CHIEF COMPLAINT: Acalculous Cholecystitis and Decubitus Ulcer

PRESENT ILLNESS: 57y M w/ protracted hospital course, initiated with an
admission for pneumonia complicated by respiratory failure
leading to intubation and eventaul tracheostomy in late
[**Month (only) **].
The patient also developed an acalculous cholecystitis, and was
treated with a percutaneous cholecystosomy on [**2114-2-21**] tube given
his debilatated state. In mid/late [**Month (only) **] pt was rehospitalized
for fevers, and elevated WBC.  An U/S on [**3-10**] demonstrated a
thickened galbladder wall without ductal dilatation or
obstruction.  On [**3-12**] his percutaneous cholecystosomy tube was
noted to be dislodged and was replaced. Pt was d/c'd to rehab
facility at this time. On [**4-7**] Pt was transfered from [**Hospital1 **] to
[**Hospital1 **] for fevers of 101 and a WBC of 31. At [**Hospital1 **] a ERCP
w/ sphincterotomy w/stent placement was performed on [**4-9**].  a
tube cholesytogram demonstrated stones in the gallbladder, and
free filling into the duodenum. At this time it was decided the
pt was to be transferred to [**Hospital1 18**] fro further management.

MEDICAL HISTORY: PMH:
DM on insulin
Afib
Decubitus ulcers (stage 4)
Pneumonia requiring intubation s/p trach ([**1-22**])
Acalculous cholecystitis ([**1-22**])
CHF (unknown EF)
? CRI
.
PSH:
trach/EG
cholecystostomy tube on [**2-21**], Tube replaced on [**3-12**]

MEDICATION ON ADMISSION: HISS, Lantus 16u QAM, Imipenem 250'QAM, Ativan 1 Q4P, Zofran 4
Q6P, Morphine 3 Q4P, Florastor 250'', Betapace 40'', Fluconazole
200', Linezolid 600'', Ceftaz 2''', Albuterol, protonix 40',
SQH, MVI, Vit C, Zinc sulfate 220', Bumex 1'

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: General: NAD, +trached, awake, nods to questions
HEENT: PEERl, dry mm
Neck: supple
+trach
Lungs: Crakels at te base belateral, tolerating PMV very well
Heart: RRR, no m/r/g
Abdom: +BS, NT, ND, soft, obese,
+PEG, Incision clean dry and intact, staples in place, flexseal
in place to protect sacral decubitus clean
Extrem: +1 edema
GU: + foley with clear fluid
Neuro: MAE, PERRL
Skin: no rash
Lymph: no cervical, axillary or inguinal LAD
+rectal tube
Back: sacral decub  clean and intact, needs dressing change wet
to dry [**Hospital1 **]

FAMILY HISTORY: NC

SOCIAL HISTORY: Rehab since admission in [**Month (only) 1096**].  Used to live
with his children, Taxi driver, Divorced, 2 children.
Unspecified septicemia,Pressure ulcer, stage IV,Calculus of gallbladder with other cholecystitis, without mention of obstruction,Hyposmolality and/or hyponatremia,Chronic respiratory failure,Cholangitis,Sepsis,Congestive heart failure, unspecified,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Anemia of other chronic disease,Tracheostomy status,Personal history of Methicillin resistant Staphylococcus aureus,Gastrostomy status,Infection with microorganisms with resistance to multiple drugs,Long-term (current) use of insulin
Septicemia NOS,Pressure ulcer, stage IV,Cholelith w cholecys NEC,Hyposmolality,Chronic respiratory fail,Cholangitis,Sepsis,CHF NOS,Atrial fibrillation,DMII wo cmp nt st uncntr,MRSA elsewhere/NOS,Anemia-other chronic dis,Tracheostomy status,Hx Methicln resist Staph,Gastrostomy status,Inf mcrg rstn oth drg ml,Long-term use of insulin
Admission Date:  [**2114-4-15**]              Discharge Date:   [**2114-4-20**]

Date of Birth:  [**2056-11-6**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Acalculous Cholecystitis and Decubitus Ulcer

Major Surgical or Invasive Procedure:
Open cholecystectomy.
Debridement of sacral decubitus ulcer.


History of Present Illness:
57y M w/ protracted hospital course, initiated with an
admission for pneumonia complicated by respiratory failure
leading to intubation and eventaul tracheostomy in late
[**Month (only) **].
The patient also developed an acalculous cholecystitis, and was
treated with a percutaneous cholecystosomy on [**2114-2-21**] tube given
his debilatated state. In mid/late [**Month (only) **] pt was rehospitalized
for fevers, and elevated WBC.  An U/S on [**3-10**] demonstrated a
thickened galbladder wall without ductal dilatation or
obstruction.  On [**3-12**] his percutaneous cholecystosomy tube was
noted to be dislodged and was replaced. Pt was d/c'd to rehab
facility at this time. On [**4-7**] Pt was transfered from [**Hospital1 **] to
[**Hospital1 **] for fevers of 101 and a WBC of 31. At [**Hospital1 **] a ERCP
w/ sphincterotomy w/stent placement was performed on [**4-9**].  a
tube cholesytogram demonstrated stones in the gallbladder, and
free filling into the duodenum. At this time it was decided the
pt was to be transferred to [**Hospital1 18**] fro further management.


Past Medical History:
PMH:
DM on insulin
Afib
Decubitus ulcers (stage 4)
Pneumonia requiring intubation s/p trach ([**1-22**])
Acalculous cholecystitis ([**1-22**])
CHF (unknown EF)
? CRI
.
PSH:
trach/EG
cholecystostomy tube on [**2-21**], Tube replaced on [**3-12**]


Social History:
Rehab since admission in [**Month (only) 1096**].  Used to live
with his children, Taxi driver, Divorced, 2 children.


Family History:
NC


Physical Exam:
General: NAD, +trached, awake, nods to questions
HEENT: PEERl, dry mm
Neck: supple
+trach
Lungs: Crakels at te base belateral, tolerating PMV very well
Heart: RRR, no m/r/g
Abdom: +BS, NT, ND, soft, obese,
+PEG, Incision clean dry and intact, staples in place, flexseal
in place to protect sacral decubitus clean
Extrem: +1 edema
GU: + foley with clear fluid
Neuro: MAE, PERRL
Skin: no rash
Lymph: no cervical, axillary or inguinal LAD
+rectal tube
Back: sacral decub  clean and intact, needs dressing change wet
to dry [**Hospital1 **]

Pertinent Results:
[**2114-4-19**] 04:50AM BLOOD WBC-17.0* RBC-3.33* Hgb-10.0* Hct-30.0*
MCV-90 MCH-29.9 MCHC-33.2 RDW-15.4 Plt Ct-92*
[**2114-4-19**] 04:50AM BLOOD Neuts-84.2* Lymphs-8.7* Monos-4.7 Eos-2.0
Baso-0.4
[**2114-4-17**] 02:11AM BLOOD PT-15.4* PTT-34.9 INR(PT)-1.4*
[**2114-4-19**] 04:50AM BLOOD Glucose-89 UreaN-12 Creat-0.7 Na-136
K-4.0 Cl-97 HCO3-35* AnGap-8

MICRO:
[**4-15**] BCx pending, UCx no growth(final)
[**4-15**] C diff negative
[**4-16**] Sputum cx - PSEUDOMONAS AERUGINOSA, sparse, sensitive to
cefepime/gent/zosyn/tobra, intermediate: ceftazidine, [**Last Name (un) 2830**],
cipro.
3/2 blood cx P
[**4-17**] peritoneal swab - negative
[**4-17**] gallbladder lumen - 1+ POLYMORPHONUCLEAR LEUKOCYTES. sparse
pseudomonas, staph aureus 2+.
[**4-17**] sacral decub swab - rare GNR, no growth
.
Imaging/Diagnostics:
[**4-15**] CXR: Moderate cardiomegaly with signs of moderate
overhydration. Small lung volumes, no evidence of focal
parenchymal
opacities. No right-sided pleural effusion.
[**4-17**] CXR: LEFT atelectasis and pleural effusion
.
Video swallow study: Pending

Brief Hospital Course:
[**4-15**]: admitted SICU
[**4-16**]: TF restarted. trach mask most of day
[**4-17**]: OR for cholecystectomy/sacral debridement
[**4-18**]: NG tube d/ced, started on TFs, PMV eval started by
speech/swallow, reglan started.
[**4-19**]: PT eval for rehab screening/discharge planning, video
swallow needed by S/S/PMV, decub ulcer dressings changed by
plastics team. Abx d/c'ed.
Hospital course:

The patient was admitted to the SICU [**2114-4-15**]. He was taken to
the OR [**2114-4-17**], he underwent open cholecyctectomy with [**First Name8 (NamePattern2) **]
[**Doctor Last Name 468**] and Sacral decubitus debridment with [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **].
tolerated both procedure without event.

Neuro: The patient received Morphine PRN iv with good effect and
adequate pain control. He also recieved intermettent dose of
versed for anxiety
CV:  The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.

Pulmonary:  The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.  Good pulmonary toilet,The
patient was switched to trach mask 24 hours after the procedure,
the patient upon discharge had passery muir valve in place
conversing appropriately.
GI/GU/FEN:
Post operatively, the patient was made NPO with IVF. The
patient's TF  was advanced to goal  when appropriate, which was
tolerated well Replete with fiber at 90cc/h. and IVF were
adjusted when necessary.  The patient's electrolytes were
routinely followed during this hospitalization, and repleted
when necessary. He was evaluated by Speach and swallow
therapoist, today he passed vedio swallow

ID: The patient's white blood count and fever curves were
closely watched for signs of infection. On addmission he was
evaluated by ID and he was started on Meropenem by ID for
presumed Psedomonas in sputum and Gallblader lumen. The
meropenem was stopped by ID on postop day 3.

Endocrine:  The patient's blood sugar was monitored throughout
this stay; insulin dosing was adjusted accordingly.

Hematology:  The patient's complete blood count was examined
routinely; no transfusions were required during this stay.

Prophylaxis:  The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
OT and PT: Evaluated by OT and PT, the paient deemed to go to
extended facility.
TLD: The jp was removed on postop day 2, discharged to rehab
with Foley, Peg,Flexseal to protecte the dicub wound, and 2
peripheral IV,
At the time of discharge, the patient was doing well, afebrile
with stable vital signs.  The patient was tolerating TF well,
pain was well controlled.

[**4-20**]: Patient discharged to rehabiliation facility in stable
condition.


Medications on Admission:
HISS, Lantus 16u QAM, Imipenem 250'QAM, Ativan 1 Q4P, Zofran 4
Q6P, Morphine 3 Q4P, Florastor 250'', Betapace 40'', Fluconazole
200', Linezolid 600'', Ceftaz 2''', Albuterol, protonix 40',
SQH, MVI, Vit C, Zinc sulfate 220', Bumex 1'


Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) 5,000
unit/mL Solution Injection TID (3 times a day).
2. Sotalol 80 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).

3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Inhalation Q6H (every 6 hours) as needed for
wheezing.
4. Bumetanide 0.5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) 50 mg/5 mL
Liquid PO BID (2 times a day).
6. Senna 8.6 mg Capsule Sig: One (1) Capsule PO BID (2 times a
day) as needed.
7. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
8. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
9. Multivitamin,Tx-Minerals     Tablet Sig: One (1) Tablet PO
DAILY (Daily).
10. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. Famotidine 20 mg IV Q12H
12. Morphine Sulfate 2-4 mg IV Q2H:PRN
13. Ondansetron 4 mg IV Q8H:PRN
14. Lantus 100 unit/mL Solution Sig: Sixteen (16) units sq
Subcutaneous at bedtime.


Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
Open cholecystectomy.
Debridement of sacral decubitus ulcer.


Discharge Condition:
Stable


Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in 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 see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or

back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
JP Drain Care:
-Please look at the site every day for signs of infection
(increased redness, swelling, odor, yellow or bloody discharge,
fever).
-Maintain the bulb deflated to provide adequate suction.
-Note color, consistency, and amount of fluid in drain. Call
doctor if amount increases significantly or changes in
character.
-Be sure to empty the drain frequently.
-You may shower, wash area gently with warm, soapy water.
-Maintain the site clean, dry, and intact.
-Avoid swimming, baths, hot tubs-do not submerge yourself in
water.
-Keep drain attached safely to body to prevent pulling
.
Humalog Insulin Sliding Scale:

Humalog Insulin SC Sliding Scale Q4H

Glucose                   Insulin Dose
0-60mg/dL                 [**2-16**] amp D50
61-120mg/dL               0   Units
121-140mg/dL              3   Units
141-160mg/dL              5   Units
161-180mg/dL              7   Units
181-200mg/dL              9   Units
201-220mg/dL              11   Units
221-240mg/dL              13   Units
241-260mg/dL              15   Units
261-280mg/dL              17   Units
281-300mg/dL              19   Units
301-320mg/dL              21   Units
> 320   mg/dL Notify M.D.

Instructons for NPO Patients: hold glargine
.
Site: R+L gluteus
Description: Pt has old decubitus ulcers stage 3, debrided in OR
[**4-17**], some fibrinous tissue building up.
Care: Moist to Dry gauze, covered with an abdominal pad, changed
[**Hospital1 **], last changed am [**4-20**].
.
Tracheostomy Care per Facility protocol


Followup Instructions:
Please call ([**Telephone/Fax (1) 471**] to schedule a follow-up appointment
with Dr. [**Last Name (STitle) 468**] (Surgery) in 3 weeks.

Please call ([**Telephone/Fax (1) 77878**] to schedule follow-up with Dr. [**First Name (STitle) **]
(Plastics) in 2 weeks



Completed by:[**2114-4-20**]
{'Unspecified septicemia,Pressure ulcer, stage IV,Calculus of gallbladder with other cholecystitis, without mention of obstruction,Hyposmolality and/or hyponatremia,Chronic respiratory failure,Cholangitis,Sepsis,Congestive heart failure, unspecified,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Anemia of other chronic disease,Tracheostomy status,Personal history of Methicillin resistant Staphylococcus aureus,Gastrostomy status,Infection with microorganisms with resistance to multiple drugs,Long-term (current) use of insulin'}


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: Acalculous Cholecystitis and Decubitus Ulcer

PRESENT ILLNESS: 57y M w/ protracted hospital course, initiated with an
admission for pneumonia complicated by respiratory failure
leading to intubation and eventaul tracheostomy in late
[**Month (only) **].
The patient also developed an acalculous cholecystitis, and was
treated with a percutaneous cholecystosomy on [**2114-2-21**] tube given
his debilatated state. In mid/late [**Month (only) **] pt was rehospitalized
for fevers, and elevated WBC.  An U/S on [**3-10**] demonstrated a
thickened galbladder wall without ductal dilatation or
obstruction.  On [**3-12**] his percutaneous cholecystosomy tube was
noted to be dislodged and was replaced. Pt was d/c'd to rehab
facility at this time. On [**4-7**] Pt was transfered from [**Hospital1 **] to
[**Hospital1 **] for fevers of 101 and a WBC of 31. At [**Hospital1 **] a ERCP
w/ sphincterotomy w/stent placement was performed on [**4-9**].  a
tube cholesytogram demonstrated stones in the gallbladder, and
free filling into the duodenum. At this time it was decided the
pt was to be transferred to [**Hospital1 18**] fro further management.

MEDICAL HISTORY: PMH:
DM on insulin
Afib
Decubitus ulcers (stage 4)
Pneumonia requiring intubation s/p trach ([**1-22**])
Acalculous cholecystitis ([**1-22**])
CHF (unknown EF)
? CRI
.
PSH:
trach/EG
cholecystostomy tube on [**2-21**], Tube replaced on [**3-12**]

MEDICATION ON ADMISSION: HISS, Lantus 16u QAM, Imipenem 250'QAM, Ativan 1 Q4P, Zofran 4
Q6P, Morphine 3 Q4P, Florastor 250'', Betapace 40'', Fluconazole
200', Linezolid 600'', Ceftaz 2''', Albuterol, protonix 40',
SQH, MVI, Vit C, Zinc sulfate 220', Bumex 1'

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: General: NAD, +trached, awake, nods to questions
HEENT: PEERl, dry mm
Neck: supple
+trach
Lungs: Crakels at te base belateral, tolerating PMV very well
Heart: RRR, no m/r/g
Abdom: +BS, NT, ND, soft, obese,
+PEG, Incision clean dry and intact, staples in place, flexseal
in place to protect sacral decubitus clean
Extrem: +1 edema
GU: + foley with clear fluid
Neuro: MAE, PERRL
Skin: no rash
Lymph: no cervical, axillary or inguinal LAD
+rectal tube
Back: sacral decub  clean and intact, needs dressing change wet
to dry [**Hospital1 **]

FAMILY HISTORY: NC

SOCIAL HISTORY: Rehab since admission in [**Month (only) 1096**].  Used to live
with his children, Taxi driver, Divorced, 2 children. 

### Response:
{'Unspecified septicemia,Pressure ulcer, stage IV,Calculus of gallbladder with other cholecystitis, without mention of obstruction,Hyposmolality and/or hyponatremia,Chronic respiratory failure,Cholangitis,Sepsis,Congestive heart failure, unspecified,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Anemia of other chronic disease,Tracheostomy status,Personal history of Methicillin resistant Staphylococcus aureus,Gastrostomy status,Infection with microorganisms with resistance to multiple drugs,Long-term (current) use of insulin'}
