CHIEF COMPLAINT: 

PRESENT ILLNESS: This is a 51 year old gentleman
with Class 3 morbid obesity with a weight of 358 pounds and a
body mass index of 53 who was referred to the Bariatric
Surgery Program after failing several attempts at weight
loss.  His medical morbidities included insulin dependent
diabetes mellitus Type 2 diabetes mellitus with difficult to
control hemoglobin A1c consistently above 8, hypertension and
obstructive sleep apnea.  There is also a history of
recurrent pneumonias.  He had no prior gallbladder disease
but has not had a cholecystectomy.  He was thus evaluated and
deemed to be a suitable candidate for gastric bypass.  So,
plans were made to perform this procedure on [**2140-3-16**].

MEDICAL HISTORY: Hypertension, Type 2 insulin dependent
diabetes mellitus with neuropathy, hyperlipidemia,
obstructive sleep apnea requiring CPAP, recurrent pneumonia,
recurrent kidney stones, history of non-A, non-B hepatitis.

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: No tobacco or alcohol.
Morbid obesity,Other specified viral hepatitis without mention of hepatic coma,Cardiac complications, not elsewhere classified,Atrial fibrillation,Pneumonia, organism unspecified,Iron deficiency anemia secondary to blood loss (chronic),Diabetes with neurological manifestations, type II or unspecified type, uncontrolled,Other pulmonary insufficiency, not elsewhere classified,Streptococcal septicemia
Morbid obesity,Oth vrl hpat wo hpt coma,Surg compl-heart,Atrial fibrillation,Pneumonia, organism NOS,Chr blood loss anemia,DMII neuro uncntrld,Other pulmonary insuff,Streptococcal septicemia
Name:  [**Known lastname 2534**], [**Known firstname **]                       Unit No:  [**Numeric Identifier 18180**]

Admission Date:  [**2140-3-16**]     Discharge Date:  [**2112-2-8**]

Date of Birth:   [**2088-2-1**]     Sex:  M

Service:

ADDENDUM TO DISCHARGE INSTRUCTIONS:
1.  Continue stage three diet until follow up with Dr. [**Last Name (STitle) **]
and nutritionist.
2.  G tube is to remain clamped and to be clamped and placed
to gravity for any abdominal distention or nausea or
vomiting.
3.  The [**First Name8 (NamePattern2) 2021**] [**Last Name (NamePattern1) 2022**] drain of the left upper quadrant is to
remain to bulb suction.  Please record the output every day
and send the results into Dr. [**Last Name (STitle) **] when the patient goes for
follow up.
4.  Prior to follow up appointment the patient should stop
his Coumadin seven days before his follow up with Dr. [**Last Name (STitle) **] on
[**2140-4-21**], which would mean he should stop his Coumadin on
[**2140-4-15**].
5.  Continue Coumadin for goal INR between 2.0 and 2.5.

DISCHARGE MEDICATIONS:
1.  Roxicet elixir prn.
2.  Lopressor 150 mg po t.i.d.
3.  Lantus 40 units q.h.s.
4.  Levofloxacin 250 mg po q 24 hours to end after dose
[**2140-4-7**].
5.  Amiodarone 400 mg po b.i.d. to change to q.d. dosing on
[**2140-4-9**].
6.  Tylenol elixir prn.
7.  Prevacid 30 mg po q.d.
8.  Humalog insulin sliding scale.
9.  Coumadin 7.5 mg po q.h.s. dose for INR 2.0 to 2.5.






                          [**First Name11 (Name Pattern1) 651**] [**Last Name (NamePattern4) 2749**], M.D.  [**MD Number(1) 2750**]

Dictated By:[**Last Name (NamePattern1) 5986**]

MEDQUIST36

D:  [**2140-4-4**]  10:41
T:  [**2140-4-4**]  11:46
JOB#:  [**Job Number 18241**]


Admission Date:  [**2140-3-16**]       Discharge Date:  [**2140-4-5**]

Date of Birth:   [**2088-2-1**]       Sex:  M

Service:  Purple-Bariatric Surgery

HISTORY OF PRESENT ILLNESS:  This is a 51 year old gentleman
with Class 3 morbid obesity with a weight of 358 pounds and a
body mass index of 53 who was referred to the Bariatric
Surgery Program after failing several attempts at weight
loss.  His medical morbidities included insulin dependent
diabetes mellitus Type 2 diabetes mellitus with difficult to
control hemoglobin A1c consistently above 8, hypertension and
obstructive sleep apnea.  There is also a history of
recurrent pneumonias.  He had no prior gallbladder disease
but has not had a cholecystectomy.  He was thus evaluated and
deemed to be a suitable candidate for gastric bypass.  So,
plans were made to perform this procedure on [**2140-3-16**].

PAST MEDICAL HISTORY:  Hypertension, Type 2 insulin dependent
diabetes mellitus with neuropathy, hyperlipidemia,
obstructive sleep apnea requiring CPAP, recurrent pneumonia,
recurrent kidney stones, history of non-A, non-B hepatitis.

PAST SURGICAL HISTORY:  Status post removal of kidney stones
in [**2137**], status post varicocele excision in [**2117**], status post
appendectomy, status post tonsillectomy.

MEDICATIONS AT HOME:  Glucophage [**2135**] mg q. AM, Lantus 180
units q.h.s., Humalog sliding scale, Gemfibrozil 600 mg
b.i.d., Neurontin 600 mg q.d., Baby Aspirin 81 mg p.o. q.d.,
dietary supplements.

ALLERGIES:  No known drug allergies.

SOCIAL HISTORY:  No tobacco or alcohol.

BRIEF HOSPITAL COURSE:  Mr. [**Known lastname 7749**] was admitted to the
hospital on [**2140-3-16**], where he underwent a laparoscopic
Roux-en-Y gastric bypass under general endotracheal
anesthesia.  He tolerated the procedure well.  There were no
intraoperative complications.  He was, however, noted to go
into rapid atrial fibrillation shortly after the induction of
anesthesia.  He was then extubated in the Operating Room and
transferred to the Recovery Room in stable condition in sinus
rhythm, however, he had bursts of rapid atrial fibrillation
in the Recovery Room requiring multiple doses of intravenous
beta blocker.  His electrolytes were checked and repleted and
the patient at that time reported a history of some
palpitations and "irregular heart beat," associated with his
pneumonia.  He was administered Methylene Blue by mouth in
the Recovery Room the evening of the operation and this was
noted immediately to extravasate into his [**Location (un) 1661**]-[**Location (un) 1662**]
drain.  Dr. [**Last Name (STitle) **] was immediately notified and he was then
taken back to the Operating Room for laparoscopic
re-exploration.  At the time of the second operation the leak
was well contained and an additional drain was then placed in
that region.  The leak was seen to originate from the gastric
staple line.  He also had a gastrostomy tube placed and was
again transferred to the Recovery Room/Intensive Care Unit
intubated and sedated.

Neurologic - He initially received Fentanyl and Propofol for
sedation while he was sedated and these were eventually
switched over to oral Roxicet.  He remained without urologic
deficits and now with good control throughout his
hospitalization.

Cardiovascular - As stated prior soon after induction of
anesthesia for the first procedure, the patient went into
rapid atrial fibrillation and over the next 24 hours was in
and out of atrial fibrillation.  This was controlled with
intravenous beta blockers, however, on postoperative day #1,
because of the recurrent nature of the fibrillation he was
started on an intravenous Amiodarone drip with bolus.  His
cardiac enzymes were cycled and he ruled out for myocardial
infarction.  His rate over the course of the next few days
was relatively well controlled and he was noted to go in and
out of atrial fibrillation.  Cardiology was consulted and
they felt that this was due to a high catecholamine state
related to his surgery.  He had an echocardiogram performed
which showed a normal ejection fraction.  He was then placed
on a Diltiazem drip on postoperative day #2 for better rate
control to which he responded quite well.  Per Cardiology
recommendations he was started on a heparin drip on
postoperative day #4 due to the fact that he was again in and
out of atrial fibrillation.  This was continued at a
therapeutic dose until it was stopped but not before Coumadin
had been started for anticoagulation for his atrial
fibrillation.  He had initially been hypertensive and was
placed on Lopressor 150 b.i.d., however, his blood pressure
was trending down and his Lopressor thus was decreased to 100
b.i.d.  Of note, he was able to be weaned off of his
Diltiazem drip and was then maintained on the Lopressor,
however, he again on postoperative day #15, he again had a
brief episode of atrial fibrillation with a rapid ventricular
response which responded to one dose of intravenous
Lopressor.  He will be sent home with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts
Monitor.

Respiratory - Due to the large volume resuscitation and the
patient's history of sleep apnea, he remained intubated on
the first postoperative day, however, the decision was made
to extubate him.  He was initially stable, however, over the
course of the day developed worsening respiratory distress
and was weaned and intubated by blind nasotracheal
intubation.  After his hemodynamics stabilized, he underwent
diuresis and was extubated on postoperative day #8.  He
remained stable and did not require reintubation at that
time.  He was having fever spikes and a chest x-ray done
showed a retrocardiac infiltrate consistent with a
ventilator-associated pneumonia for which he was started on
Levaquin.  He remained afebrile with a normal white blood
cell count for the remainder of his hospital stay.  After
transfer to the floor, he was encouraged to ambulate with
incentive spirometry and chest physical therapy for pulmonary
toilet.

Gastrointestinal - Given the evidence of anastomotic leak on
the Methylene Blue swallow test, an upper gastrointestinal
series was deferred.  He was made NPO, his gastrostomy tube
was placed to gravity and he was placed on broad-spectrum
antibiotics to help control the leak with the hope that it
would seal over.  He was also started on gastric feeds by his
gastrostomy tube which he tolerated well and these were
advanced to a goal of 100 cc/hr.  After his sepsis resolved
his tube feeds were weaned down and he was started on a Stage
1 diet which he tolerated well.  He was subsequently advanced
to a Stage 3 diet without difficulty.  He had a repeat
Methylene Blue test that was again negative for any leak or
contrast extravasation.  He had a computerized tomography
scan of his abdomen done because of fevers and this did not
show any intra-abdominal abscess infiltrate and no
collections.  He currently is tolerating a Stage 3 diet and
was A-clamped of the gastrostomy tube, and he is tolerating
this well.  He initially had some diarrheal stools, however,
his tube feeds were decreased and his ileostomy output
decreased as well with that.

Genitourinary - Mr. [**Known lastname 7749**] did and continues to make adequate
amounts of urine during the hospital course.  He failed a
voiding trial while in the Intensive Care Unit, so his Foley
catheter was replaced and left in place.  His renal function
had deteriorated somewhat with an increase in his creatinine
to 1.5 from 1.0, however, on postoperative day #15, his
creatinine bumped to 2.4.  He also had a decrease in his
hematocrit to 27 at that time.  Nephrology was consulted and
they suspected contrast-induced nephropathy as the inciting
event and recommended discontinuing all nephrotoxic drugs and
checking a renal ultrasound.  This ultrasound revealed a
bilateral nonocclusive, nonobstructing calculi with no
evidence of hydronephrosis.  His volume status was closely
monitored and his creatinine eventually plateaued at 2.4 and
subsequently decreased at the time of this dictation.  Of
note, due to the large amount of volume given
perioperatively, diuresis with intravenous Lasix was
initiated, however, that was subsequently discontinued when
the rising creatinine was noted.  He currently has a 24 hour
urine electrolytes pending.

Fluids, electrolytes and nutrition - Mr. [**Known lastname 7749**] was initially
NPO, however, he was started on tube feeds on postoperative
day #12 at a low dose.  These were advanced to goal without
difficulty.  His tube feeds were stopped on [**2140-4-1**]
and he is currently tolerating a Stage 3 diet.  Mr. [**Known lastname 7749**]
initially was placed on the standard subcutaneous heparin,
however, his multiple episodes of atrial fibrillation over
the hospital course he was heparinized and Coumadin was
started for goal INR of 2.0 to 2.5.  He did received some
blood transfusions for blood loss anemia of critical illness
and otherwise remained stable from a hematologic standpoint.

Infectious disease - He received periopreative antibiotics
and after his second exploration with identification of his
leak he was started on intravenous Zosyn.  This was continued
for  a course, however, he started to spike fevers and was
pancultured.  Abdominal computerized tomography scan was done
as mentioned before and showed no abscess, however, his chest
x-ray did show a retrocardiac density for which he was
started on Levofloxacin to which he has completed a 14 day
course.

Endocrine - In the immediate postoperative period his blood
glucoses were difficult to control requiring an insulin drip
and large amounts of daily insulin.  [**Last Name (un) **] consult was
called and they followed him closely throughout his
hospitalization.  After his tube feeds were weaned down he
was able to be discontinued off of his insulin drip and that
was maintained on Lantus and a Humalog sliding scale.

SUMMARY:  This is a 52 year old gentleman with morbid
obesity, status post laparoscopic Roux-en-Y gastric bypass
with a prolonged and complicated hospital course significant
for atrial fibrillation, insulin dependent diabetes mellitus
with insulin-resistance and acute renal failure.

CONDITION ON DISCHARGE:  Stable.

DISCHARGE STATUS:  The patient will be discharged to a
rehabilitation facility as continued assessment by physical
therapy has deemed this to be the best course for expeditious
recovery.

DISCHARGE INSTRUCTIONS:  Mr. [**Known lastname 7749**] should remain on a Stage 3
diet.  He should keep the [**Location (un) 1661**]-[**Location (un) 1662**] drain in place for
now.  He is to follow up with Dr. [**Last Name (STitle) **] in the Bariatric
Surgery Clinic in two weeks.  He should also follow up with
Cardiology for an outpatient [**Doctor Last Name **] of Hearts Monitor to be
placed given his atrial fibrillation.

DISCHARGE DIAGNOSIS:
1.  Morbid obesity.
2.  Insulin dependent diabetes mellitus.
3.  Paroxysmal atrial fibrillation.
4.  Hypertension.
5.  Acute renal failure.
6.  Sleep apnea.
7.  Ventilator-associated pneumonia, resolving.
8.  Blood loss anemia, resolving.

MEDICATIONS ON DISCHARGE:
1.  Albuterol prn, administered as nebulizers.
2.  Atrovent nebulizers prn.
3.  Hydrocortisone cream prn.
4.  Roxicet elixir 5 to 10 cc q. 4-6 hours prn.
5.  Prevacid elixir 30 mg p.o. q.d.
6.  Lopressor 100 mg p.o. b.i.d.
7.  Lantus insulin 40 units subcutaneously q.h.s.
8.  Humalog insulin sliding scale.
9.  Coumadin 5 to 10 mg q.d. for a goal INR of 2.0 to 2.5.
He should have his INR checked daily or every other day until
he is at a steady state.
10. Amiodarone 400 mg p.o. b.i.d.  He is to change to a q.d.
dosing of Amiodarone on [**2140-4-9**].
11. Tylenol prn.
12. Amiodarone 400 mg p.o. q.d. to start on [**2140-4-9**].




                            [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3799**], M.D.  [**MD Number(1) 3800**]

Dictated By:[**Last Name (NamePattern1) 2682**]
MEDQUIST36

D:  [**2140-4-3**]  13:35
T:  [**2140-4-3**]  06:46
JOB#:  [**Job Number 110932**]


Admission Date:  [**2140-3-16**]       Discharge Date:  [**2140-4-7**]

Date of Birth:   [**2088-2-1**]       Sex:  M

Service:  Purple/Bariatric surgery

ADDENDUM:

BRIEF HOSPITAL COURSE:  In addition to the prior dictated
summaries the patient was scheduled to be discharged to a
rehabilitation facility.  However, on the morning of [**2140-4-5**]
repeat laboratories revealed an elevated BUN and creatinine
of 48 and 2.8 from a creatinine of 2.1 previously.  Due to
the rise in his creatinine the decision was made to delay his
discharge.  He was given additional intravenous hydration and
his creatinine came down to 2.6.  A repeat renal ultrasound
was performed on [**2140-4-6**] which again revealed bilateral
nonobstructing renal calculi with no hydronephrosis and an
empty bladder.  He was given additional intravenous
hydration.  Renal was contact[**Name (NI) **] and from their perspective he
was stable to be discharged to a rehabilitation facility and
follow up with them in clinic.  This was thought to be from
mild dehydration.  In addition his Levofloxacin was stopped
in case this was contributing to his worsening renal
function.  In addition, he had a few episodes of atrial
fibrillation and a rapid heart rate and as noted on his
telemetry was in and out of atrial fibrillation.  His
Lopressor dose increased to 150 mg three times a day and he
remained rate controlled with rhythm between sinus rhythm,
atrial fibrillation/atrial flutter pattern.  Additionally his
[**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**] drain was noted to be putting out more fluid of
a brownish initially thick then thin consistency up to 200 cc
per day.  The decision was made then to limit his oral intake
and to change him to the Carnation Instant Breakfast three
times a day by his G tube and to give him additional
hydration via his G tube with him taking only sips of water
or small sips of ice chips by mouth until he follows up with
Dr. [**Last Name (STitle) **].

DISCHARGE DIAGNOSIS:
See prior summary.

DISCHARGE FOLLOW UP:
1.  With Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in the gastric bypass clinic on [**2140-4-14**], phone number [**Telephone/Fax (1) 110933**].
2.  With Dr. [**Last Name (STitle) 6073**] from cardiology on [**2140-5-2**] at 3
P.M., phone number [**Telephone/Fax (1) 2386**].
3.  With Dr. [**Last Name (STitle) 1366**] from nephrology/renal at [**Telephone/Fax (1) 60**].

DISCHARGE INSTRUCTIONS:
1.  Diet, only small sips of water or ice chips by mouth
until follow up with Dr. [**Last Name (STitle) **] at which time his [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**]
drain will be pulled if the output is low.
2.  Sugar free Carnation Instant Breakfast via G tube three
times a day.
3.  The G tube is remain clamped between feedings and to be
unclamped and placed to gravity if there is any abdominal
distention or nausea or vomiting.
4.  He is to receive a total of 2 liters of additional water
via his G tube.  This can be divided in 500 cc aliquots given
four times a day.
5.  His [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**] drain is to remain in place to bulb
suction.  The output is to be recorded and sent in with him
when he follow up with Dr. [**Last Name (STitle) **] on [**2140-4-14**].
6.  He is to be anticoagulated.  However, his [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**]
drain will likely be pulled by Dr. [**Last Name (STitle) **] on his follow up so he
is not to receive any Coumadin until he follows up with Dr.
[**Last Name (STitle) **].  He would have received his last dose of Coumadin on
[**2140-4-7**] and his INR as of [**2140-4-6**] is 2.8.  After he follows
up with Dr. [**Last Name (STitle) **] his Coumadin will be restarted.

DISCHARGE MEDICATIONS:  Albuterol nebs q 6 hours p.r.n.,
Atrovent nebs q 6 hours p.r.n., Roxicet elixir 5 to 10 cc via
G tube every four to six hours as needed.  Lopressor 150 mg
via G tube t.i.d., Lantus insulin 40 units subcutaneously
q.h.s., amiodarone 400 mg by mouth b.i.d. through [**2140-4-8**],
amiodarone 400 mg p.o. q.d. to start [**2140-4-9**] and to continue
until follow up with [**Doctor Last Name 6073**] of cardiology whose number is
listed above.  Prevacid suspension 30 mg p.o. q.d.  Humalog
insulin sliding scale.  Coumadin.  This is to begin after the
patient's follow up with Dr. [**Last Name (STitle) **], which would be after
[**2140-4-14**].

Mr. [**Known lastname 7749**] has been deemed stable for discharge with the
instructions and follow up listed above.  If there are any
questions please contact Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 110933**].






                            [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3799**], M.D.  [**MD Number(1) 3800**]

Dictated By:[**Last Name (NamePattern1) 2682**]
MEDQUIST36

D:  [**2140-4-6**]  17:30
T:  [**2140-4-6**]  17:42
JOB#:  [**Job Number 110934**]


Name:  [**Known lastname 2534**], [**Known firstname **]              Unit No:  [**Numeric Identifier 18180**]

Admission Date: [**2140-3-16**]        Discharge Date: [**2140-4-22**]

Date of Birth:  [**2088-2-1**]        Sex:  M

Service:  [**Last Name (un) **]


Please see previous dictation for events leading to this
dictation.

On postoperative day 28 and six, patient was begun on
linezolid for VRE UTI.  Patient was afebrile.  Vital signs
are stable.  JP continued to drain some whitish material
approximately 200 cc/day.  Patient was continued on IV
antibiotics.  Urology was contact[**Name (NI) **] for laser lithotripsy.
Patient was seen by Renal.  Renal felt with improving
creatinine after placement of bilateral ureteral stents,
patient would be stable for followup after urology laser
lithotripsy.  The patient was instructed to followup with
Nephrology in approximately two weeks.  Patient also was
instructed to be discharged on Urocit-K to alkalinize the
urine.

Patient was started on tube feeds per gastric bypass Stage
III diet calorie needs.  Patient was seen by the EPS service
for atrial flutter.  Felt patient would be a suitable
candidate for atrial ablation to correct atrial flutter.
Patient was preoped for atrial flutter.  Patient was given a
unit of packed red blood cells x2 for low hematocrits.

On postoperative day 29 and seven, patient was continued on
antibiotics.  Patient was afebrile with stable vital signs.
JP continued to put out minimal amounts of whitish fluid.
Heparin drip was removed, and [**Initials (NamePattern4) 1325**] [**Last Name (NamePattern4) 2021**]-[**Location (un) 2022**] drain
was removed.  Patient tolerated removal of [**Location (un) 2021**]-[**Location (un) 2022**]
drain.  Patient was off Heparin for two days to prevent
bleeding after removal of his drain.

On postoperative day number 30 and eight, patient was
continued on IV linezolid.  Patient had no drainage from the
JP site.  Patient was doing well, was kept NPO.  Patient was
back on Heparin drip and tube feeds were restarted.  The
patient was seen by Podiatry for nail clipping.  Patient
continued to be in atrial flutter, and was preoped for an
atrial ablation.

On postoperative day 32 and 10, patient was continued on
Heparin drip.  Patient was afebrile with stable vital signs.
Antibiotics were switched to p.o. per the G tube.  Patient
was NPO after midnight, tolerating a Stage III diet during
the day, but NPO for procedure atrial ablation.

On postoperative day 33 and 11, patient was afebrile with
stable vital signs.  Was taken to EPS for atrial ablation,
for specific atrial ablation procedure, please see EPS note.
Patient tolerated the procedure well, and was transferred
back to the floor in sinus rhythm.  Plans were discussed with
Urology to remove ureteral stents and attempt laser
lithotripsy.

On [**2140-4-19**], patient was brought to cystoscopy suite, in
which right-sided ureteroscopy was performed with laser
lithotripsy and stent placement.  Patient tolerated the
procedure well, and was transferred back to the floor.
Patient was continued on Stage III diet.  Patient's
creatinine was improved.  Patient never had fever or
elevation of his white count.

On postoperative day 35 and 13, patient was on linezolid, day
number 8.  Patient was afebrile with stable vital signs.
Patient was doing well.  Patient was tolerating a Stage III
diet.  Patient was scheduled to go back to cystoscopy on
[**4-21**] for treatment of the left kidney.  Patient was preoped
on [**4-19**], postoperative day 36 and 14.  Patient went back to
cystoscopy suite for left laser lithotripsy.  The patient
tolerated the procedure well, and was transferred back to the
floor.
Patient had a Foley catheter in place, and a ureteral drain.

On postoperative day number 37 and 15, patient was on all
oral medicines crushed by mouth.  Patient was tolerating a
Stage III diet.  Patient was afebrile.  The Foley catheter
was removed, and patient voided on his own.  Patient was
discharged to home in stable condition with VNA care.

FOLLOW-UP INSTRUCTIONS:
1. Patient will follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**12-11**] weeks in
   Gastric [**Hospital 18181**] Clinic.  Patient will call to schedule
   appointment.
2. Patient will follow up in two weeks for CT scan without
   contrast to stage kidney stones.
3. Patient will follow up with Dr. [**Last Name (STitle) **] in Cardiac
   services.  Patient will call to schedule an appointment.
4. Patient will follow up Dr. [**Last Name (STitle) 18182**] of Nephrology.
   Patient will call for an appointment.


DISCHARGE DIAGNOSES:
1. Laparoscopic gastric bypass.
2. Reexploration laparoscopically.
3. Acute renal failure.
4. Nephrolithiasis.
5. Atrial flutter.
6. Status post atrial ablation.
7. Status post bilateral laser lithotripsy and ureteral stent
   placement.
8. Hypertension.
9. Diabetes mellitus.
10.      Morbid obesity.


DISCHARGE MEDICATIONS:
1. Roxicet elixir [**4-18**] mL p.o. every 4-6 hours as needed for
   pain.
2. Amiodarone 200 mg tablet one tablet p.o. q.d.
3. Zantac 150 mg elixir p.o. b.i.d.
4. Urocit-K 10 1080 mg p.o. q.d.  Patient must take crushed.
5. Allopurinol 100 mg two tablets p.o. q.d., must take
   crushed.
6. Metoprolol 75 mg p.o. b.i.d., must take crushed.
7. Linezolid 600 mg one tablet p.o. b.i.d. for 14 days, must
   take crushed.
8. Humalog insulin per sliding scale.
9.
   Lantus insulin 20 units p.o. q.h.s.
10.      Ursodiol 300 mg tablet p.o. b.i.d.




                        [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD 2331

Dictated By:[**Last Name (NamePattern1) 18183**]
MEDQUIST36
D:  [**2140-4-22**] 08:09:06
T:  [**2140-4-22**] 08:31:26
Job#:  [**Job Number **]
{'Morbid obesity,Other specified viral hepatitis without mention of hepatic coma,Cardiac complications, not elsewhere classified,Atrial fibrillation,Pneumonia, organism unspecified,Iron deficiency anemia secondary to blood loss (chronic),Diabetes with neurological manifestations, type II or unspecified type, uncontrolled,Other pulmonary insufficiency, not elsewhere classified,Streptococcal septicemia'}


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: 

PRESENT ILLNESS: This is a 51 year old gentleman
with Class 3 morbid obesity with a weight of 358 pounds and a
body mass index of 53 who was referred to the Bariatric
Surgery Program after failing several attempts at weight
loss.  His medical morbidities included insulin dependent
diabetes mellitus Type 2 diabetes mellitus with difficult to
control hemoglobin A1c consistently above 8, hypertension and
obstructive sleep apnea.  There is also a history of
recurrent pneumonias.  He had no prior gallbladder disease
but has not had a cholecystectomy.  He was thus evaluated and
deemed to be a suitable candidate for gastric bypass.  So,
plans were made to perform this procedure on [**2140-3-16**].

MEDICAL HISTORY: Hypertension, Type 2 insulin dependent
diabetes mellitus with neuropathy, hyperlipidemia,
obstructive sleep apnea requiring CPAP, recurrent pneumonia,
recurrent kidney stones, history of non-A, non-B hepatitis.

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: No tobacco or alcohol. 

### Response:
{'Morbid obesity,Other specified viral hepatitis without mention of hepatic coma,Cardiac complications, not elsewhere classified,Atrial fibrillation,Pneumonia, organism unspecified,Iron deficiency anemia secondary to blood loss (chronic),Diabetes with neurological manifestations, type II or unspecified type, uncontrolled,Other pulmonary insufficiency, not elsewhere classified,Streptococcal septicemia'}
