CHIEF COMPLAINT: Abdominal Pain

PRESENT ILLNESS: 65 y.o. male with PMH of ETOH abuse quitting 2 weeks ago,
narcotics use who p/w acute onset nausea and vomiting one hour
after eating a knish and coleslaw for lunch today from a
favorite place of his.  The patient states he knows that this
places food makes him sick and has made him sick in the past,
but he likes their food so he tried again.  His emesis consisted
of undigested food and bilious contents without blood. He also
reported abdominal distention and gradual onset sharp constant
LLQ pain with progressive worsening without radiation. He
assumed that he was having food poisoning and self induced
further vomitting.  Pain is alleviated with narcotics. The
patient states that he hasnt had a bowel movement for "days" and
he feels constipated.  He hasnt been passing gas since his
arrival in the ED.
.
Of note he took percocet as recently as yesterday for
recreational purposes, he takes [**2-4**] xanax per day as needed for
anxiety and recently self d/c'd paxil.  The patient has never
had bloody bowel movements or diarrhea in his own medical
history.
.
In the ED, initial vs were: 98.3 78 170/98 20 100% 2L NC. Noted
to be guaiac negative. Abdominal X-ray performed did not show
free air. CT abdomen showed evidence of acute colitis. Labs were
notable for a lactate of initial lactate was 3.7.  Surgery was
consulted and felt that his exam was inconsistent with
peritonitis and that his CT and the distribution of his colitis
was inconsistent with ischemic colitis.  They had initially
triaged the patient to the floor to have a GI consult.
.
Around 4:00 the patient suddenly decompensation his heart rate
rose to the 130s, his SBP dropped to the 70s, and his skin
became mottled. A repeat lactate was performed and was 5.8.  He
received a total of 6L of IVF with improvement in his blood
pressure to 158/107.  Surgery re-evaluated and felt that this
was still a non-surgical issue.  He was admitted to the MICU for
further management.  His stool guaiac was checked and was
negative x 2.  While in the ED he was given Vancomycin,
ciprofloxacin, and flagyl along with 5 mg IV dilaudid, IV
zofran, and IV ativan. Vital Signs prior to transfer were 103.2
158/107 129 29 96% RA. No cultures were sent.

MEDICAL HISTORY: Chronic Knee Pain
Insomnia
anxiety
hx of ETOH abuse
Narcotic abuse

MEDICATION ON ADMISSION: MVI
PRN Xanax

ALLERGIES: Cipro

PHYSICAL EXAM: Temp  98.3    BP  170/90   HR  78   RR 18    O2 sat 100% 2L.
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: Denies h/o GI disease in his family specifically Inflamatory
bowel disease. His father had an MI in his late 50s. He has a
sister with mental illness who died of cancer in her early 50s,
unclear type.

SOCIAL HISTORY: He is a writer, former political media specialist. Does not
smoke, quit in [**2095**], heavy drinker but quit 2 weeks ago, reports
recreational use of vicodin and percocet, 2-3 tabs daily.
Acute vascular insufficiency of intestine,Septicemia due to gram-negative organism, unspecified,Acute respiratory failure,Acute kidney failure with lesion of tubular necrosis,Septic shock,Severe sepsis,Other ascites,Colitis, enteritis, and gastroenteritis of presumed infectious origin,Unspecified pleural effusion,Acidosis,Suicidal ideation,Alcohol abuse, unspecified,Insomnia, unspecified,Pain in joint, lower leg,Depressive disorder, not elsewhere classified,Personal history of noncompliance with medical treatment, presenting hazards to health
Ac vasc insuff intestine,Gram-neg septicemia NOS,Acute respiratry failure,Ac kidny fail, tubr necr,Septic shock,Severe sepsis,Ascites NEC,Enteritis of infect orig,Pleural effusion NOS,Acidosis,Suicidal ideation,Alcohol abuse-unspec,Insomnia NOS,Joint pain-l/leg,Depressive disorder NEC,Hx of past noncompliance
Admission Date:  [**2131-2-3**]              Discharge Date:   [**2131-2-16**]

Date of Birth:  [**2065-5-6**]             Sex:   M

Service: SURGERY

Allergies:
Cipro

Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Abdominal Pain

Major Surgical or Invasive Procedure:
[**2131-2-5**]
Subtotal colectomy and end ileostomy
depression


History of Present Illness:
65 y.o. male with PMH of ETOH abuse quitting 2 weeks ago,
narcotics use who p/w acute onset nausea and vomiting one hour
after eating a knish and coleslaw for lunch today from a
favorite place of his.  The patient states he knows that this
places food makes him sick and has made him sick in the past,
but he likes their food so he tried again.  His emesis consisted
of undigested food and bilious contents without blood. He also
reported abdominal distention and gradual onset sharp constant
LLQ pain with progressive worsening without radiation. He
assumed that he was having food poisoning and self induced
further vomitting.  Pain is alleviated with narcotics. The
patient states that he hasnt had a bowel movement for "days" and
he feels constipated.  He hasnt been passing gas since his
arrival in the ED.
.
Of note he took percocet as recently as yesterday for
recreational purposes, he takes [**2-4**] xanax per day as needed for
anxiety and recently self d/c'd paxil.  The patient has never
had bloody bowel movements or diarrhea in his own medical
history.
.
In the ED, initial vs were: 98.3 78 170/98 20 100% 2L NC. Noted
to be guaiac negative. Abdominal X-ray performed did not show
free air. CT abdomen showed evidence of acute colitis. Labs were
notable for a lactate of initial lactate was 3.7.  Surgery was
consulted and felt that his exam was inconsistent with
peritonitis and that his CT and the distribution of his colitis
was inconsistent with ischemic colitis.  They had initially
triaged the patient to the floor to have a GI consult.
.
Around 4:00 the patient suddenly decompensation his heart rate
rose to the 130s, his SBP dropped to the 70s, and his skin
became mottled. A repeat lactate was performed and was 5.8.  He
received a total of 6L of IVF with improvement in his blood
pressure to 158/107.  Surgery re-evaluated and felt that this
was still a non-surgical issue.  He was admitted to the MICU for
further management.  His stool guaiac was checked and was
negative x 2.  While in the ED he was given Vancomycin,
ciprofloxacin, and flagyl along with 5 mg IV dilaudid, IV
zofran, and IV ativan. Vital Signs prior to transfer were 103.2
158/107 129 29 96% RA. No cultures were sent.


Past Medical History:
Chronic Knee Pain
Insomnia
anxiety
hx of ETOH abuse
Narcotic abuse


Social History:
He is a writer, former political media specialist. Does not
smoke, quit in [**2095**], heavy drinker but quit 2 weeks ago, reports
recreational use of vicodin and percocet, 2-3 tabs daily.

Family History:
Denies h/o GI disease in his family specifically Inflamatory
bowel disease. His father had an MI in his late 50s. He has a
sister with mental illness who died of cancer in her early 50s,
unclear type.

Physical Exam:
Temp  98.3    BP  170/90   HR  78   RR 18    O2 sat 100% 2L.
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

Physical examination upon discharge:  [**2131-2-16**]

VITAL SIGNS:  t=99.7, hr- 84, bp=101/67, oxygen saturation 98%
room air, resp. rate 18

General: NAD, pleasant, alert and oriented x 3
CV:  Ns1, s2, -s3, s-4
LUNGS:  Clear
ABDOMEN:  Soft, [**Month/Day/Year 9341**] stoma red, small amount watery brown
stool in bag, mid line incision with W-D dressing
EXT: + dp bil., no calf tenderness

Pertinent Results:
LABS:
[**2131-2-3**] 09:30AM   GLUCOSE-163* UREA N-32* CREAT-1.4* SODIUM-145
POTASSIUM-3.5 CHLORIDE-113* TOTAL CO2-16* ANION GAP-20
[**2131-2-3**] 09:30AM   CALCIUM-7.3* PHOSPHATE-2.1* MAGNESIUM-1.9
[**2131-2-3**] 09:30AM   WBC-3.9* RBC-4.65 HGB-15.5 HCT-44.8 MCV-96
MCH-33.4* MCHC-34.7 RDW-12.9
[**2131-2-3**] 09:30AM   PLT COUNT-233
[**2131-2-3**] 09:30AM   PT-14.4* PTT-30.1 INR(PT)-1.3*
[**2131-2-3**] 07:33AM URINE  COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.044*
[**2131-2-3**] 07:33AM URINE  BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-1 PH-6.5 LEUK-NEG
[**2131-2-3**] 07:33AM URINE  RBC-[**12-23**]* WBC-0-2 BACTERIA-FEW
YEAST-NONE EPI-0-2
[**2131-2-3**] 06:51AM   PO2-90 PCO2-37 PH-7.20* TOTAL CO2-15* BASE
XS--12 COMMENTS-GREEN TOP
[**2131-2-3**] 06:51AM   LACTATE-4.6*
[**2131-2-3**] 09:30AM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2131-2-2**] 09:00PM   ALT(SGPT)-28 AST(SGOT)-33 ALK PHOS-32* TOT
BILI-1.8* DIR BILI-0.4* INDIR BIL-1.4
[**2131-2-2**] 09:00PM   LIPASE-23

[**2131-2-2**] CT Abd/pelvis ;
1. Diffuse wall thickening and hyperenhancement of descending
colon and minimally of the transverse colon and sigmoid colon,
with surrounding pericolonic fat stranding and fluid are
compatible with acute colitis. This is most likely infectious or
inflammatory in etiology.
2. Hypodense right upper pole renal lesion, is not well
characterized in this study. [**Month (only) 116**] represent a hemorrhagic cyst,
recommended non emergent ultrasound for further evaluation.

1/2/11/ CT Abd/pelvis :
1. Dilated loops of small bowel without a clear transition
points compatible with ileus, new from prior study.
2. Bilateral pleural effusions and intra-abdominal ascites, new
from prior
study.
3. Unchanged mild thickening of the colon wall but with less
pericolonic
inflammatory fat stranding.

[**2131-2-5**] Cardiac eccho :
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
and cavity size are normal. Regional left ventricular wall
motion is normal. Left ventricular systolic function is
hyperdynamic (EF>75%). There is no ventricular septal defect.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Trivial mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.

[**2131-2-8**]:  Chest x-ray:

  FINDINGS: As compared to the previous radiograph, the
monitoring and support devices are unchanged. Minimal increase
of the bilateral pleural effusions that were visible on the
previous radiograph. Unchanged subsequent areas of bilateral
atelectasis. No newly occurred focal parenchymal opacities. No
pneumothorax

[**2131-2-9**]:  chest x-ray:

IMPRESSION:
1. Bilateral lower lobe collapse.
2. Moderate right pleural effusion and small left pleural
effusion, both
decreased.
3. Improved vascular congestion.




Brief Hospital Course:
 Mr. [**Known lastname **] was evaluated by the Medical and Surgical teams in
the Emergency Room for left lower quadrant pain. He was
admitted to the floor for further management and diagnostics
including a GI consult.
 Shortly thereafter he decompensated with tachycardia,
hypotension and mottled extremities.  He was urgently
transferred to the MICU for fluid rescussitation and pressor
support. He was not improving and was taken to the Operating
Room for abdominal exploration. ( See formal Op note for
details). He underwent a subtotal colectomy and ileostomy for a
necrotic colon.  He tolerated the procedure well and returned to
the ICU in stable condition with stable hemodynamics. Areas of
necrotic bowel were identified during the operative procedure.
He was given broad spectrum antibiotics following full cultures
in the Emergency Room and the antibiotics continued
post-operatively. Currently, he is on augmentin until [**2-16**], at
which point his course of antibiotics will be completed.
 His initial post op course included weaning pressors and
eventually weaning from the respirator and extubation.  His pain
was adequately controlled and he was slowly started on liquids
while awaiting [**Month/Year (2) 9341**] activity.  Unfortunately he expressed
wishes that he wanted to kill himself and the Psychiatric
service was consulted for help with management and coping and he
also had a 1:1 sitter for 24 hours and then they were
discontinued. He will be evauluated by Psychiatry prior to
discharge to determine if he would benefit from out-patient
psychiatry. Psychiatry has indicated that he does not need
out-patient follow-up, but reports that patient will seek
assistance if needed through his primary care provider.

 During his hospitalization, he was evaluated by the Social
Worker.  He has also been seen by the [**Month/Year (2) **] nurse [**First Name (Titles) **] [**Last Name (Titles) 9341**]
care teaching.  According to the [**Last Name (Titles) **] nurse, he has
demonstrated good ability to care for his [**Last Name (Titles) 9341**].  He will
change his [**Last Name (Titles) 9341**] appplicance with supervision today prior to
discharge.

 His vital signs are stable and he is tolerating a regular diet.
 He has been out of bed and ambulating. He will be discharged
home with VNA assistance.  He has been instructed to follow-up
with the Acute Care Service in [**3-8**] weeks.








Medications on Admission:
MVI
PRN Xanax

Discharge Medications:
1. 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:*2*
2. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
3. docusate sodium 100 mg Capsule Sig: [**2-4**] Capsules PO twice a
day as needed for constipation.
Disp:*80 Capsule(s)* Refills:*0*
4. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO three
times a day for 1 days: thru [**2131-2-16**].
Disp:*3 Tablet(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
Necrotic colon


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
You were admitted to the hospital with abdominal pain and
ultimately required surgery on your colon as there were areas of
necrosis.  A diversion of the bowel was done and you will need a
few months to heal.  In the meantime you will need to care for
your [**Hospital 9341**] and the VNA will help you with this along with the
teaching that you have received in the hospital.  Your doctors
[**Name5 (PTitle) **] let [**Name5 (PTitle) **] know when you will be reconnected.

Please call your doctor or go to the emergency department if:
*You experience new chest pain, pressure, squeezing or
tightness.
*You develop new or worsening cough, shortness of breath, or
wheeze.
*You are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons.  Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
*Your pain is not improving within 12 hours or is not under
control within 24 hours.
*Your pain worsens or changes location.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*You develop any concerning symptoms.

General Discharge Instructions:
Please resume all regular home medications, unless specifically
advised not to take a particular medication.  Please take any
new medications as prescribed.
Please take the prescribed analgesic medications as needed.  You
may not drive or heavy machinery while taking narcotic analgesic
medications.  You may also take acetaminophen (Tylenol) as
directed, but do not exceed 4000 mg in one day.
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids.  Avoid strenuous
physical activity and refrain from heavy lifting greater than 10
lbs., until you follow-up with your surgeon, who will instruct
you further regarding activity restrictions.  Please also
follow-up with your primary care physician.

Incision Care:
*Please call your surgeon or go to the emergency department if
you have increased pain, swelling, redness, or drainage from the
incision site.
*Avoid swimming and baths until cleared by your surgeon.
*You may shower and wash incisions with a mild soap and warm
water.  Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.

Monitoring [**Name5 (PTitle) **] Output:
*Keep well hydrated.
*Replace fluid loss from [**Name5 (PTitle) 9341**] daily.
*Avoid drinking only plain water.  Include gatorade and/or other
vitamin drinks to replace fluid.


Followup Instructions:
Please follow up in the Acute Care Services clinic in [**3-8**] weeks
after discharge.  You can contact them at [**Telephone/Fax (1) 600**] to
schedule an appointment.



Completed by:[**2131-2-20**]
{'Acute vascular insufficiency of intestine,Septicemia due to gram-negative organism, unspecified,Acute respiratory failure,Acute kidney failure with lesion of tubular necrosis,Septic shock,Severe sepsis,Other ascites,Colitis, enteritis, and gastroenteritis of presumed infectious origin,Unspecified pleural effusion,Acidosis,Suicidal ideation,Alcohol abuse, unspecified,Insomnia, unspecified,Pain in joint, lower leg,Depressive disorder, not elsewhere classified,Personal history of noncompliance with medical treatment, presenting hazards to health'}


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: 65 y.o. male with PMH of ETOH abuse quitting 2 weeks ago,
narcotics use who p/w acute onset nausea and vomiting one hour
after eating a knish and coleslaw for lunch today from a
favorite place of his.  The patient states he knows that this
places food makes him sick and has made him sick in the past,
but he likes their food so he tried again.  His emesis consisted
of undigested food and bilious contents without blood. He also
reported abdominal distention and gradual onset sharp constant
LLQ pain with progressive worsening without radiation. He
assumed that he was having food poisoning and self induced
further vomitting.  Pain is alleviated with narcotics. The
patient states that he hasnt had a bowel movement for "days" and
he feels constipated.  He hasnt been passing gas since his
arrival in the ED.
.
Of note he took percocet as recently as yesterday for
recreational purposes, he takes [**2-4**] xanax per day as needed for
anxiety and recently self d/c'd paxil.  The patient has never
had bloody bowel movements or diarrhea in his own medical
history.
.
In the ED, initial vs were: 98.3 78 170/98 20 100% 2L NC. Noted
to be guaiac negative. Abdominal X-ray performed did not show
free air. CT abdomen showed evidence of acute colitis. Labs were
notable for a lactate of initial lactate was 3.7.  Surgery was
consulted and felt that his exam was inconsistent with
peritonitis and that his CT and the distribution of his colitis
was inconsistent with ischemic colitis.  They had initially
triaged the patient to the floor to have a GI consult.
.
Around 4:00 the patient suddenly decompensation his heart rate
rose to the 130s, his SBP dropped to the 70s, and his skin
became mottled. A repeat lactate was performed and was 5.8.  He
received a total of 6L of IVF with improvement in his blood
pressure to 158/107.  Surgery re-evaluated and felt that this
was still a non-surgical issue.  He was admitted to the MICU for
further management.  His stool guaiac was checked and was
negative x 2.  While in the ED he was given Vancomycin,
ciprofloxacin, and flagyl along with 5 mg IV dilaudid, IV
zofran, and IV ativan. Vital Signs prior to transfer were 103.2
158/107 129 29 96% RA. No cultures were sent.

MEDICAL HISTORY: Chronic Knee Pain
Insomnia
anxiety
hx of ETOH abuse
Narcotic abuse

MEDICATION ON ADMISSION: MVI
PRN Xanax

ALLERGIES: Cipro

PHYSICAL EXAM: Temp  98.3    BP  170/90   HR  78   RR 18    O2 sat 100% 2L.
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: Denies h/o GI disease in his family specifically Inflamatory
bowel disease. His father had an MI in his late 50s. He has a
sister with mental illness who died of cancer in her early 50s,
unclear type.

SOCIAL HISTORY: He is a writer, former political media specialist. Does not
smoke, quit in [**2095**], heavy drinker but quit 2 weeks ago, reports
recreational use of vicodin and percocet, 2-3 tabs daily. 

### Response:
{'Acute vascular insufficiency of intestine,Septicemia due to gram-negative organism, unspecified,Acute respiratory failure,Acute kidney failure with lesion of tubular necrosis,Septic shock,Severe sepsis,Other ascites,Colitis, enteritis, and gastroenteritis of presumed infectious origin,Unspecified pleural effusion,Acidosis,Suicidal ideation,Alcohol abuse, unspecified,Insomnia, unspecified,Pain in joint, lower leg,Depressive disorder, not elsewhere classified,Personal history of noncompliance with medical treatment, presenting hazards to health'}
