CHIEF COMPLAINT: 

PRESENT ILLNESS: This is an 82-year-old male with
a history of alcohol abuse and atrial fibrillation who was
found down by a neighbor on [**2166-5-30**] and subsequently
taken to the [**Hospital3 8834**] Emergency Department
for further evaluation and management.

MEDICAL HISTORY: 1.  Atrial fibrillation.
2.  Hypertension.
3.  Alcohol abuse with a history of associated withdrawal
seizures.
4.  Status post bilateral cataract surgery.

MEDICATION ON ADMISSION: Home medications included
Coumadin, digoxin, hydrochlorothiazide, Flomax, and atenolol.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: An extensive past smoking history.  A
history of alcohol abuse.  A history of intravenous drug use.
Subdural hemorrhage following injury without mention of open intracranial wound, with loss of consciousness of unspecified duration,Closed fracture of acetabulum,Congestive heart failure, unspecified,Other specified intestinal obstruction,Other pulmonary embolism and infarction,Other postoperative infection,Atrial fibrillation,Chronic obstructive asthma, unspecified,Unspecified protein-calorie malnutrition
Subdural hemorr-coma NOS,Fracture acetabulum-clos,CHF NOS,Intestinal obstruct NEC,Pulm embol/infarct NEC,Other postop infection,Atrial fibrillation,Chronic obst asthma NOS,Protein-cal malnutr NOS
Admission Date:  [**2166-5-31**]       Discharge Date:  [**2166-6-27**]


Service:

ADDENDUM:  On hospital day number five the patient underwent
a cecostomy placement secondary to the above mentioned
indications.  The patient tolerated the procedure well and
was seen post procedure by the Gold Surgery team who assessed
the patient in stable condition status post cecostomy and
chronic atrial fibrillation and the patient continued to do
well on postoperative day one where the patient was continued
on Levofloxacin and Flagyl as well as Diltiazem.  His vital
signs were stable and he was afebrile.  His postoperative
electrolytes were remarkable for a potassium of 3.7 and a
magnesium of 1.6, which were repleted.  The patient's belly
postoperatively was distended and appropriately tender and
the patient was continued NPO on postoperative day one.  On
postoperative day one the patient was also seen by the
orthopedics consult service who left recommendations for
nonoperative management.  The recommendations were for two
weeks nonweight bearing right lower extremity, out of bed to
chair followed by three months of touch down weight bearing
with a knee immobilizer and post dislocation precautions.
The orthopedic service also recommended anticoagulation,
however, this suggestion was to be considered in light of the
patient's history of subdural hematoma and other surgical
considerations.  The orthopedics service requested follow up
on this patient with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1022**] in his clinic the [**Location (un) 86**]
Orthopedic Group in approximately two weeks.

The medicine attending on the [**6-5**] commented that the
patient had done well after the surgery, which he had
tolerated well.  The patient received 2 units of packed red
blood cells and was in rapid atrial fibrillation.  On
postoperative day two the patient remained stable status post
cecotomy.  The Diltiazem drip was reduced to 15 and as the
patient had been in stable condition disposition to the
Vascular Intensive Care Unit floor was considered.  On the
next postoperative day the nutrition service was consulted to
provide recommendations in regard to the patient's calorie
and protein intake requirement.  Their recommendation was to
initiate total parenteral nutrition at 1.8 liters containing
210 grams of dextrose, 112 grams of amino acid and 40 grams
of fat.  Assuming that the patient's blood glucoses remained
within normal limits on this regimen the total parenteral
nutrition could be advanced to the goal rate.  On
postoperative day two the patient continued to be in stable
condition and in accordance with routine post surgical care
the patient's Foley catheter was discontinued.  A upright
kidney, ureters and bladder sinogram was also obtained,
however, this study was not able to elucidate the cause of
the patient's continuing abdominal distention.

On postoperative day three the patient continued to be in
stable condition and was given 20 mg of intravenous Lasix in
an effort to effect gentle diuresis in light of the patient's
recent surgery and likely volume overload given the
appearance of the patient's most recent chest x-ray as well
as his lung examination.  In light of the patient's
concerning persistent abdominal distention the
gastroenterology service was consulted on [**2166-6-7**].  The
recommendation of the gastroenterology service was for
decompressive colonoscopy and attempted decompressive tube
placement.  This procedure was performed by the
gastroenterology service and after the procedure it was
suggested by the gastroenterology service that the cecostomy
tube could be flushed vigorously to ensure that it was not
kinked or coiled in the cecum.  On the following day the
colonoscopy report taken from the day prior showed normal
mucosa without evidence of ischemia, cecostomy tube located
in the cecum perhaps coiled.  The tube flushed easily with
water to verify the identity of the tube.  The colonoscopist
also commented on their inability to place a decompressive
tube successfully.  Over the next two postoperative days the
patient continued to improve, however, his abdominal
distention continued to be relatively stable and persistent.

On postoperative day six a follow up KUB was obtained, which
did not show a clear cause of the patient's continued
distention.  On postoperative day number seven the patient
was continued on total parenteral nutrition, given another
dose of intravenous Lasix to which he diuresed well and he
was transferred to the floor on a telemetry bed in stable
condition.  Once on the floor the remainder of the [**Hospital 228**]
hospital course was marked by gradual return of bowel
function and reduction in abdominal distention.  Specifically
the patient tolerated anterograde Fleets enemas times two for
at least two consecutive days after which the patient's bowel
function appeared to return at which time the patient moved a
bowel spontaneously.  Other events during the patient's
tenure on the floor telemetry includes at least three
separate instances of acute shortness of breath generally
related to the patient's refusal to receive his standing
orders for Albuterol and Atrovent nebulizer treatments.  As
the patient has had multiple medical issues and due to his
advanced age of 82 the patient received extensive workups for
each of these episodes, which were successful in ruling out
myocardial infarction as well as new pulmonary embolism as
sources of the patient's acute shortness of breath.  Of note,
the patient has a long history of pulmonary embolus including
involving the upper, middle and lower lobes that was seen on
CT scan taken in the context of acute shortness of breath.
However, the appearance of these pulmonary emboli did not
appear to have acutely worsened and therefore conclusively
established as the cause of the patient's shortness of
breath.  The patient's episodes of shortness of breath were
clearly episodic and were relieved by nebulizer treatments.

Also of note the patient had positive cultures constituting
the following.  He had at least one blood culture growing out
staph aureus as well as coag negative staph.  In addition,
the patient had a urine culture that was positive for
Levofloxacin resistant, but Vancomycin sensitive
enterococcus.  In light of these culture data the patient was
started on Vancomycin intravenous at a dosage of 750 mg
b.i.d. on [**2164-6-20**].  Largely to treat the patient's coag
negative staph in his blood culture this regimen was intended
to continue for a 14 day course per Dr. [**First Name (STitle) 2819**].

Another issue for the patient on the floor was an acute
attack of pseudogout for which the rheumatology service was
consulted.  In accordance with the recommendations of that
service the patient was started on Vioxx and Colchicine for a
short course.  Prior to his discharge it was determined by
discussion with the rheumatology service that the Colchicine
could be discontinued after a few days of the patient's
discharge to rehabilitation and it was further decided that
the patient's Vioxx could be discontinued on the day of
discharge.  The patient's final other significant events
during his stay on the floor was the closure of his mid
abdominal wound, which had been treated for several day using
a V.A.C. sponge dressing.  This was effected approximately
four days prior to the patient's discharge and by the time of
the patient's discharge the wound was seen to be well
approximated with no breakdown erythema or signs of
infection.  The patient was discharged on [**2166-6-27**] with
appropriate instructions for follow up for the following
services, orthopedic surgery, rheumatology and
gastroenterology.  In addition appropriate instructions
regarding his medications, activity as well as dressing
changes was given to the rehabilitation center.

DISCHARGE CONDITION:  The patient was in good condition at
the time of discharge.

DISCHARGE STATUS:  Approved.






                            [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.  [**MD Number(1) 19318**]

Dictated By:[**Last Name (NamePattern1) 20242**]
MEDQUIST36

D:  [**2166-6-27**]  08:55
T:  [**2166-6-27**]  09:33
JOB#:  [**Job Number 20243**]


Admission Date:  [**2166-5-31**]       Discharge Date:  [**2166-6-27**]


Service:  General Surgery

HISTORY OF PRESENT ILLNESS:  This is an 82-year-old male with
a history of alcohol abuse and atrial fibrillation who was
found down by a neighbor on [**2166-5-30**] and subsequently
taken to the [**Hospital3 8834**] Emergency Department
for further evaluation and management.

At [**Hospital3 1280**] Hospital, the patient received a full trauma
workup including a cervical spine film demonstrating
degenerative joint disease, a computed tomography of the
pelvis which demonstrated a right acetabular fracture, and
head computed tomography which revealed a bilateral subdural
hematoma right and subacute.

At baseline, the patient reportedly oriented times one (per
his daughter) and was noted to be similarly oriented in the
[**Hospital3 1280**] Hospital Emergency Department.  By report, the
patient was also noted to be in rapid atrial fibrillation and
was subsequently begun on a diltiazem drip prior to transfer
to [**Hospital1 69**] for further
evaluation and management.

PAST MEDICAL HISTORY:
1.  Atrial fibrillation.
2.  Hypertension.
3.  Alcohol abuse with a history of associated withdrawal
seizures.
4.  Status post bilateral cataract surgery.

MEDICATIONS ON ADMISSION:  Home medications included
Coumadin, digoxin, hydrochlorothiazide, Flomax, and atenolol.

ALLERGIES:  No known drug allergies.

SOCIAL HISTORY:  An extensive past smoking history.  A
history of alcohol abuse.  A history of intravenous drug use.

PHYSICAL EXAMINATION ON PRESENTATION:  Physical examination
on arrival to the Emergency Department revealed blood
pressure was 130/86, heart rate was 79, respiratory rate was
27, and oxygen saturation was 99% on 3 liters.  The patient's
general examination revealed an elderly gentleman in no
apparent distress.  Head, eyes, ears, nose, and throat
examination revealed no jugular venous distention.  Mucous
membranes were moist.  No lymphadenopathy.  The neck was
noted to be stiff without tenderness at the midline.  Pupils
were noted to be equal, round, and reactive to light and
accommodation with surgical changes.  Extraocular movements
were noted to be intact.  Cardiovascular examination
demonstrated an irregularly irregular heart rate with normal
first heart sounds and second heart sounds.  Respiratory
examination demonstrated diffuse expiratory wheezes
bilaterally.  The patient's abdomen was noted to be soft and
distended with positive bowel sounds.  Tenderness in the
right upper quadrant and left lower quadrant.  No rebound was
noted, but voluntary guarding was noted.  Extremity
examination demonstrated warm and well perfused extremities,
and no evidence of clubbing, cyanosis, or edema.  Neurologic
examination demonstrated cranial nerves II through XII were
grossly intact.  Strength was noted to be [**5-26**] bilaterally.
The patient was noted to be oriented times one with
cerebellar ataxia.  Deep tendon reflexes were noted to be 1+
in all extremities.  The toes were downgoing.

PERTINENT LABORATORY VALUES ON PRESENTATION:  Laboratory
studies on admission revealed sodium was 128, potassium was
4.5, chloride was 86, bicarbonate was 24, blood urea nitrogen
was 27, creatinine was 1.3, and blood glucose was 121.  White
blood cell count was 21.8, hematocrit was 35.9, and platelets
were 199.  Creatine kinase was 1395.  MB was 24.  MB index
was noted to be 1.7.  Troponin was less than 0.3.  Calcium
was 9.1, magnesium was 1.9, and phosphate was 3.3.
Prothrombin time was 14.8, partial thromboplastin time was
29, and INR was 1.4.

PERTINENT RADIOLOGY/IMAGING:  A computed tomography of the
head demonstrated a small right parietal subdural hematoma
and right cerebellar encephalomalacic changes; consistent
with chronic microvascular infarction.

A computed tomography of the pelvis and abdomen demonstrated
a colonic adhesion versus stricture with acute narrowing at
the splenic flexure and proximal colonic dilatation as well
as a comminuted/horizontal fracture of the right acetabular
roof and associated hematoma.

HOSPITAL COURSE:  On [**2166-5-31**] the patient was admitted to
the Medical Intensive Care Unit under the direction of Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].

A Neurosurgery consultation was obtained.  Given the nature
of the patient's imaging studies, it was believed that his
hematoma represented a subacute event, and close monitoring
was recommended.

An Orthopaedic consultation was also obtained to evaluate the
patient's acetabular fracture.  Initial recommendations
advised conservative management with knee immobilization and
posterior dislocation precautions with nonweightbearing
status and close clinical monitoring with plans for
consideration of operative repair.

The patient was continued on intravenous diltiazem to achieve
rate control for his rapid atrial fibrillation with good
success.  An initial evaluative electrocardiogram was
obtained which demonstrated 1-mm ST depressions in leads V4
through V6.  A rule out myocardial infarction protocol was
therefore conducted; for which the patient demonstrated no
evidence of acute myocardial infarction as demonstrated by
serial clinical examinations as well as cardiac enzymes
studies.

Given the patient's reported history of alcohol abuse, the
patient was placed on a CIWA protocol Ativan schedule with
good affect.

Given the findings of the patient's abdominal computed
tomography in conjunction with increasing complaints of
abdominal distention, a Gastroenterology consultation was
obtained who recommended the patient for colonoscopy.

A colonoscopy performed on [**2166-6-1**] demonstrated ischemic
proctitis, previous side-to-end colocolonic anastomosis of
the sigmoid colon, diverticulosis of the sigmoid colon, as
well as a massively dilated air-filled colon prior to air
insufflation.  A decompression tube was placed successfully
in the right colon; which, in conjunction with the patient's
previously placed nasogastric tube, provided suitable
decompression.

Ultimately patient underwent an open cecostomy tube placement.
Patients post op course from this procedure was punctuated by
delayed bowel function secondary to small bowel obstruction and
constipation. A Surgical wound infection requiring open drainage,
dressing changes and ultimately delayed primary closure at the
bedside. The patient also suffered bilateral small pulmonary
emboli requiring anticoagulation, CHF requiring gentle diuresis,
rapid atrial fibrillation requiring intravenous rate control
medication and monitoring, a urinary tract infection and positive
blood cultures in the setting of central access requiring
intravenous antibiotics.

Mr. [**Known lastname 20240**] gradually improved, the cecostomy was clamped and he
began to have spontaneous bowel movements and began to eat.  The
TPN was weaned and then more acutely discontinued secondary to
PICC line displacment without replacement.


Discharge Diagnoses:

1. Acetabular Fracture
2. [**Last Name (un) 3696**] Syndrome requiring Cecostomy Tube Placement
3. Surgical Wound Infection requiring open drainage and dressing
changes
4. Pulmonary Emboli
5. Urinary Tract Infection with enterococcus
6. Atrial Fibrillation with Rapid Ventricular Response
7. COPD/Asthma
8. Congestive Heart Failure
9. Malnutrition
10. EtOH Abuse
11. Constipation
12. Positive blood cultures for Staph aureus and Coag Neg. Staph


[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.  [**MD Number(1) 19318**]

Dictated By:[**Last Name (NamePattern1) 1053**]
MEDQUIST36

D:  [**2166-6-27**]  04:18
T:  [**2166-6-27**]  07:57
JOB#:  [**Job Number 20241**]
{'Subdural hemorrhage following injury without mention of open intracranial wound, with loss of consciousness of unspecified duration,Closed fracture of acetabulum,Congestive heart failure, unspecified,Other specified intestinal obstruction,Other pulmonary embolism and infarction,Other postoperative infection,Atrial fibrillation,Chronic obstructive asthma, unspecified,Unspecified protein-calorie malnutrition'}


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 an 82-year-old male with
a history of alcohol abuse and atrial fibrillation who was
found down by a neighbor on [**2166-5-30**] and subsequently
taken to the [**Hospital3 8834**] Emergency Department
for further evaluation and management.

MEDICAL HISTORY: 1.  Atrial fibrillation.
2.  Hypertension.
3.  Alcohol abuse with a history of associated withdrawal
seizures.
4.  Status post bilateral cataract surgery.

MEDICATION ON ADMISSION: Home medications included
Coumadin, digoxin, hydrochlorothiazide, Flomax, and atenolol.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: An extensive past smoking history.  A
history of alcohol abuse.  A history of intravenous drug use. 

### Response:
{'Subdural hemorrhage following injury without mention of open intracranial wound, with loss of consciousness of unspecified duration,Closed fracture of acetabulum,Congestive heart failure, unspecified,Other specified intestinal obstruction,Other pulmonary embolism and infarction,Other postoperative infection,Atrial fibrillation,Chronic obstructive asthma, unspecified,Unspecified protein-calorie malnutrition'}
