CHIEF COMPLAINT: Abdominal pain.

PRESENT ILLNESS: The patient is a 67 year old
male who presented to the [**Hospital1 188**] Emergency Department on [**2141-12-6**], complaining of
crampy abdominal pain that had worsened during the previous
ten days.  The patient was status post cardiac catheterization on
[**2141-11-29**] for atypical chest pain, during which he had been noted
to have three vessel coronary disease with no intervention
performed.  The patient reported having intermittent less severe
pain over the previous weeks to months.  The patient reported the
pain was worse after meals.  The patient had lost fifteen pounds
of weight in the previous one and one half weeks.  The patient
had food fear.  The patient denied having any recent [**Doctor Last Name **] or
bloody bowel movements or melena.  The patient had had no
hematemesis.  The patient had no lower extremity claudication or
rest pain since is aortobifemoral bypass.

MEDICAL HISTORY: 1.  Coronary artery disease, status post cardiac
catheterization [**2141-11-29**] without intervention
2.  Peripheral vascular disease, status post aorto-bifemoral
bypass in [**2131**].
3.  Hypertension.
4.  Achalasia s/p dilation
5.  Hypercholesterolemia.

MEDICATION ON ADMISSION: 1.  Lipitor 10 mg p.o. once daily.
2.  Pepcid 20 mg p.o. twice a day.
3.  Lisinopril 40 mg p.o. once daily.
4.  Aspirin 325 mg p.o. once daily.
5.  Toprol XL 75 mg p.o. once daily.
6.  Imdur sustained release 30 mg p.o. once daily.
7.  Plavix 75 mg p.o. once daily.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient occasionally drank alcohol and
smoked one to two cigarettes per day.  The patient denied
intravenous drug use.
Acute vascular insufficiency of intestine,Unspecified protein-calorie malnutrition,Congestive heart failure, unspecified,Blood in stool,Cardiac complications, not elsewhere classified,Subendocardial infarction, initial episode of care,Atrial fibrillation,Acute respiratory failure,Acute appendicitis without mention of peritonitis
Ac vasc insuff intestine,Protein-cal malnutr NOS,CHF NOS,Blood in stool,Surg compl-heart,Subendo infarct, initial,Atrial fibrillation,Acute respiratry failure,Acute appendicitis NOS
Admission Date:  [**2141-12-6**]       Discharge Date:  [**2142-1-2**]

Date of Birth:   [**2074-4-26**]       Sex:  M

Service:  SURGERY/BLUE

CHIEF COMPLAINT:  Abdominal pain.

HISTORY OF PRESENT ILLNESS:  The patient is a 67 year old
male who presented to the [**Hospital1 188**] Emergency Department on [**2141-12-6**], complaining of
crampy abdominal pain that had worsened during the previous
ten days.  The patient was status post cardiac catheterization on
[**2141-11-29**] for atypical chest pain, during which he had been noted
to have three vessel coronary disease with no intervention
performed.  The patient reported having intermittent less severe
pain over the previous weeks to months.  The patient reported the
pain was worse after meals.  The patient had lost fifteen pounds
of weight in the previous one and one half weeks.  The patient
had food fear.  The patient denied having any recent [**Doctor Last Name **] or
bloody bowel movements or melena.  The patient had had no
hematemesis.  The patient had no lower extremity claudication or
rest pain since is aortobifemoral bypass.

PAST MEDICAL HISTORY:
1.  Coronary artery disease, status post cardiac
catheterization [**2141-11-29**] without intervention
2.  Peripheral vascular disease, status post aorto-bifemoral
bypass in [**2131**].
3.  Hypertension.
4.  Achalasia s/p dilation
5.  Hypercholesterolemia.

MEDICATIONS ON ADMISSION:
1.  Lipitor 10 mg p.o. once daily.
2.  Pepcid 20 mg p.o. twice a day.
3.  Lisinopril 40 mg p.o. once daily.
4.  Aspirin 325 mg p.o. once daily.
5.  Toprol XL 75 mg p.o. once daily.
6.  Imdur sustained release 30 mg p.o. once daily.
7.  Plavix 75 mg p.o. once daily.

ALLERGIES:  No known drug allergies.

SOCIAL HISTORY:  The patient occasionally drank alcohol and
smoked one to two cigarettes per day.  The patient denied
intravenous drug use.

PHYSICAL EXAMINATION:  On presentation, the patient's
temperature was 98.9, heart rate 78, blood pressure 220/90,
respiratory rate 18 and oxygen saturation 95% in room air.
Physical examination was notable for abdomen that was softly
distended and diffusely tender to palpation with the
tenderness greatest to the right of the midabdomen.  On
rectal examination, the patient was guaiac positive.

LABORATORY DATA:  The patient's white blood cell count was
18.8, hematocrit 44.0, platelet count 424,000.  He had 80%
neutrophils and 12% lymphocytes, as well as 5% monocytes.
His INR was 1.1. with a prothrombin time of 13.1 and partial
thromboplastin time of 26.8.  His serum sodium was 134, serum
potassium 5.0, chloride 98, bicarbonate 24, blood urea
nitrogen 26, creatinine 1.5, glucose 104.  Liver function
tests were normal.

HOSPITAL COURSE:  While in the Emergency Department, general
surgery and vascular surgery consultations were requested.
The patient's presentation was strongly suspicious for
mesenteric ischemia.  A CAT scan was obtained showing
occlusion of the proximal superior mesenteric artery with
distal reconstitution.  There was mild narrowing of the
proximal celiac axis. There were no secondary signs of
mesenteric ischemia on this imaging study.  The patient was also
noted to have an appendix that was borderline in size with some
thickening (0.8 cm) with no definite surrounding inflammatory
changes.  Suspicion was still strong for mesenteric ischemia. The
patient was started on empiric antibiotic coverage with
Levofloxacin and Flagyl.  Plans for mesenteric catheterization
were initiated.  The decision was made to continue performing
serial examinations through the night of [**2141-12-6**].  On the
morning of [**2141-12-7**], the patient had an increase in his abdominal
pain.  CAT scan at 7:25 a.m. on the morning of [**2141-12-7**], revealed
a large amount of mesenteric venous and portal venous gas with
pneumatosis of the cecum.  The occlusion of the patient's
superior mesenteric artery and the high grade stenosis of the
proximal celiac axis was stable from previous CAT scan.  The
appendix remained dilated with minimal stranding.  Given the
concerning findings on the CT scan, the patient was emergently
taken to the operating room for exploration.  The patient was
found to have ischemic small bowel with necrotic colon secondary
to superior mesenteric artery occlusion and thrombus.  The
patient underwent lysis of adhesions, subtotal abdominal
colectomy, partial omental resection, creation of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3379**]
pouch, superior mesenteric artery thrombectomy and patch
angioplasty.  Estimated blood loss was 400cc and the patient
received three liters of lactated ringer's.  Please refer to
the dictated operative notes for further details.

Postoperatively, the patient was kept intubated with a plan
to return for second look operation on [**2141-12-8**].  In the
postoperative period, the patient was noted to have
electrocardiographic changes and increasing cardiac enzymes
and ultimately ruled in for a postoperative myocardial
infarction.  Cardiology involvement was requested and
obtained.  The patient was taken to the operating room as
planned on [**2141-12-8**], for a second look.  Intraoperatively,
the patient was noted to have approximately 700ml of old
blood in the right and left gutters as well as the pelvis.
This was irrigated out. The liver was found to be normal in
appearance.  There was some oozing at the previous site of the
superior mesenteric artery dissection.  Bleeding was ultimately
controlled.  The distal tip of the [**Initials (NamePattern4) 228**] [**Last Name (NamePattern4) 3379**] pouch
appeared dusky and a segment of this was resected.  An ileostomy
was also performed.  Intraoperatively, the patient also had a
transesophageal echocardiogram performed which was notable
for identifying a large mobile thrombus in the descending
arch of the patient's aorta.  Jejunostomy tube was also
placed.  The patient received two liters of intravenous
fluids, one unit of blood and two units of fresh frozen
plasma.  Estimated blood loss was 750ml.  In the
postoperative period, the patient developed rapid atrial
fibrillation to the 140s which ultimately required
intravenous Amiodarone for control.  The patient was
continued on Levaquin, Ampicillin and Flagyl.  The patient
was transferred to the Intensive Care Unit intubated.   The
patient was started on Heparin drip and was also on
Nitroglycerin drip per cardiology.  On postoperative day
number three and two, the patient's mean arterial pressures
were noted to increase and diuresis was initiated.  The
patient was also started on TPN.  Cardiac catheterization was
also performed on postoperative day three and two which
revealed severe three vessel disease with vasospasm.  No
intervention was performed due to the risk of reocclusion and
the diffuse nature of his disease.  Trophic tube feeds were
started on [**2141-12-11**].  The patient continued to have intermittent
episodes of rapid atrial fibrillation.   The patient's ileostomy
put out occasional old blood and clots but appeared viable.  By
[**2141-12-13**], the patient appeared stable and ready for extubation
and ventilator weaning was initiated.  By this point, the patient
remained sedated on a Fentanyl drip but was easily arousable and
following commands. On [**2141-12-14**], the patient self extubated by
tonguing out his endotracheal tube.  The patient appeared to
tolerate being off the ventilator and was kept on a face mask.
Decision was made not to reintubate at that time.  The patient
was also started on a Clonidine patch for his high blood
pressure. On [**2141-12-18**], the decision was made to obtain CAT scan
of the patient's abdomen to rule out an abscess when the patient
developed a fever and a rising white count.  No evidence of an
intra-abdominal abscess was identified.  The celiac and superior
mesenteric arteries were patent.  On [**2141-12-19**], the patient
experienced desaturation in his oxygenation to between 70 and 80
and was also tachypneic, tachycardic and hypertensive.  The
patient was suctioned without effect and the decision made to
reintubate.  A chest x-ray obtained revealed a white out of the
patient's right lung lower lobe.  The patient was believed to
have mucous plugging.  A bronchoscopy was performed with thick
copious mucus suctioned from the patient's right lower lobe.  A
chest x-ray obtained after the bronchoscopy revealed reexpansion
of the patient's right lower lobe lung.  The patient was
empirically started on Ceftriaxone.  On [**2141-12-20**], a repeat
bronchoscopy was performed with further suctioning of mucus.
The patient was started on Mucomyst to assist in clearing his
secretions.  Around that period, the patient's hematocrit was
occasionally noted to be decreased to the high 20s and he
received occasional units of blood.  On [**2141-12-21**], the patient
was successfully extubated. His hematocrit was once again
noted to be decreased and the patient's Plavix was held.  The
patient also complained of some abdominal pain and a CAT scan
of the patient's abdomen as well as CT angiogram were ordered
and performed.  The CT angiogram revealed that the patient's
vessels were patent with no evidence of bleeding.  A right
upper quadrant ultrasound was also ordered given a slight
increase in the patient's liver function tests.  This showed
no evidence of cholecystitis or biliary outlet obstruction.
The patient experienced some chest pain on transfer back from
radiology following his CAT scan and was restarted on
Diltiazem, Nitroglycerin and was also briefly on an Esmolol
drip to control his heart rate.  The patient's symptoms
resolved and he had minimal electrocardiographic changes.  On
[**2141-12-23**], the patient's tube feeds were restarted.  Shortly
after the patient's tube feeds were restarted, the patient
had a large melanotic output from his ileostomy.  The
decision was made to request gastroenterology consultation
for possible esophagogastroduodenoscopy and ileoscopy.  The
esophagogastroduodenoscopy was performed on [**2141-12-27**],
revealing just some mild gastritis with no evidence of active
bleeding.  The ileoscopy revealed diffuse erythema and
inflammation of the distal ileum but no evidence of acute
bleeding.  In the day or two following this study, the
patient's ileostomy output became nonbloody and his
hematocrit stabilized.  By [**2141-12-29**], the patient was deemed
stable enough for transfer to the Stepdown Unit.  The patient
was started on clears and his diet later advanced to regular
food.  Physical therapy was initiated.  The patient's tube
feeds were cycled.  A calorie count was initiated.  By
[**2141-12-29**], which was postoperative day twenty-two, the
patient's TPN was discontinued and rehabilitation placement
initiated.  The patient had by this time been transitioned to
oral Amiodarone with his heart rate in sinus rhythm.  The
patient continued on Coumadin dosed once daily.  The
patient's Heparin drip had been stopped.  By [**2142-1-2**], the
patient was deemed ready for discharge.

At the time of discharge, the patient's midline incision
appeared to be healing well with no evidence of infection.
The patient also had a groin incision that appeared to be
healing well.

The patient complained of a worsening in his vision shortly
prior to discharge.  A visual examination by the house
officer revealed no visual field deficits and no scotoma.
The decrease in the patient's visual acuity appeared to be
bilateral.  Neurologic examination revealed intact
extraocular muscular function and symmetric strength with no
evidence of a stroke.  Outpatient follow-up was deemed to be
appropriate.

CONDITION ON DISCHARGE:  Stable.

MEDICATIONS ON DISCHARGE:
1.  Coumadin 5 and 2.5 mg alternating.
2.  Dilaudid 2 to 4 mg p.o. q4hours p.r.n.
3.  Protonix 40 mg p.o. twice a day.
4.  Loperamide 2 mg p.o. four times a day.
5.  Amiodarone 200 mg p.o. once daily.
6.  Lisinopril 10 mg p.o. once daily.
7.  Paxil 20 mg p.o. once daily.
8.  Diltiazem 90 mg p.o. four times a day.
9.  Plavix 75 mg p.o. once daily.
10. Metoprolol 50 mg p.o. twice a day.
11. Clonidine patch q.week.
12. Albuterol one to two puffs every six hours as needed for
wheezing.
13. Albuterol nebulizer every six hours as needed.
14. Aspirin 325 mg p.o. once daily.

FOLLOW-UP:  The patient is to follow-up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 2819**] one to two weeks following discharge.  The patient is
also to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of the vascular
service following discharge.  The patient is expected to
continue receiving cardiology care.  The patient will need to
follow-up with his primary care physician within one to two
weeks following discharge.  The patient will need follow-up
with an optician for visual acuity testing.

DISCHARGE DIAGNOSES:
1.  Superior mesenteric artery occlusion secondary to
thromboembolis with mesenteric ischemia/infarction and portal
venous gas
2.  Congestive heart failure
3.  Myocardial infarction and coronary vasospasm
4.  Hypertension
5.  Vancomycin resistant Enterococcus colonization (this was
noted on routine weekly Intensive Care Unit VRE screening on
[**2141-12-25**])
6.  Lower GI bleed
7.  Anemia requiring multiple blood transfusions
8.  Malnutrition requiring parenteral and enteral nutrition
9.  Atrial Fibrillation
10. Respiratory failure requiring reintubation
11. Cholestatic Jaundice
12. Mental Status Delirium from acute illness





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

Dictated By:[**Name8 (MD) 997**]
MEDQUIST36

D:  [**2142-1-1**]  18:24
T:  [**2142-1-1**]  19:13
JOB#:  [**Job Number 93983**]





Y
{'Acute vascular insufficiency of intestine,Unspecified protein-calorie malnutrition,Congestive heart failure, unspecified,Blood in stool,Cardiac complications, not elsewhere classified,Subendocardial infarction, initial episode of care,Atrial fibrillation,Acute respiratory failure,Acute appendicitis without mention of peritonitis'}


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 67 year old
male who presented to the [**Hospital1 188**] Emergency Department on [**2141-12-6**], complaining of
crampy abdominal pain that had worsened during the previous
ten days.  The patient was status post cardiac catheterization on
[**2141-11-29**] for atypical chest pain, during which he had been noted
to have three vessel coronary disease with no intervention
performed.  The patient reported having intermittent less severe
pain over the previous weeks to months.  The patient reported the
pain was worse after meals.  The patient had lost fifteen pounds
of weight in the previous one and one half weeks.  The patient
had food fear.  The patient denied having any recent [**Doctor Last Name **] or
bloody bowel movements or melena.  The patient had had no
hematemesis.  The patient had no lower extremity claudication or
rest pain since is aortobifemoral bypass.

MEDICAL HISTORY: 1.  Coronary artery disease, status post cardiac
catheterization [**2141-11-29**] without intervention
2.  Peripheral vascular disease, status post aorto-bifemoral
bypass in [**2131**].
3.  Hypertension.
4.  Achalasia s/p dilation
5.  Hypercholesterolemia.

MEDICATION ON ADMISSION: 1.  Lipitor 10 mg p.o. once daily.
2.  Pepcid 20 mg p.o. twice a day.
3.  Lisinopril 40 mg p.o. once daily.
4.  Aspirin 325 mg p.o. once daily.
5.  Toprol XL 75 mg p.o. once daily.
6.  Imdur sustained release 30 mg p.o. once daily.
7.  Plavix 75 mg p.o. once daily.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient occasionally drank alcohol and
smoked one to two cigarettes per day.  The patient denied
intravenous drug use. 

### Response:
{'Acute vascular insufficiency of intestine,Unspecified protein-calorie malnutrition,Congestive heart failure, unspecified,Blood in stool,Cardiac complications, not elsewhere classified,Subendocardial infarction, initial episode of care,Atrial fibrillation,Acute respiratory failure,Acute appendicitis without mention of peritonitis'}
