulmonary embolism and infarction,Other postoperative infection,Cellulitis and abscess of trunk,Hyperplasia of prostate, unspecified, without urinary obstruction and other lower urinary symptoms (LUTS),Unspecified essential hypertension,Esophageal reflux,Other late effects of cerebrovascular disease, ataxia
Volvulus of intestine,Ac vasc insuff intestine,Iatrogen pulm emb/infarc,Other postop infection,Cellulitis of trunk,BPH NOS w/o ur obs/LUTS,Hypertension NOS,Esophageal reflux,Ataxia
Admission Date:  [**2152-1-7**]              Discharge Date:   [**2152-1-24**]

Date of Birth:  [**2071-9-4**]             Sex:   M

Service: SURGERY

Allergies:
No Known Allergies

Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
unremitting chest pain and abd pain out-of-proportion to exam

Major Surgical or Invasive Procedure:
. Exploratory laparotomy.
2. Small intestinal resection


History of Present Illness:
This was an 80-year-old man who
entered the hospital with a 1-day history of abdominal
discomfort. He had a known history of chronic bilateral chest
discomfort of which he also complained. He underwent an
initial CT scan of the abdomen which demonstrated a small
amount of free fluid, but no other obvious abnormality. It
was suggested that he had a larger amount of small intestine
than expected lateral to the ascending colon, potentially
suggestive of an internal hernia. The initial CT scan was
done without oral contrast. It had been performed in the
context of a CT angio of the chest to rule out aortic
dissection or embolus. His initial lactate was 1.1. A few
hours later while being observed, he complained of increased
pain. The lactate was found to be 4.8. A repeat CT scan with
contrast now showed an increased amount of free abdominal
fluid. He appeared to have an area of small bowel which was
somewhat dilated and thickened. Although his feeding vessels
were normal, the possibility of ischemic colitis, perhaps on
a mechanical basis such as a volvulus or internal hernia,
could not be discounted. Exploratory laparotomy was suggested
to the family and accepted by them.


Past Medical History:
headache, cerebellar CVA (ataxia), BPH, HTN, GERD, left foot
pain

Physical Exam:
NAD AOx3
CTA b/l
RRR
soft, mildly tender mildy distended hypoactive bowel sounds
no c/c/e

Pertinent Results:
[**2152-1-7**] 01:25PM BLOOD WBC-7.3# RBC-4.02* Hgb-13.4* Hct-37.9*
MCV-94 MCH-33.3* MCHC-35.3* RDW-13.4 Plt Ct-155
[**2152-1-9**] 03:17AM BLOOD WBC-4.6 RBC-2.93* Hgb-9.7* Hct-28.0*
MCV-96 MCH-33.1* MCHC-34.6 RDW-13.5 Plt Ct-116*
[**2152-1-11**] 04:50AM BLOOD WBC-4.6 RBC-2.78* Hgb-9.2* Hct-27.0*
MCV-97 MCH-33.0* MCHC-34.0 RDW-13.3 Plt Ct-125*
[**2152-1-18**] 02:57AM BLOOD WBC-6.0 RBC-2.51* Hgb-7.9* Hct-24.3*
MCV-97 MCH-31.5 MCHC-32.4 RDW-13.7 Plt Ct-204
[**2152-1-20**] 06:41PM BLOOD WBC-5.6 RBC-3.00* Hgb-9.5* Hct-27.9*
MCV-93 MCH-31.6 MCHC-33.9 RDW-15.1 Plt Ct-205
[**2152-1-22**] 03:45AM BLOOD Hct-30.8*
[**2152-1-7**] 01:25PM BLOOD PT-11.5 PTT-24.8 INR(PT)-1.0
[**2152-1-17**] 05:16AM BLOOD PT-12.0 PTT-73.3* INR(PT)-1.0
[**2152-1-19**] 05:50AM BLOOD PT-15.8* PTT-51.9* INR(PT)-1.4*
[**2152-1-20**] 02:50PM BLOOD PT-29.8* PTT-105.4* INR(PT)-3.1*
[**2152-1-24**] 05:00AM BLOOD PT-27.7* INR(PT)-2.9*
[**2152-1-7**] 01:25PM BLOOD Glucose-144* UreaN-19 Creat-0.9 Na-137
K-5.0 Cl-102 HCO3-25 AnGap-15
[**2152-1-11**] 04:50AM BLOOD Glucose-86 UreaN-19 Creat-0.6 Na-140
K-4.1 Cl-107 HCO3-27 AnGap-10
[**2152-1-18**] 02:57AM BLOOD Glucose-112* UreaN-20 Creat-0.6 Na-134
K-4.4 Cl-105 HCO3-27 AnGap-6*
[**2152-1-7**] 01:25PM BLOOD ALT-16 AST-22 CK(CPK)-56 AlkPhos-47
Amylase-126* TotBili-0.7
[**2152-1-7**] 01:25PM BLOOD Albumin-4.1 Calcium-9.8 Phos-1.2*# Mg-1.9
[**2152-1-13**] 11:30AM BLOOD Calcium-8.1* Phos-2.6* Mg-1.6
[**2152-1-18**] 02:57AM BLOOD Calcium-7.9* Phos-3.3 Mg-2.0
[**2152-1-17**] 05:16AM BLOOD calTIBC-163* TRF-125*
[**2152-1-14**] 06:25AM BLOOD Triglyc-89
[**2152-1-7**] 04:57PM BLOOD Glucose-122* Lactate-0.9 K-4.2
[**2152-1-8**] 02:48AM BLOOD Lactate-3.6*
[**2152-1-8**] 05:46AM BLOOD freeCa-1.25
[**2152-1-16**] 03:48PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2152-1-16**] 03:48PM URINE RBC-0-2 WBC-0 Bacteri-FEW Yeast-NONE
Epi-0

CTA ABD W&W/O C & RECONS  [**2152-1-7**] 1:57 PM

CTA CHEST W&W/O C &RECONS; CTA ABD W&W/O C & RECONS

Reason: eval aorta
Contrast: OPTIRAY

[**Hospital 93**] MEDICAL CONDITION:
80 year old man with unremitting CP/ab pain
REASON FOR THIS EXAMINATION:
eval aorta
CONTRAINDICATIONS for IV CONTRAST: None.

INDICATION: Unremitting chest pain and abdominal pain, please
evaluate the aorta.

COMPARISON: [**2147-9-3**].

TECHNIQUE: CT angiogram of the chest, abdomen and pelvis to
evaluate for aortic dissection was reviewed. Multiplanar CT
reformations were obtained and reviewed.

CT CHEST WITH CONTRAST: There is no evidence for dissection. The
heart and great vessels of the mediastinum are unremarkable. The
lungs are clear. The pleura are normal. The soft tissues are
unremarkable. The thoracic aorta is calcified secondary to
atherosclerotic disease. The bronchi are patent to the
subsegmental level.

CT ABDOMEN WITH CONTRAST: There is an abnormal edematous loop of
small bowel in the right mid/upper quadrant with associated
edematous mesentery. There is also some trace free fluid in this
area. This abnormal loop of bowel lies lateral to the ascending
colon, and its superior mesenteric artery feeding branch has a
stretched appearance. This finding may represent internal small
bowel hernia. The remainder of the small bowel appears normal.
The liver, pancreas, spleen, and adrenal glands are normal. The
nephrograms are normal, but the expiratory state cannot be
evaluated. There is nonspecific non- pathologically enlarged
lymphadenopathy.

CT PELVIS WITH CONTRAST: Rectum, sigmoid colon, and large bowel
are unremarkable. The descending colon lies medial to the
abnormal loop of small bowel. There is no free fluid in the
pelvis. The prostate is enlarged. The bladder is normal. There
is no lymphadenopathy.

BONE WINDOWS: There is no evidence for fracture. Soft tissues
are unremarkable.

CT REFORMATIONS: The reformations again demonstrate no
dissection but an abnormal small bowel loop in the right
mid/upper quadrant.

IMPRESSION:
1. Abnormal edematous small bowel loop within the right
mid/upper quadrant susspicious for internal hernia with edema
(R/O strangulation - closed loop obstruction or volvulous)
Surgical consult is recommended. These findings were discussed
with Dr. [**Last Name (STitle) **] at the time of the study.
Report to:   DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by:   DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/dif



SPECIMEN SUBMITTED: SMALL BOWEL.

Procedure date     Tissue received     Report Date    Diagnosed
by
[**2152-1-7**] [**2152-1-8**] [**2152-1-12**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/stu
Previous biopsies:    [**-4/2352**]  ANAL POLYP.
  [**-1/4138**]  GI BX/da/ah.

DIAGNOSIS:



Small bowel segment:

Acute transmural hemorrhagic infarction of intestine and
adjacent mesentery.
There is mucosal infarction in the 3.5 cm margin.
The 3.0 cm margin shows no ischemic change.

   RADIOLOGY  Final Report

CTA CHEST W&W/O C &RECONS  [**2152-1-16**] 11:00 PM

CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST

Reason: r/o PE.
Field of view: 38 Contrast: OPTIRAY

[**Hospital 93**] MEDICAL CONDITION:
80 year old man POD 9 SB resection, fever, received CT Abdomen
today on which there was a concern for possible PE.
REASON FOR THIS EXAMINATION:
r/o PE.
CONTRAINDICATIONS for IV CONTRAST: None.

HISTORY: 80-year-old man postop day 9, status post small bowel
resection, fever, received CT abdomen today where there was a
concern of PE.

COMPARISON: [**2152-1-7**] chest CTA and [**2152-1-16**]
abdominal CT.

TECHNIQUE: Multidetector axial images of the chest were obtained
without and with IV contrast. 100 cc Optiray. Multiplanar
reformatted images were obtained.

CT CHEST WITHOUT AND WITH IV CONTRAST: A filling defect is
observed in a left lower lobe subsegmental pulmonary artery and
extending into three of the branches consistent with pulmonary
embolism. No other pulmonary emboli are observed. The heart,
pericardium, and great vessels are stable, with coronary and
aortic calcifications again noted. Prominent mediastinal lymph
nodes are stable in appearance and calcifications are seen in
some of the nodes. There is no hilar or axillary
lymphadenopathy. There are small bilateral pleural effusions.
Associated dependent and bibasilar atelectasis is observed. The
visualized portions of the upper abdomen are stable. Hepatic
calcifications are identified. Vicarious excretion of contrast
is observed in the gallbladder.

BONE WINDOWS: There are no suspicious lytic or sclerotic osseous
lesions.

IMPRESSION:

1. Subsegmental left lower lobe pulmonary embolism.

2. Small bilateral pleural effusions.
RADIOLOGY  Final Report

CT ABDOMEN W/CONTRAST  [**2152-1-16**] 6:43 PM

CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST

Reason: FEVER
Contrast: OPTIRAY

[**Hospital 93**] MEDICAL CONDITION:
80 year old man POD 9 from SB resection for infarction due to
volvulus. new fever to 102, wound erythema.
REASON FOR THIS EXAMINATION:
r/o intraperitoneal abscess.
CONTRAINDICATIONS for IV CONTRAST: None.

CT OF THE ABDOMEN

CLINICAL INDICATION: 80-year-old man with prior small bowel
resection for infarction due to volvulus. New fever to 102.
Wound erythema. Rule out intraperitoneal abscess.

COMPARISON: CT from [**2152-1-7**], is available for
comparison.

TECHNIQUE: Multidetector CT of the abdomen and pelvis was
performed from the base of the lungs to the symphysis pubis
after administration of oral contrast and 100 cc of Optiray.

RECONSTRUCTIONS: Multiplanar reformations including sagittal and
coronal reconstructions were performed in a 3D workstation and
were essential in evaluating the findings.

FINDINGS:

CT ABDOMEN: Visualized portions of the lung bases demonstrate
filling defects in segmental branches of the left lower lobe
pulmonary arteries. This is consistent with pulmonary embolism.
There are small bilateral pleural effusions. The liver is
homogeneous without focal lesions. A small hypodense area in the
upper aspect of the right lower lobe may represent segmental
biliary dilatation at this level. Spleen, pancreas, adrenal
glands, and extrahepatic biliary tree is normal. There is mild
distention of the gallbladder without gallbladder wall edema or
pericholecystic fluid. Small hypodensities are noted in the
right kidney likely representing cysts. The kidneys enhance
symmetrically and excrete contrast normally. There is no
evidence for hydronephrosis. There are no enlarged lymph nodes
in the abdomen. There is marked distention of the stomach
without dilatation of the proximal small bowel.

There is a small hiatal hernia status post laparotomy. There are
surgical changes in the anterior abdominal wall without fluid
collection.

CT PELVIS: The distal portion of the ureters are not well
opacified. There is no significant abnormality at this level.
The bladder is collapsed with a Foley catheter inside. Extensive
stool in the rectum and sigmoid colon. Contrast reached the
right colon. The visualized portion of the small bowel in the
abdomen and pelvis are normal. There is a small-to-moderate
amount of free fluid in the abdomen.

CT BONES: No lytic or sclerotic lesions are noted in the bones.

IMPRESSION:
1. Pulmonary embolism in the left lower lobe. A dedicated chest
CTA is recommended for further assessment of this finding.
2. Small bilateral pleural effusions and bibasilar atelectasis.
3. Mild-to-moderate amount of free fluid in the abdomen without
evidence for organized fluid collection.
4. No evidence for small-bowel obstruction or abnormal loops of
small bowel.
5. Marked distention of the stomach without dilatation of the
duodenum. This may represent gastroparesis. Clinical correlation
is recommended. Small hiatal hernia.

These findings were discussed with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 14135**] on [**1-16**] at 9 p.m.
BILAT LOWER EXT VEINS  [**2152-1-17**] 3:44 PM

BILAT LOWER EXT VEINS

Reason: ? clot

[**Hospital 93**] MEDICAL CONDITION:
80 year old man with LLL PE
REASON FOR THIS EXAMINATION:
? clot
DUPLEX ULTRASOUND OF BOTH LOWER EXTREMITIES.

INDICATION: Patient with lower lobe pulmonary embolism.

TECHNIQUE: Grayscale, color flow and pulse wave Doppler
insonation of the deep vessels of both lower extremities was
performed using dynamic compression maneuvers where appropriate.

COMPARISON: None. Reference is made to recent chest examination.

REPORT:
There is normal compressibility, augmentation, and respiratory
variation within the deep veins of both lower extremities. There
is no evidence of lower limb DVT. Significant arterial
calcification is noted in the common femoral arteries.

CONCLUSION:
Negative DVT study bilaterally.


Brief Hospital Course:
Patient was taken to the operating as described above, where
they found a volvulus of the small bowel requiring resection.
Patient was extubated in the OR, and taken to the recovery room
and then to the intensive care until for further monitoring
post-operatively. Patient's respiratory status was good and made
a quick recovery. Patient did well and was transferred to the
floor on POD2, still with an NGT and central line. NGT was dc'd
on POD4, and POD5 patient was started on clears. Physical
therapy worked with the patient and determined that the patient
could go home with services and home PT.
Patient was still experiences some abdominal pain and was
distended, so was made NO again on POD6 and started on TPN.
Awaited bowel function to return and continued course allowing
patient sips to drink for the next few days. Patient had an NGT
placed for 1 day with decent outpu on POD8 for an
ileus/increasing distension. Pateint had CT of abdomen on POD9
which showed a possible PE prompting a formal CTA chest showing
subsegmental LLL PEs. Also spiked a fever and noticed some
erythema by the incision and was started on kefzol. lower
extremity ultrasounds were negative for dvts. Patient was
immediately started on a heparin drip and made therapeutic.
Levoquin was then added after  the inferior part of the wound
was opened for pus. Patient was started back on clears POD11 and
then advanced to regular diet on POD12. Patient then started
having multiple BMs, but had 3 negative C diff cultures.
Antibiotics were dc'd on POD14 after all final cultures were
negative for growth. Patient was started on coumadin on POD14,
and was therapeutic shortly thereafter and heparin was stopped.
Patient failed 3 voiding trials, so kept foley in until POD16,
when he finally voided with it out. All home meds were
restarted.
patient was discharged on POD17 in good condition with home VNA
for PT, dressing change, and INR checks which will be phoned to
his PCPs ofice. Patient will follow up with Dr [**Last Name (STitle) 519**] in 3 weeks
and has an appointment.

Medications on Admission:
Protonix, enalapril 5, ASA 81, Cardura 4, Celexa 20, Lumigan
0.03% [**Hospital1 **], timolol 0.5% [**Hospital1 **]

Discharge Medications:

1. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic  [**Hospital1 **]
(2 times a day).
2. Bimatoprost 0.03 % Drops Sig: One (1)  Ophthalmic  qHS ().
3. Enalapril Maleate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*0 Tablet(s)* Refills:*0*
4. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).

5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

7. Pantoprazole 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:*0*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
11. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3-4H
(Every 3 to 4 Hours) as needed.
Disp:*20 Tablet(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Hospital6 1952**], [**Location (un) 86**]

Discharge Diagnosis:
small bowel volvulus


Discharge Condition:
good


Discharge Instructions:

please seek medical attention if you expereience fever > 101.5,
severe nausea, vomitting, pain

no driving while on narcotic pain meds

may shower

need to have INR checked biweekly. have the VNA call Dr. [**Name (NI) 28326**] office with the results


Followup Instructions:

please folow up with Dr. [**Last Name (STitle) 519**] in clinic on [**2-14**] @ 9:45am.
Call ([**Telephone/Fax (1) 5323**] with any questions.

please follow up with Dr. [**Last Name (STitle) **] for INR check and also an
appointment in about 10 days. Her office will call you with a
time.


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]

Completed by:[**2152-1-24**]
{'Volvulus,Acute vascular insufficiency of intestine,Iatrogenic pulmonary embolism and infarction,Other postoperative infection,Cellulitis and abscess of trunk,Hyperplasia of prostate, unspecified, without urinary obstruction and other lower urinary symptoms (LUTS),Unspecified essential hypertension,Esophageal reflux,Other late effects of cerebrovascular disease, ataxia'}


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: unremitting chest pain and abd pain out-of-proportion to exam

PRESENT ILLNESS: This was an 80-year-old man who
entered the hospital with a 1-day history of abdominal
discomfort. He had a known history of chronic bilateral chest
discomfort of which he also complained. He underwent an
initial CT scan of the abdomen which demonstrated a small
amount of free fluid, but no other obvious abnormality. It
was suggested that he had a larger amount of small intestine
than expected lateral to the ascending colon, potentially
suggestive of an internal hernia. The initial CT scan was
done without oral contrast. It had been performed in the
context of a CT angio of the chest to rule out aortic
dissection or embolus. His initial lactate was 1.1. A few
hours later while being observed, he complained of increased
pain. The lactate was found to be 4.8. A repeat CT scan with
contrast now showed an increased amount of free abdominal
fluid. He appeared to have an area of small bowel which was
somewhat dilated and thickened. Although his feeding vessels
were normal, the possibility of ischemic colitis, perhaps on
a mechanical basis such as a volvulus or internal hernia,
could not be discounted. Exploratory laparotomy was suggested
to the family and accepted by them.

MEDICAL HISTORY: headache, cerebellar CVA (ataxia), BPH, HTN, GERD, left foot
pain

MEDICATION ON ADMISSION: Protonix, enalapril 5, ASA 81, Cardura 4, Celexa 20, Lumigan
0.03% [**Hospital1 **], timolol 0.5% [**Hospital1 **]

ALLERGIES: No Known Allergies

PHYSICAL EXAM: NAD AOx3
CTA b/l
RRR
soft, mildly tender mildy distended hypoactive bowel sounds
no c/c/e

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Volvulus,Acute vascular insufficiency of intestine,Iatrogenic pulmonary embolism and infarction,Other postoperative infection,Cellulitis and abscess of trunk,Hyperplasia of prostate, unspecified, without urinary obstruction and other lower urinary symptoms (LUTS),Unspecified essential hypertension,Esophageal reflux,Other late effects of cerebrovascular disease, ataxia'}
