CHIEF COMPLAINT: Morbid Obesity

PRESENT ILLNESS: [**Known firstname **] has class III morbid obesity with weight of 278.4 pounds
as of [**2200-2-25**] (his initial screen weight on [**2200-2-3**] was 282.8
pounds), height 66 inches and BMI of 44.9.  His previous weight
loss efforts has included most recently HMR for 26 weeks in [**2198**]
losing 35 pounds that he is still maintaining.  He lost 120
pounds with 38 weeks of HMR in [**2192**] that he kept off for 15
months plus multiple other diets but has not been able to
maintain the weight loss.

MEDICAL HISTORY: PMH
1. hypertension
2. paroxysmal atrial fibrillation for about 10 years
3. obstructive sleep apnea on CPAP
4. hyperlipidemia
5. fatty liver by ultrasound
PSH
none

MEDICATION ON ADMISSION: 1. aspirin 81 mg daily
2. vitamin C 1000 mg daily
3. vitamin B complex daily
4. Biotin 300 mg daily
5. vitamin D 1000 units daily
6. folic acid 0.4 mg daily
7. glucosamine 1500 mg daily
8. Garlic one tablet daily
9. iron 18 mg daily
10. magnesium 400 mg daily
11. potassium gluconate 595 mg daily
12. MVI 1 tab daily
13. Omega-3 fatty acids 1000 mg 200 mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Blood pressure was 162/94, pulse 82, respirations 16 and O2
saturation 96% on room air.  On physical examination [**Known firstname **] was
casually dressed, pleasant and in no distress.  His skin was
warm, dry with no rashes, and there were a few follicular
lesions
on trunk and benign cherry hemangiomas.  Sclerae were anicteric,
conjunctiva clear, pupils were equal round and reactive to
light,
fundi were normal, mucous membranes were moist, tongue was pink
and the oropharynx was without exudates or hyperemia.  Trachea
was in the midline and the neck was supple with no adenopathy,
thyromegaly, carotid bruits or JVD.  Chest was symmetric and the
lungs were clear to auscultation bilaterally with good air
movement.  Cardiac exam was regular rate and rhythm with normal
S1 and S2, no murmurs, rubs or gallops.  The abdomen was obese
but soft and non-tender, non-distended with positive bowel
sounds
and no appreciable masses or incision scars, there was a
moderate
sized ventral hernia that was reducible.  There was no spinal
tenderness or flank pain.  Lower extremities were without edema,
venous insufficiency or clubbing, perfusion was good, pulses
were
intact.  There was no evidence of joint swelling or inflammation
of the joints.  There were no focal neurological deficits and
his
gait was normal.

FAMILY HISTORY: father deceased age 71 of cancer, heart disease and obesity.

SOCIAL HISTORY: tobacco: none
alcohol at least two cocktails one to two times a week
He is employed in the insurance business as a claims adjuster.
He has no children and lives with his spouse age 52.
Morbid obesity,Accidental puncture or laceration during a procedure, not elsewhere classified,Acute posthemorrhagic anemia,Paralytic ileus,Dietary surveillance and counseling,Other ventral hernia without mention of obstruction or gangrene,Unspecified essential hypertension,Atrial fibrillation,Obstructive sleep apnea (adult)(pediatric),Other and unspecified hyperlipidemia,Other chronic nonalcoholic liver disease,Laparoscopic surgical procedure converted to open procedure,Accidental cut, puncture, perforation or hemorrhage during surgical operation,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Other acute postoperative pain,Tachycardia, unspecified
Morbid obesity,Accidental op laceration,Ac posthemorrhag anemia,Paralytic ileus,Dietary surveil/counsel,Ventral hernia NEC,Hypertension NOS,Atrial fibrillation,Obstructive sleep apnea,Hyperlipidemia NEC/NOS,Chronic liver dis NEC,Lap surg convert to open,Acc cut/hem in surgery,Abn react-anastom/graft,Acute postop pain NEC,Tachycardia NOS
Admission Date:  [**2200-4-14**]              Discharge Date:   [**2200-4-21**]

Date of Birth:  [**2150-6-10**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Morbid Obesity

Major Surgical or Invasive Procedure:
[**2200-4-14**]
1. Laparoscopic converted to open approach.
2. Roux-en-Y gastric bypass.
3. Repair of colotomy (transverse colon).
4. Repair of ventral hernias x2.
[**2200-4-15**]
1. Exploratory laparotomy.
2. Endoscopy with clot evacuation.


History of Present Illness:
[**Known firstname **] has class III morbid obesity with weight of 278.4 pounds
as of [**2200-2-25**] (his initial screen weight on [**2200-2-3**] was 282.8
pounds), height 66 inches and BMI of 44.9.  His previous weight
loss efforts has included most recently HMR for 26 weeks in [**2198**]
losing 35 pounds that he is still maintaining.  He lost 120
pounds with 38 weeks of HMR in [**2192**] that he kept off for 15
months plus multiple other diets but has not been able to
maintain the weight loss.


Past Medical History:
PMH
1. hypertension
2. paroxysmal atrial fibrillation for about 10 years
3. obstructive sleep apnea on CPAP
4. hyperlipidemia
5. fatty liver by ultrasound
PSH
none


Social History:
tobacco: none
alcohol at least two cocktails one to two times a week
He is employed in the insurance business as a claims adjuster.
He has no children and lives with his spouse age 52.


Family History:
father deceased age 71 of cancer, heart disease and obesity.

Physical Exam:
Blood pressure was 162/94, pulse 82, respirations 16 and O2
saturation 96% on room air.  On physical examination [**Known firstname **] was
casually dressed, pleasant and in no distress.  His skin was
warm, dry with no rashes, and there were a few follicular
lesions
on trunk and benign cherry hemangiomas.  Sclerae were anicteric,
conjunctiva clear, pupils were equal round and reactive to
light,
fundi were normal, mucous membranes were moist, tongue was pink
and the oropharynx was without exudates or hyperemia.  Trachea
was in the midline and the neck was supple with no adenopathy,
thyromegaly, carotid bruits or JVD.  Chest was symmetric and the
lungs were clear to auscultation bilaterally with good air
movement.  Cardiac exam was regular rate and rhythm with normal
S1 and S2, no murmurs, rubs or gallops.  The abdomen was obese
but soft and non-tender, non-distended with positive bowel
sounds
and no appreciable masses or incision scars, there was a
moderate
sized ventral hernia that was reducible.  There was no spinal
tenderness or flank pain.  Lower extremities were without edema,
venous insufficiency or clubbing, perfusion was good, pulses
were
intact.  There was no evidence of joint swelling or inflammation
of the joints.  There were no focal neurological deficits and
his
gait was normal.


Pertinent Results:
[**2200-2-25**] Abdominal US : 1. Echogenic liver consistent with fatty
infiltration. Other forms of liver disease and more advanced
liver disease including significant hepatic fibrosis/cirrhosis
cannot be excluded on this study.
2. No evidence of cholelithiasis.

[**2200-4-14**] 12:15PM   WBC-13.9*# RBC-4.87 HGB-14.2 HCT-41.7 MCV-86
MCH-29.1 MCHC-34.0 RDW-14.2
[**2200-4-14**] 07:40PM   WBC-19.4* RBC-4.03* HGB-11.5* HCT-33.8*
MCV-84 MCH-28.5 MCHC-34.0 RDW-13.6
[**2200-4-14**] 11:30PM   WBC-19.6* RBC-3.35* HGB-9.8* HCT-28.3* MCV-85
MCH-29.3 MCHC-34.7 RDW-13.7

HCT [**4-19**]:  34.4

Brief Hospital Course:
Mr. [**Known lastname 18799**] was admitted to the hospital and taken to the
Operating Room where he underwent a laparoscopic gastric bypass,
repair of a colotomy in the transverse colon and hernia repair.
( See formal operative note for details )  He tolerated the
procedure well and returned to the PACU in stable condition.  On
the evening of surgery he gradually became tachycardic and pale.
 His pre op hematocrit was 41 and post op drifted to 28.
Based on his symptoms and decreasing hematocrit he was taken
back to the Operating Room for exploration.  No active bleeding
was identified so he then underwent endoscopy which revealed
adherent clot at the GJ anastomosis. ( See formal Operative Note
for details )  He was transfused both intra and post op and
always maintained stable hemodynamics.  His tachycardia
resolved.  Following exploration he was transferred to the SICU
for close monitoring.
He developed paroxysmal atrial fibrillation on post op day #1
and was treated with IV Lopressor.  Over the next 48 hours he
continued to have bursts of PAF eventually controlled with a
Diltiazem drip and repletion of electrolytes.  PAF has been a
pre op problem but so infrequent that he was not on any
medications for rate control.  He was evaluated by the
Cardiology service who recommended Lopressor 25 mg PO BID and
titrate up as needed for rate control while the Diltiazem was
weaned off. Eventually he was controlled with 50mg PO TID.
Following transfer to the surgical floor he continued to make
good progress.  He started a stage 1 diet  and over a 48 hour
period was advanced to stage 3. He developed some gas and
bloating on stage 3 and was eventually switched to a soy based
diet which he tolerated much better. He was up and walking
independently and his hematocrit remained stable.  His surgical
sites were healing well and after a prolonged hospital course he
was discharged to home and will follow up with Dr. [**Last Name (STitle) **]
with in 2 weeks.  At that time his staples will be removed.

Medications on Admission:
1. aspirin 81 mg daily
2. vitamin C 1000 mg daily
3. vitamin B complex daily
4. Biotin 300 mg daily
5. vitamin D 1000 units daily
6. folic acid 0.4 mg daily
7. glucosamine 1500 mg daily
8. Garlic one tablet daily
9. iron 18 mg daily
10. magnesium 400 mg daily
11. potassium gluconate 595 mg daily
12. MVI 1 tab daily
13. Omega-3 fatty acids 1000 mg 200 mg daily


Discharge Medications:
1. Multivitamins     Tablet, Chewable Sig: One (1) Tablet,
Chewable PO twice a day.
2. Roxicet 5-325 mg/5 mL Solution Sig: [**4-14**] ml PO every four (4)
hours as needed for pain.
Disp:*500 ml* Refills:*0*
3. Colace 50 mg/5 mL Liquid Sig: Ten (10) ml PO twice a day.
Disp:*250 ml* Refills:*2*
4. Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
5. Potassium Gluconate 595 (99) mg Tablet Sig: One (1) Tablet PO
once a day: please crush.
6. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a
day: Please crush.
7. Actigall 300 mg Capsule Sig: One (1) Capsule PO twice a day:
Empty capsule in waater and mix.
Disp:*60 Capsule(s)* Refills:*4*
8. Zantac 15 mg/mL Syrup Sig: Ten (10) ml PO twice a day.
Disp:*250 * Refills:*2*
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
1. Hypertension.
2. Morbid obesity.
3. Obstructive sleep apnea.
4. Hyperlipidemia
5. Acute blood loss anemia
6. paroxysmal atrial fibrillation


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


Discharge Instructions:
Discharge Instructions: Please call your surgeon or return to
the emergency department if you develop a fever greater than
101.5, chest pain, shortness of breath, severe abdominal pain,
pain unrelieved by your pain medication, severe nausea or
vomiting, severe abdominal bloating, inability to eat or drink,
foul smelling or colorful drainage from your incisions, redness
or swelling around your incisions, or any other symptoms which
are concerning to you.

Diet: Stay on Stage III diet until your follow up appointment.
Do not self advance diet, do not drink out of a straw or chew
gum.

Medication Instructions:
* Please follow-up with your PCP or Cardiologist regarding
starting Metoprolol for Paroxysmal A-Fib.
Resume your home medications, CRUSH ALL PILLS.
You will be starting some new medications:
1.  You are being discharged on medications to treat the pain
from your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
2. You should begin taking a chewable complete multivitamin with
minerals. No gummy vitamins.
3. You will be taking Zantac liquid 150 mg twice daily for one
month. This medicine prevents gastric reflux.
4. You will be taking Actigall 300 mg twice daily for 6 months.
This medicine prevents you from having problems with your
gallbladder.
5. You should take a stool softener, Colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
6. You must not use NSAIDS (non-steroidal anti-inflammatory
drugs) Examples are Ibuprofen, Motrin, Aleve, Nuprin and
Naproxen. These agents will cause bleeding and ulcers in your
digestive system.

Activity:
No heavy lifting of items [**9-19**] pounds for 6 weeks. You may
resume moderate exercise at your discretion, no abdominal
exercises.

Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.


Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 18800**], RD Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2200-5-1**] 3:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], MD Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2200-5-1**] 3:30



Completed by:[**2200-4-21**]
{'Morbid obesity,Accidental puncture or laceration during a procedure, not elsewhere classified,Acute posthemorrhagic anemia,Paralytic ileus,Dietary surveillance and counseling,Other ventral hernia without mention of obstruction or gangrene,Unspecified essential hypertension,Atrial fibrillation,Obstructive sleep apnea (adult)(pediatric),Other and unspecified hyperlipidemia,Other chronic nonalcoholic liver disease,Laparoscopic surgical procedure converted to open procedure,Accidental cut, puncture, perforation or hemorrhage during surgical operation,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Other acute postoperative pain,Tachycardia, unspecified'}


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: Morbid Obesity

PRESENT ILLNESS: [**Known firstname **] has class III morbid obesity with weight of 278.4 pounds
as of [**2200-2-25**] (his initial screen weight on [**2200-2-3**] was 282.8
pounds), height 66 inches and BMI of 44.9.  His previous weight
loss efforts has included most recently HMR for 26 weeks in [**2198**]
losing 35 pounds that he is still maintaining.  He lost 120
pounds with 38 weeks of HMR in [**2192**] that he kept off for 15
months plus multiple other diets but has not been able to
maintain the weight loss.

MEDICAL HISTORY: PMH
1. hypertension
2. paroxysmal atrial fibrillation for about 10 years
3. obstructive sleep apnea on CPAP
4. hyperlipidemia
5. fatty liver by ultrasound
PSH
none

MEDICATION ON ADMISSION: 1. aspirin 81 mg daily
2. vitamin C 1000 mg daily
3. vitamin B complex daily
4. Biotin 300 mg daily
5. vitamin D 1000 units daily
6. folic acid 0.4 mg daily
7. glucosamine 1500 mg daily
8. Garlic one tablet daily
9. iron 18 mg daily
10. magnesium 400 mg daily
11. potassium gluconate 595 mg daily
12. MVI 1 tab daily
13. Omega-3 fatty acids 1000 mg 200 mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Blood pressure was 162/94, pulse 82, respirations 16 and O2
saturation 96% on room air.  On physical examination [**Known firstname **] was
casually dressed, pleasant and in no distress.  His skin was
warm, dry with no rashes, and there were a few follicular
lesions
on trunk and benign cherry hemangiomas.  Sclerae were anicteric,
conjunctiva clear, pupils were equal round and reactive to
light,
fundi were normal, mucous membranes were moist, tongue was pink
and the oropharynx was without exudates or hyperemia.  Trachea
was in the midline and the neck was supple with no adenopathy,
thyromegaly, carotid bruits or JVD.  Chest was symmetric and the
lungs were clear to auscultation bilaterally with good air
movement.  Cardiac exam was regular rate and rhythm with normal
S1 and S2, no murmurs, rubs or gallops.  The abdomen was obese
but soft and non-tender, non-distended with positive bowel
sounds
and no appreciable masses or incision scars, there was a
moderate
sized ventral hernia that was reducible.  There was no spinal
tenderness or flank pain.  Lower extremities were without edema,
venous insufficiency or clubbing, perfusion was good, pulses
were
intact.  There was no evidence of joint swelling or inflammation
of the joints.  There were no focal neurological deficits and
his
gait was normal.

FAMILY HISTORY: father deceased age 71 of cancer, heart disease and obesity.

SOCIAL HISTORY: tobacco: none
alcohol at least two cocktails one to two times a week
He is employed in the insurance business as a claims adjuster.
He has no children and lives with his spouse age 52. 

### Response:
{'Morbid obesity,Accidental puncture or laceration during a procedure, not elsewhere classified,Acute posthemorrhagic anemia,Paralytic ileus,Dietary surveillance and counseling,Other ventral hernia without mention of obstruction or gangrene,Unspecified essential hypertension,Atrial fibrillation,Obstructive sleep apnea (adult)(pediatric),Other and unspecified hyperlipidemia,Other chronic nonalcoholic liver disease,Laparoscopic surgical procedure converted to open procedure,Accidental cut, puncture, perforation or hemorrhage during surgical operation,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Other acute postoperative pain,Tachycardia, unspecified'}
