CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is a 55-year-old
female transferred to the ED from outside hospital, [**Hospital6 3622**], with question small-bowel obstruction.  Per
report, she has had increasing abdominal pain coinciding with
decreased ostomy output over the past 24 hours.  Per her
husband, she had no vomiting, fevers or chills.

MEDICAL HISTORY: Significant for recurrent fungemia;
Klebsiella pneumonia; VRE UTI; mesenteric ischemia;
respiratory failure; end-stage renal disease, on hemodialysis
since [**2158-8-25**], the patient was actually due for
hemodialysis on the day she presented to the ED; breast CA;
status post chemo and radiation therapy; peripheral vascular
disease; CAD; status post MI x 2; hypercholesterolemia;
hypertension; DM; chronic anemia; gout; depression.

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Acute vascular insufficiency of intestine,Unspecified peritonitis,Diabetes with renal manifestations, type I [juvenile type], not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Hypotension, unspecified,Pure hypercholesterolemia,Gout, unspecified,Ileostomy status,Peritoneal adhesions (postoperative) (postinfection),Personal history of malignant neoplasm of breast,Old myocardial infarction,Below knee amputation status
Ac vasc insuff intestine,Peritonitis NOS,DMI renl nt st uncntrld,Hyp kid NOS w cr kid V,End stage renal disease,Hypotension NOS,Pure hypercholesterolem,Gout NOS,Ileostomy status,Peritoneal adhesions,Hx of breast malignancy,Old myocardial infarct,Status amput below knee
Admission Date: [**2158-12-20**]        Discharge Date: [**2158-12-23**]

Date of Birth:  [**2103-6-1**]        Sex:  F

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


REASON FOR ADMISSION:  The patient was sent to the emergency
room with complaints of abdominal pain, decreased colostomy
output x 24 hours and increased abdominal pain.  Denied
vomiting, fevers or chills.  She was seen at an outside
hospital, and reportedly had a small-bowel obstruction.

HISTORY OF PRESENT ILLNESS:  The patient is a 55-year-old
female transferred to the ED from outside hospital, [**Hospital6 3622**], with question small-bowel obstruction.  Per
report, she has had increasing abdominal pain coinciding with
decreased ostomy output over the past 24 hours.  Per her
husband, she had no vomiting, fevers or chills.

PAST MEDICAL HISTORY:  Significant for recurrent fungemia;
Klebsiella pneumonia; VRE UTI; mesenteric ischemia;
respiratory failure; end-stage renal disease, on hemodialysis
since [**2158-8-25**], the patient was actually due for
hemodialysis on the day she presented to the ED; breast CA;
status post chemo and radiation therapy; peripheral vascular
disease; CAD; status post MI x 2; hypercholesterolemia;
hypertension; DM; chronic anemia; gout; depression.

PAST SURGICAL HISTORY:  Extended right colectomy with
ileostomy in [**2158-4-24**], renal transplant in [**2143**],
transplant nephrectomy in [**2158-10-25**], tracheostomy in
[**2158-4-24**], breast lumpectomy, left BKA, right fem-[**Doctor Last Name **] and
popliteal-to-dorsalis pedis.

PHYSICAL EXAMINATION:  Temperature 98.6, heart rate 101, BP
107/53, 93% on room air.  The patient was awake, in moderate
distress, with regular rhythm and tachycardia.  Lungs were
clear bilaterally with tachypnea.  Abdomen was firm,
distended, tympanitic, and diffusely tender to palpation; but
no apparent peritoneal signs.  No masses or hernias.  Ostomy
appeared pink.  There was brown fluid in the ostomy bag
without air.  Warm extremities.

LABORATORIES ON ADMISSION:  White count 14, hematocrit 32.1,
platelet count 115.  Sodium 137, potassium 5.6, chloride 107,
CO2 of 21, BUN 32, creatinine 2, glucose 102, potassium was
3.8 after repletion.  Lactate was 3.7.  INR was 1.6 in the
ED.

HOSPITAL COURSE:  An NG tube was placed at the outside
hospital.  An admission, a chest x-ray demonstrated bilateral
large pleural effusions and CHF.  A KUB demonstrated mildly
dilated loops of small bowel, likely representing early or
partial obstruction versus ileus with a moderate right
pleural effusion.  An abdominal CT with and without contrast
was done.  This demonstrated bowel ischemia with pneumatosis
of a loop of small bowel in the right lower quadrant.  The
assessment of the SMA was severely limited due to heavy
calcification and the presence or absence of clot in the
superior mesenteric artery, which could not be evaluated.
There was generalized bowel dilatation consistent with ileus.
The evaluation of the gallbladder was limited due to
artifact.  Increased bilateral pleural effusions with
bilateral lower lobe collapse was noted, increased from prior
study with mild edema.  Endotracheal tube was terminating at
the level of thoracic inlet with possible
tracheobroncomalacia, and atrophic kidneys were noted.

A transplant surgical consult was obtained.  The patient was
seen by Dr. [**First Name (STitle) **] [**Name (STitle) **].  The patient was taken to the OR
for urgent laparotomy.  She underwent resection of the
ischemic portion of the small bowel under general anesthesia
with minimal EBL.  Dr. [**First Name (STitle) **] [**Name (STitle) **], assisted by Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 21082**], performed the surgery.  Please see operative
report for further details.  The abdomen was left open and
was covered with towels and Ioban.  The patient was
transferred to the ICU after the procedure.  A nephrology
consult was obtained.  The patient was intubated in the
surgical intensive care unit, on a fentanyl drip and a
Levophed drip.  A heparin drip was also instituted per
vascular for mesenteric ischemia.  She was transfused with a
unit of packed red blood cells, and CV VHD was initiated.

On postop day #1, the patient still required pressure support
with multiple fluid boluses for a low blood pressure.  The
patient remained on ventilator.  She was taken back to the OR
on postop day #1 by Dr. [**First Name (STitle) **] [**Name (STitle) **] for exploratory
laparotomy with small-bowel resection for ischemic bowel.  On
the previous day she had 60 cm of gangrenous distal jejunum,
which was resected.  The remaining distal bowel looked dusky.
She was brought back for a second look.  Please see operative
report for details.  It was felt that the patient either had
emboli or low-flow situation.  Vascular surgery was
consulted.  Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] was consulted, and the
patient was scheduled for an angiogram.  She continued to
receive aggressive resuscitation.  It was noted that the
superior mesenteric artery was palpable with a strong
Doppler.  The patient continued on CV VHD.  Systolic blood
pressures remained in the 90s on Levophed.  She received
ultrafiltration, IV antibiotics including vancomycin,
meropenem, Flagyl and fluconazole maintained.  Blood cultures
were negative.  A swab of the abdomen on [**5-20**] demonstrated
Enterococcus sensitive to vancomycin, resistant to ampicillin
and penicillin.  Repeat blood culture on the 28th was
negative.

On [**12-22**], the patient presented for her third
laparotomy for ischemic bowel.  Prior to this, vascular
surgery performed an angiogram with stenting of the proximal
superior mesenteric artery stenosis.  The patient underwent
reexploration of the abdomen with creation of an ileostomy
and closure of the abdomen for ischemic bowel.  [**Month (only) **] was
again Dr. [**First Name (STitle) **] [**Name (STitle) **], assisted by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 21082**] and
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **].  Intraop findings demonstrated the
remaining 150 cm of proximal small bowel was pink and viable
upon exploration.  The patient returned to the surgical
intensive care unit.  While in the surgical intensive care
unit, she remained intubated.  CV VHD was reinstituted.
Systolic blood pressure remained in the 110s on pressors.
She remained on a propofol and fentanyl drip.  On postop days
#2, 1 and 0, the patient remained sedated.  The patient was
in a sinus rhythm with sinus tachycardia with PVCs and PACs.
The patient went into rapid AFib with a rate up to 128.
Systolic BP dropped down to 88 to 94 with a MAP in the low
50s.  Levophed was titrated back to 0.3, and a STAT EKG was
done.  The patient was noted to be in AFib with a rapid
ventricular response.  She was given 25 grams of albumin with
no response.  Cardiology was consulted, and the patient was
started on an amiodarone drip.  The patient converted back to
a normal sinus rhythm with PACs and PVCs.  She continued on a
calcium gluconate drip and potassium drip, per CRRT protocol.
The patient was noted be hypothermic with a temperature of
35.1.  A bear-hugger was placed on with a temperature up to
36.  She remained on IV heparin.  The patient's lactate was
2.3.  The patient remained on A/C ventilatory support.
Respiratory rate was down from 20 to 16.  ABG demonstrated
moderately severe partially compensated metabolic acidosis
with good oxygenation.

The patient coded in the OR on [**12-22**].  She remained on
Levophed and amiodarone.  Systolic dropped down to the 40s.
She reacted to several chest compressions.  In the OR, the
patient had loss of ectopy.  She was given an amiodarone
drip.  Her abdomen was closed, and the ileostomy was
completed.  On [**12-23**] - postop day #[**1-25**] - the patient
remained on meropenem, Flagyl, fluconazole and vancomycin.
Blood pressure continued to run on the low side, 97/48 to
113/54, with a heart rate of 117, respiratory rate of 22.
She was on assist control.  She reverted to sinus rhythm.
Digoxin was started.

On [**2158-12-23**], the patient's systolic blood pressure
dropped down into the 70s despite pressure support.  Her
stoma appeared dusky, and the patient was evaluated by Dr.
[**First Name (STitle) **].  After discussion with the patient's husband and
family, they decided to remove life support.  The patient
expired on [**2158-12-23**].



                        [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 4841**]

Dictated By:[**Name8 (MD) 4664**]
MEDQUIST36
D:  [**2159-1-11**] 17:48:52
T:  [**2159-1-11**] 19:52:59
Job#:  [**Job Number 21083**]
{'Acute vascular insufficiency of intestine,Unspecified peritonitis,Diabetes with renal manifestations, type I [juvenile type], not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Hypotension, unspecified,Pure hypercholesterolemia,Gout, unspecified,Ileostomy status,Peritoneal adhesions (postoperative) (postinfection),Personal history of malignant neoplasm of breast,Old myocardial infarction,Below knee amputation status'}


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: The patient is a 55-year-old
female transferred to the ED from outside hospital, [**Hospital6 3622**], with question small-bowel obstruction.  Per
report, she has had increasing abdominal pain coinciding with
decreased ostomy output over the past 24 hours.  Per her
husband, she had no vomiting, fevers or chills.

MEDICAL HISTORY: Significant for recurrent fungemia;
Klebsiella pneumonia; VRE UTI; mesenteric ischemia;
respiratory failure; end-stage renal disease, on hemodialysis
since [**2158-8-25**], the patient was actually due for
hemodialysis on the day she presented to the ED; breast CA;
status post chemo and radiation therapy; peripheral vascular
disease; CAD; status post MI x 2; hypercholesterolemia;
hypertension; DM; chronic anemia; gout; depression.

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Acute vascular insufficiency of intestine,Unspecified peritonitis,Diabetes with renal manifestations, type I [juvenile type], not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Hypotension, unspecified,Pure hypercholesterolemia,Gout, unspecified,Ileostomy status,Peritoneal adhesions (postoperative) (postinfection),Personal history of malignant neoplasm of breast,Old myocardial infarction,Below knee amputation status'}
