CHIEF COMPLAINT: abdominal pain

PRESENT ILLNESS: The patient is a 82F otherwise healthy who presented to
[**Hospital 8**] hospital on [**2129-9-2**] via EMS with abdominal pain,
hypotension, nausea, and emesis. Upon arrival to the ED she was
tachycardic and complaining of lower abdominal pain with
persistent loose stools, emesis, and dysuria. She denied any
chest pain, SOB, or other complaints. She remained hypotensive
despite fluid resuscitation and blood products in the ER. CT
scan
was performed that showed hemoperitoneum with extravasation of
contrast concerning for acute inta-abdominal bleed.

MEDICAL HISTORY: PMH: HLD, osteoporosis, compression L1 fx - received steroid
shots

MEDICATION ON ADMISSION: MVI, calcium

ALLERGIES: Tetanus&Diphtheria Toxoid / Pneumovax 23

PHYSICAL EXAM: Temp 97.3   HR 124   BP 107/60   RR 21   O2 sat 100% CMV FIO2
100%, PEEP 8
GEN: Intubated/sedated
HEENT: anicteric
CV: RRR
Lungs: clear anteriorly, no distress
ABD: soft, Open abdomen covered with towels and ioban, JPx2
exiting from inferior portion of wound, with serosanguinous
drainage
EXT: warm well perfused, palpable DP/PT bilaterally

FAMILY HISTORY: non contributory

SOCIAL HISTORY: Denies smoking, ETOH, drug use
Hemorrhage complicating a procedure,Acute vascular insufficiency of intestine,Perforation of intestine,Acute kidney failure, unspecified,Hemoperitoneum (nontraumatic),Acidosis,Other and unspecified coagulation defects,Hypotension, unspecified,Delirium due to conditions classified elsewhere,Acute posthemorrhagic anemia,Other ascites,Urinary tract infection, site not specified,Other and unspecified hyperlipidemia,Osteoporosis, unspecified,Diarrhea
Hemorrhage complic proc,Ac vasc insuff intestine,Perforation of intestine,Acute kidney failure NOS,Hemoperitoneum,Acidosis,Coagulat defect NEC/NOS,Hypotension NOS,Delirium d/t other cond,Ac posthemorrhag anemia,Ascites NEC,Urin tract infection NOS,Hyperlipidemia NEC/NOS,Osteoporosis NOS,Diarrhea
Admission Date:  [**2129-9-3**]              Discharge Date:   [**2129-9-15**]

Date of Birth:  [**2047-1-27**]             Sex:   F

Service: SURGERY

Allergies:
Tetanus&Diphtheria Toxoid / Pneumovax 23

Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
abdominal pain

Major Surgical or Invasive Procedure:
[**2129-9-6**]
Closure of abdominal wall, irrigation of the abdominal cavity

[**2129-9-6**]
Removal of lap pad from previous surgery and enterocolic
anastomosis

[**2129-9-4**]
1. Re-exploration with right colectomy and no anastomosis.
2. Placement of negative-pressure dressing

[**2129-9-3**]
Reopen of recent laparotomy with exploration of the abdomen and
packing of the pelvis.


History of Present Illness:
The patient is a 82F otherwise healthy who presented to
[**Hospital 8**] hospital on [**2129-9-2**] via EMS with abdominal pain,
hypotension, nausea, and emesis. Upon arrival to the ED she was
tachycardic and complaining of lower abdominal pain with
persistent loose stools, emesis, and dysuria. She denied any
chest pain, SOB, or other complaints. She remained hypotensive
despite fluid resuscitation and blood products in the ER. CT
scan
was performed that showed hemoperitoneum with extravasation of
contrast concerning for acute inta-abdominal bleed.

The patient was taken emergently to the operating room on
[**2129-9-2**] for exlap. She was noted to have several mesenteric
hematomas, but no obvious bleeding source. 3 liters of blood was
evacuated from the abdomen and it was packed with towels and
surgicel and the abdomen was left open. Postoperatively, the
patient required NEO gtt to maintain MAP > 60, but this was
discontinued in the am [**9-3**]. She was maintained intubated and
sedated with fentanyl/versed on CMV ventilator support. In total
the patient received 6 units PRBCs, 2 units FFP, 1 cryo. She
started to become coagulopathic with decrease in plts,
increasing
INR, and decreasing fibrinogen. She was transferred to [**Hospital1 18**] for
further management.


Past Medical History:
PMH: HLD, osteoporosis, compression L1 fx - received steroid
shots

PSH: none


Social History:
Denies smoking, ETOH, drug use


Family History:
non contributory

Physical Exam:
Temp 97.3   HR 124   BP 107/60   RR 21   O2 sat 100% CMV FIO2
100%, PEEP 8
GEN: Intubated/sedated
HEENT: anicteric
CV: RRR
Lungs: clear anteriorly, no distress
ABD: soft, Open abdomen covered with towels and ioban, JPx2
exiting from inferior portion of wound, with serosanguinous
drainage
EXT: warm well perfused, palpable DP/PT bilaterally


Pertinent Results:
[**2129-9-15**] 05:07AM BLOOD WBC-13.2* RBC-2.98* Hgb-8.8* Hct-27.5*
MCV-92 MCH-29.5 MCHC-31.9 RDW-16.6* Plt Ct-429
[**2129-9-14**] 05:03AM BLOOD WBC-18.0* RBC-3.00* Hgb-8.8* Hct-27.5*
MCV-92 MCH-29.4 MCHC-32.1 RDW-16.0* Plt Ct-359
[**2129-9-13**] 05:20AM BLOOD WBC-20.5* RBC-3.02* Hgb-9.3* Hct-26.8*
MCV-89 MCH-30.7 MCHC-34.6 RDW-16.2* Plt Ct-321
[**2129-9-3**] 01:26PM BLOOD WBC-3.1* RBC-2.62* Hgb-8.2* Hct-22.4*
MCV-86 MCH-31.3 MCHC-36.6* RDW-14.9 Plt Ct-90*
[**2129-9-10**] 01:45AM BLOOD Neuts-92.9* Lymphs-5.2* Monos-1.7*
Eos-0.1 Baso-0.1
[**2129-9-15**] 05:07AM BLOOD Plt Ct-429
[**2129-9-7**] 02:06AM BLOOD PT-15.4* PTT-23.3 INR(PT)-1.3*
[**2129-9-15**] 05:07AM BLOOD Glucose-110* UreaN-10 Creat-0.8 Na-139
K-4.0 Cl-112* HCO3-18* AnGap-13
[**2129-9-14**] 05:03AM BLOOD Glucose-130* UreaN-13 Creat-0.9 Na-136
K-3.4 Cl-107 HCO3-18* AnGap-14
[**2129-9-3**] 01:26PM BLOOD Glucose-95 UreaN-14 Creat-1.2* Na-141
K-3.9 Cl-116* HCO3-20* AnGap-9
[**2129-9-6**] 01:46AM BLOOD ALT-118* AST-113* AlkPhos-48 TotBili-0.8
[**2129-9-5**] 01:54AM BLOOD ALT-120* AST-140* AlkPhos-30* TotBili-1.2
[**2129-9-15**] 05:07AM BLOOD Calcium-7.6* Phos-3.7 Mg-1.9
[**2129-9-14**] 05:03AM BLOOD Calcium-7.9* Phos-2.6* Mg-1.8
[**2129-9-4**] 11:54AM BLOOD CEA-<1.0 AFP-2.2
[**2129-9-9**] 06:01AM BLOOD Vanco-11.8
[**2129-9-8**] 03:12AM BLOOD Lactate-1.2
[**2129-9-7**] 05:39PM BLOOD Lactate-1.1

[**2129-9-3**]:  chest x-ray:

Heart size and mediastinum are grossly unchanged since the prior
study, but there is interval progression of pulmonary edema,
currently interstitial, associated with bibasilar atelectasis,
left more than right, and left pleural effusion. No pneumothorax
is seen.

[**2129-9-4**]:  chest x-ray:

FINDINGS: Nasogastric tube has been advanced with side port now
terminating in the stomach. Others support devices are unchanged
in position. Heart size is normal. Bibasilar opacities have
nearly resolved. There is no evidence of pulmonary edema or new
areas of consolidation to suggest a developing
pneumonia. Small pleural effusions are again demonstrated, left
greater than right

[**2129-9-9**]:  chest x-ray:

IMPRESSION: Mild to moderate left pleural effusion has minimally
increased, minimal right pleural effusion has decreased since
[**2129-9-8**].

[**2129-9-9**]:  x-ray of the abdomen:

IMPRESSION: No retained surgical objects within the visualized
abdomen.
These findings were discussed between Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] from
radiology and Dr. [**Last Name (STitle) **] from the surgical service by
telephone at 4:25 p.m. on [**2129-9-9**]

[**2129-9-8**]:

[**2129-9-8**] 2:02 pm CATHETER TIP-IV      Source: cvl.

                            **FINAL REPORT [**2129-9-10**]**

   WOUND CULTURE (Final [**2129-9-10**]):    No significant growth.

[**2129-9-8**]:  sputum:

[**2129-9-8**] 2:02 pm SPUTUM      Source: Endotracheal.

                            **FINAL REPORT [**2129-9-10**]**

   GRAM STAIN (Final [**2129-9-8**]):
      >25 PMNs and <10 epithelial cells/100X field.
      NO MICROORGANISMS SEEN.

   RESPIRATORY CULTURE (Final [**2129-9-10**]):
      Commensal Respiratory Flora Absent.
      YEAST.    RARE GROWTH.

 [**2129-9-9**] 8:24 pm STOOL     CONSISTENCY: LOOSE      Source:
Stool.

                            **FINAL REPORT [**2129-9-10**]**

   CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2129-9-10**]):
      Feces negative for C.difficile toxin A & B by EIA.
           (Reference Range-Negative).

[**2129-9-12**] 11:01 am STOOL     CONSISTENCY: WATERY      Source:
Stool.

                            **FINAL REPORT [**2129-9-13**]**

   CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2129-9-13**]):
      Feces negative for C.difficile toxin A & B by EIA.
           (Reference Range-Negative).

Time Taken Not Noted     Log-In Date/Time: [**2129-9-13**] 9:22 pm
      STOOL     CONSISTENCY: NOT APPLICABLE

                            **FINAL REPORT [**2129-9-14**]**

   CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2129-9-14**]):
      Feces negative for C.difficile toxin A & B by EIA.
           (Reference Range-Negative).










Brief Hospital Course:
Mrs [**Known lastname 2271**] was admitted on [**2129-9-3**] transferred from [**Hospital 8**]
hospital where she had undergone an exploratory laparotomy and
packing for spontaneous hemoperitoneum. Of note, she had
received L5/S1 epidural steroid injection two days prior to
admission.
The patient arrived to [**Hospital1 18**] intubated but off pressors. She had
been started on broad spectrum antibiotics empirically. She had
an open abdomen and was taken back to the operating room for
further exploration and re-packing.

On HD2 since her clinical status failed to improve and she had
worsening lactic acidosis she was taken to the operating room
once more.  A patch of gangrene in hepatic flexure with a small
perforation was noted and an extended right hmeicolectomy was
performed. The abdomen was left open with the intention to
re-explore in 24-48 hours. Please refer to operative reports for
full detail.

On HD4 she was therefore taken back to the operating room for
re-exploration, removal of lap pad placed during previous
surgery and enterocolic anastomosis. Her abdomen was left open
with a [**State 19827**] patch. Postoperatively she was diuresed with
lasix in attempt to improve her respiratory status.
Her LFTs were noted to be mildly elevated, possibly because of
hypoperfusion injury, were trended and found to be normalizing.

On HD6 Tube feedings were started and tolerated except for some
loose stools. C difficile was negative.

On HD7 the patient was taken back to the operating room for
abdominal washout and closure of the abdominal wall. The patient
tolerated the procedure well. Her WBC increased to 27.5 on HD7.
Blood cultures are negative to date. The tip of her CVL was also
cultured after being taken out and results were negative. Sputum
and urine culture were also negative. Broad spectrum antibiotics
were continued.

On HD8 she was able to be extubated, NGT was removed and she was
started on a full liquid diet. Her diahhrea was decreasing and a
second stool for C difficile was negative. On HD9 she was doing
well and was stable to be transferred to the floor.

Following transfer to the Surgical floor she continued to make
good progress. Her WBC continued to decline and she remained
afebrile.  Her Foley catheter was removed without difficulty.
Her antibiotics were also stopped on [**2129-9-12**]. Her diarrhea
continued and on [**9-13**] she was started on flagyl for c.diff
prophalaxsis.  Her stools have been negative for c.diff.  Her
appetite has diminshed and she has required encouragement to
eat.

The Physical Therapy service evaluated her in light of her
prolonged hospitalization and found her to be well below her
functional baseline.  A short term rehab was recommended prior
to her returning home.

Medications on Admission:
MVI, calcium


Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
2. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
3. acetaminophen 650 mg/20.3 mL Solution Sig: Thirty (30) mls PO
Q4H (every 4 hours).
4. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
5. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day) as needed for HTN: Hold for SBP < 100, HR < 60.
6. oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO Q4H (every 4
hours) as needed for pain.
7. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
9. senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime as
needed for constipation.
10. multivitamin     Tablet Sig: One (1) Tablet PO once a day.
11. Calcium 600 + D(3) 600 mg(1,500mg) -400 unit Tablet Sig: One
(1) Tablet PO twice a day.
12. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a
day for 5 days: started [**9-13**]...1 week course).


Discharge Disposition:
Extended Care

Facility:
[**First Name4 (NamePattern1) 1820**] [**Last Name (NamePattern1) **]

Discharge Diagnosis:
1. Hemoperitoneum.
2. Retroperitoneal hematoma
3. Patchy gangrene, right colon hepatic flexure.
4. Perforated intestine
5. Acute blood loss anemia


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:

*You experience new chest pain, pressure, squeezing or
tightness.

*New or worsening cough, shortness of breath, or wheeze.

*If you are vomiting and cannot keep down 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.

*You experience burning when you urinate, have blood in your
urine, or experience a discharge.

*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.

*Any change in your symptoms, or any new symptoms that concern
you.

Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.

Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**3-29**] lbs until you follow-up with your
surgeon.

Avoid driving or operating heavy machinery while taking pain
medications.

Incision Care:

*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.

*Avoid swimming and baths until your follow-up appointment.

*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.

*Your staples will be removed on [**2129-9-20**].


Followup Instructions:
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment in 2 eweeks.

Call your primary care doctor for a follow up appointment after
you are discharged from rehab.



Completed by:[**2129-9-15**]
{'Hemorrhage complicating a procedure,Acute vascular insufficiency of intestine,Perforation of intestine,Acute kidney failure, unspecified,Hemoperitoneum (nontraumatic),Acidosis,Other and unspecified coagulation defects,Hypotension, unspecified,Delirium due to conditions classified elsewhere,Acute posthemorrhagic anemia,Other ascites,Urinary tract infection, site not specified,Other and unspecified hyperlipidemia,Osteoporosis, unspecified,Diarrhea'}


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: abdominal pain

PRESENT ILLNESS: The patient is a 82F otherwise healthy who presented to
[**Hospital 8**] hospital on [**2129-9-2**] via EMS with abdominal pain,
hypotension, nausea, and emesis. Upon arrival to the ED she was
tachycardic and complaining of lower abdominal pain with
persistent loose stools, emesis, and dysuria. She denied any
chest pain, SOB, or other complaints. She remained hypotensive
despite fluid resuscitation and blood products in the ER. CT
scan
was performed that showed hemoperitoneum with extravasation of
contrast concerning for acute inta-abdominal bleed.

MEDICAL HISTORY: PMH: HLD, osteoporosis, compression L1 fx - received steroid
shots

MEDICATION ON ADMISSION: MVI, calcium

ALLERGIES: Tetanus&Diphtheria Toxoid / Pneumovax 23

PHYSICAL EXAM: Temp 97.3   HR 124   BP 107/60   RR 21   O2 sat 100% CMV FIO2
100%, PEEP 8
GEN: Intubated/sedated
HEENT: anicteric
CV: RRR
Lungs: clear anteriorly, no distress
ABD: soft, Open abdomen covered with towels and ioban, JPx2
exiting from inferior portion of wound, with serosanguinous
drainage
EXT: warm well perfused, palpable DP/PT bilaterally

FAMILY HISTORY: non contributory

SOCIAL HISTORY: Denies smoking, ETOH, drug use 

### Response:
{'Hemorrhage complicating a procedure,Acute vascular insufficiency of intestine,Perforation of intestine,Acute kidney failure, unspecified,Hemoperitoneum (nontraumatic),Acidosis,Other and unspecified coagulation defects,Hypotension, unspecified,Delirium due to conditions classified elsewhere,Acute posthemorrhagic anemia,Other ascites,Urinary tract infection, site not specified,Other and unspecified hyperlipidemia,Osteoporosis, unspecified,Diarrhea'}
