CHIEF COMPLAINT: abdominal pain

PRESENT ILLNESS: 88F with h/o DM, CHF, afib, recent pneumonia (Zosyn) and C diff
(course of Flagyl), among other med issues, presents with one
day of abdominal pain. Pain began at epigastrium and migrated by
presentation to ED to hypogastrium, and finally localized to RLQ
at time of admission. No N/V/BRBPR. Diarrhea per recent c diff,
but normal BM yesterday was her last BM. Dark stools secondary
to iron supplementation, but guiaic neg in ED. Pt denies nausea
per se, but had one episode of emesis yesterday brought on by
coughing spell.
   Additional issues for this admission developed as patient was
in rapid afib in ED, tachypneic, and had B diffuse crackles on
lung exam. O2 sats stable on 100%, but patients normal
requirement is only 2L. CPAP was attempted in ED, but patient
refused and became agitated. After multiple doses of Diltiazem
IV brought pulse rate to 90's, O2 was pulled back to 4L and O2
sat was 98%.
   Patient has had multiple admissions recently for pulmonary
edema, at [**Hospital1 112**] and [**Hospital1 18**], treated effectively with diuresis and
diltiazem drip when patient in rapid afib.

MEDICAL HISTORY: CHF--> (last echo [**5-19**] showed good LVF with EF=60%, mild
symmetric .... LVH, and mildly increased pulm artery pressures)
Afib
DM Type 2
Polycythemia [**Doctor First Name **]
CRI (Cr 1.6 to 2.6)
Hypothyroidism
Pneumonia
DVT few months ago; off coumadin based on risk of falls

MEDICATION ON ADMISSION: Aranesp 200mg PO q14d
Cardizem CD 240 PO qday
Trazodone 25mg PO qhs
Atrovent INH 2.5mLq6h PRN SOB
Levoxyl 100mcg PO qam
Hydrea 500mg PO qday
Heparin 5000units SQ qday
ASA EC 81mg PO qday
Lasix 40mg PO qday
Oscal 250+D 500mg po TID
Allopurinol 100mg PO Qday
Zocor 20mg PO qhs
Thiamine 50mg PO qday
Fosamax 70mg PO qday
Lido 5% patch qam to lower back
Bisacodyl 10mg PR PRN constipation
FeSO4 325mg PO BID
Lactinex 2 tabs PO BID
MVI
Vitamin C 500mg PO BID
Insulin NPH 12 units qam, 8units qhs + sliding scale

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T:99r   P:126   BP:181/90  R:36   O2:98% on 5L
Gen: elderly female, breathing rapidly and shallowly, otherwise
in NAD
HEENT: NCAT, PERRLA, EOMI, +proptosis, +exotropia, MMM
Neck: no bruit, JVP to level of superior thyroid cartilage
CV: tachy, irreg rhythm, no m/g/r
Pulm: crackles B from bases to 1/2 up, diffuse rhonchi
Abd: distended with hypoactive bowel sounds; tender only to deep
palpation at LLQ
Ext: 1+ pitting edema BLE to knees, but not grossly edematous
Neuro:A&O to self, place, year; however, did not recognize
examiner on return to exam room after 5 minute absence.
Guiaic: neg

FAMILY HISTORY: No h/o clotting disorders.

SOCIAL HISTORY: Since falling about a year ago the patient has been in and out
of [**Hospital1 112**]. She is now living at [**Hospital3 95406**]. She was widowed 2 years ago.No alcohol and no smoking.
Her son is a urologist at [**Hospital6 **]. She has three
grandchildren.
Acute vascular insufficiency of intestine,Congestive heart failure, unspecified,Atrial fibrillation,Accidental puncture or laceration during a procedure, not elsewhere classified,Perforation of intestine,Urinary tract infection, site not specified,Acute kidney failure with lesion of tubular necrosis,Paralytic ileus,Polycythemia vera,Peritoneal adhesions (postoperative) (postinfection),Intestinal infection due to Clostridium difficile,Benign neoplasm of ovary,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Unspecified acquired hypothyroidism,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Personal history of venous thrombosis and embolism
Ac vasc insuff intestine,CHF NOS,Atrial fibrillation,Accidental op laceration,Perforation of intestine,Urin tract infection NOS,Ac kidny fail, tubr necr,Paralytic ileus,Polycythemia vera,Peritoneal adhesions,Int inf clstrdium dfcile,Benign neoplasm ovary,DMII renl nt st uncntrld,Hy kid NOS w cr kid I-IV,Hypothyroidism NOS,Klebsiella pneumoniae,Hx-ven thrombosis/embols
Admission Date:  [**2157-8-12**]              Discharge Date:   [**2157-9-2**]


Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**Last Name (NamePattern1) 15344**]
Chief Complaint:
abdominal pain

Major Surgical or Invasive Procedure:
exploratory laporotomy, lysis of adheasions, small bowel
resection


History of Present Illness:
88F with h/o DM, CHF, afib, recent pneumonia (Zosyn) and C diff
(course of Flagyl), among other med issues, presents with one
day of abdominal pain. Pain began at epigastrium and migrated by
presentation to ED to hypogastrium, and finally localized to RLQ
at time of admission. No N/V/BRBPR. Diarrhea per recent c diff,
but normal BM yesterday was her last BM. Dark stools secondary
to iron supplementation, but guiaic neg in ED. Pt denies nausea
per se, but had one episode of emesis yesterday brought on by
coughing spell.
   Additional issues for this admission developed as patient was
in rapid afib in ED, tachypneic, and had B diffuse crackles on
lung exam. O2 sats stable on 100%, but patients normal
requirement is only 2L. CPAP was attempted in ED, but patient
refused and became agitated. After multiple doses of Diltiazem
IV brought pulse rate to 90's, O2 was pulled back to 4L and O2
sat was 98%.
   Patient has had multiple admissions recently for pulmonary
edema, at [**Hospital1 112**] and [**Hospital1 18**], treated effectively with diuresis and
diltiazem drip when patient in rapid afib.

Past Medical History:
CHF--> (last echo [**5-19**] showed good LVF with EF=60%, mild
symmetric .... LVH, and mildly increased pulm artery pressures)
Afib
DM Type 2
Polycythemia [**Doctor First Name **]
CRI (Cr 1.6 to 2.6)
Hypothyroidism
Pneumonia
DVT few months ago; off coumadin based on risk of falls

Social History:
Since falling about a year ago the patient has been in and out
of [**Hospital1 112**]. She is now living at [**Hospital3 95406**]. She was widowed 2 years ago.No alcohol and no smoking.
Her son is a urologist at [**Hospital6 **]. She has three
grandchildren.


Family History:
No h/o clotting disorders.

Physical Exam:
T:99r   P:126   BP:181/90  R:36   O2:98% on 5L
Gen: elderly female, breathing rapidly and shallowly, otherwise
in NAD
HEENT: NCAT, PERRLA, EOMI, +proptosis, +exotropia, MMM
Neck: no bruit, JVP to level of superior thyroid cartilage
CV: tachy, irreg rhythm, no m/g/r
Pulm: crackles B from bases to 1/2 up, diffuse rhonchi
Abd: distended with hypoactive bowel sounds; tender only to deep
palpation at LLQ
Ext: 1+ pitting edema BLE to knees, but not grossly edematous
Neuro:A&O to self, place, year; however, did not recognize
examiner on return to exam room after 5 minute absence.
Guiaic: neg

Pertinent Results:
[**2157-8-12**] 05:38PM   LACTATE-1.3
[**2157-8-12**] 05:37PM   CK(CPK)-85
[**2157-8-12**] 05:37PM   CK-MB-2 cTropnT-0.01
[**2157-8-12**] 01:56PM   TYPE-ART PO2-199* PCO2-39 PH-7.35 TOTAL
CO2-22 BASE XS--3
[**2157-8-12**] 12:20PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016
[**2157-8-12**] 12:20PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2157-8-12**] 12:20PM URINE  RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0 RENAL EPI-<1
[**2157-8-12**] 12:20PM URINE  AMORPH-OCC
[**2157-8-12**] 11:46AM   LACTATE-1.49
[**2157-8-12**] 11:40AM   GLUCOSE-140* UREA N-48* CREAT-1.8* SODIUM-142
POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-24 ANION GAP-15
[**2157-8-12**] 11:40AM   CK(CPK)-26
[**2157-8-12**] 11:40AM   CK-MB-NotDone cTropnT-0.03*
[**2157-8-12**] 11:40AM   WBC-19.2*# RBC-3.56* HGB-12.0 HCT-39.2
MCV-110* MCH-33.8* MCHC-30.7* RDW-22.1*
[**2157-8-12**] 11:40AM   NEUTS-87 BANDS-3 LYMPHS-8 MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2157-8-12**] 11:40AM   HYPOCHROM-2+ ANISOCYT-3+ POIKILOCY-1+
MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-1+ OVALOCYT-1+
SCHISTOCY-1+ TEARDROP-1+
[**2157-8-12**] 11:40AM   PLT SMR-VERY HIGH PLT COUNT-1026*#

Brief Hospital Course:
Pt was admitted for obervation and control of her rapid a-fib.
It was hoped that controling the a-fib would help resolve her
CHF.  She was started on a diltiazem drip and on HD 1 her HR
began to normalize.  On HD 2 pt's abdominal pain worsened and
she was taken to the OR where she was found to have a possible
right ovarian mass and necrotic small bowel.  She underwent an
exploratory laporotomy, lysis of adheasions, repair of
enterotomy, resection of small bowel, and right oopherectomy.

Postoperatively she was noted to have a significantly decreased
urine output, and a nephrology consult was obtained.  By HD3
(POD1) the pt's creatinine had increased to 3.1 from 2.1.
Nephrology confirmed the diagnosis of post IV-contrast
nephropathy.  Pt was monitored in the SICU for the following 4
days to monitor closely her volume and renal status.  It was
during this time that she developed one episode of hemoptosis
after her swan was wedged.  The swan was removed and a CT
surgery consult was obtained when a chest x-ray was read as
having a possibly widened mediastienem.  CT showed no
abnormality and CT surgery signed off.  Mrs.[**Known lastname 109877**] urine
output was at this time minimally responsive to lasix, and her
creatinine ultimately peaked at a value of 4.1.  Mrs. [**Known lastname **]
slowly improved and was moved to the floor.  Her creatinine
slowly dropped to a new baseline of 2.2.

On POD 11 she developed diarrhea and the suspicion of repeat
c.diff enterocolitis was confirmed.  Pt was started on flagyl,
but her white counts remained persistently elevated and a UTI of
a poly resistant klebsiella grew.  ID was consulted and an
antibiotic regimen of vanco PO and ceftriaxone IV was initiated.


On several occations, pt's PO2 dropped from the mid 90s to the
high 80s, and her O2 requirement grew.  These episodes occured
on several nights, but seemed to be related to aspiration of
thin liquids at night.  A swallow study during the day
demonstrated no impairment, but aspiration precautions were
initiated, especially at night.

Pt's WBC continued to increase and Heme-Onc was consulted to
rule out transformation of her [**Last Name (NamePattern4) **] to lukemia.  They
confirmed that the WBCs were all mature forms, and a combination
of hydroyurea and epo was started to help resolve the pt's
anemia and high WBC count.  The pt's wbc peaked at 57'000.  It
then has declined to a value of 12'200 on [**9-1**].  Heme-onc has
reccommended that we continue the hydroxyurea and epo and follow
cbcs with diff every four days or so.

Pt ultimately was dced to rehab after her coumadin was
theraputic (INR=2.9), her SaO2 was stable, her diarrhea is
tapering, her CHF is much improved (now minimal crackles in b/l
bases, her UTI is being adequately treated, her anemia is
resolving (hct 33.9), her WBC count is normalizing (last 12.2),
her heart rate is controled (80s and 90s), and her creatinine is
much improved (now 2.2).  She still needs to improve her caloric
intake and begin physical rehab.

Medications on Admission:
Aranesp 200mg PO q14d
Cardizem CD 240 PO qday
Trazodone 25mg PO qhs
Atrovent INH 2.5mLq6h PRN SOB
Levoxyl 100mcg PO qam
Hydrea 500mg PO qday
Heparin 5000units SQ qday
ASA EC 81mg PO qday
Lasix 40mg PO qday
Oscal 250+D 500mg po TID
Allopurinol 100mg PO Qday
Zocor 20mg PO qhs
Thiamine 50mg PO qday
Fosamax 70mg PO qday
Lido 5% patch qam to lower back
Bisacodyl 10mg PR PRN constipation
FeSO4 325mg PO BID
Lactinex 2 tabs PO BID
MVI
Vitamin C 500mg PO BID
Insulin NPH 12 units qam, 8units qhs + sliding scale


Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation q6 hrs prn as needed.
Disp:*15 neb* Refills:*2*
2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
Disp:*15 Tablet(s)* Refills:*2*
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
Disp:*30 Tablet(s)* Refills:*2*
4. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Disp:*180 Tablet(s)* Refills:*2*
6. Docusate Sodium 100 mg Tablet Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Epoetin Alfa 10,000 unit/mL Solution Sig: Four (4) ml
Injection once a week.
Disp:*20 ml* Refills:*2*
9. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO once a day
for 2 weeks.
Disp:*14 Capsule(s)* Refills:*0*
10. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
11. Hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
12. Ceftriaxone Sodium 1 g Recon Soln Sig: One (1) g Intravenous
 once a day for 7 days: if no IV than can give as IM shot. to
give IM, recon the ceftriaxone with 2.1 mL of strerile water or
lidocaine.  .
Disp:*7 g* Refills:*0*
13. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
Disp:*5 Suppository(s)* Refills:*0*
14. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Currently being held.  Last INR 2.9 on [**9-1**].  Target INR 1.8 to
2.0 as per Dr. [**Last Name (STitle) 1365**] (Heme-Onc) .
Disp:*30 Tablet(s)* Refills:*2*
15. Outpatient [**Name (NI) **] Work
Pt will need to have her INR checked to maintain a target INR of
1.8-2.0
16. Outpatient [**Name (NI) **] Work
Please monitor the pt's CBC as her hydroxyuria dose was just
decreased.
17. Insulin Regular Human 100 unit/mL Solution Sig: sliding
scale  Injection four times a day: We have been maintaining her
on an insulin sliding scale QID for glycemic control.
Disp:*5 mL* Refills:*2*


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - LTC

Discharge Diagnosis:
Primary:
small bowel necrosis, treated with lysis of adheasions and small
bowel resection, c.diff colitis, UTI, post IV-contrast
nephropathy, malnutrution
Secondary:
A-fib, CHF, DM, polycythemia [**Doctor First Name **], HTN, hypothyroidism, chronic
renal insuff. incontinence


Discharge Condition:
stable


Discharge Instructions:
You may retrun to [**Hospital 100**] Rehab.  You need to have two more weeks
of vancomycin and one more week of ceftriaxone.  You may eat a
regular diet and may resume your regular activities.  If you
develop worsening diarrhea, fevers, chills, or pain please call
the office or return to the hospital.

Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **].  Her phone number is [**Telephone/Fax (1) 73613**].  Please call to make an appointment.

Please also follow up with Dr. [**Last Name (STitle) 2036**] at [**Hospital Ward Name **] CENTER
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2157-9-5**] 10:00

Please also follow up with your PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) 216**].  His number is:
[**Telephone/Fax (1) 1300**]



Completed by:[**2157-9-2**]
{"Acute vascular insufficiency of intestine,Congestive heart failure, unspecified,Atrial fibrillation,Accidental puncture or laceration during a procedure, not elsewhere classified,Perforation of intestine,Urinary tract infection, site not specified,Acute kidney failure with lesion of tubular necrosis,Paralytic ileus,Polycythemia vera,Peritoneal adhesions (postoperative) (postinfection),Intestinal infection due to Clostridium difficile,Benign neoplasm of ovary,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Unspecified acquired hypothyroidism,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Personal history of venous thrombosis and embolism"}


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: 88F with h/o DM, CHF, afib, recent pneumonia (Zosyn) and C diff
(course of Flagyl), among other med issues, presents with one
day of abdominal pain. Pain began at epigastrium and migrated by
presentation to ED to hypogastrium, and finally localized to RLQ
at time of admission. No N/V/BRBPR. Diarrhea per recent c diff,
but normal BM yesterday was her last BM. Dark stools secondary
to iron supplementation, but guiaic neg in ED. Pt denies nausea
per se, but had one episode of emesis yesterday brought on by
coughing spell.
   Additional issues for this admission developed as patient was
in rapid afib in ED, tachypneic, and had B diffuse crackles on
lung exam. O2 sats stable on 100%, but patients normal
requirement is only 2L. CPAP was attempted in ED, but patient
refused and became agitated. After multiple doses of Diltiazem
IV brought pulse rate to 90's, O2 was pulled back to 4L and O2
sat was 98%.
   Patient has had multiple admissions recently for pulmonary
edema, at [**Hospital1 112**] and [**Hospital1 18**], treated effectively with diuresis and
diltiazem drip when patient in rapid afib.

MEDICAL HISTORY: CHF--> (last echo [**5-19**] showed good LVF with EF=60%, mild
symmetric .... LVH, and mildly increased pulm artery pressures)
Afib
DM Type 2
Polycythemia [**Doctor First Name **]
CRI (Cr 1.6 to 2.6)
Hypothyroidism
Pneumonia
DVT few months ago; off coumadin based on risk of falls

MEDICATION ON ADMISSION: Aranesp 200mg PO q14d
Cardizem CD 240 PO qday
Trazodone 25mg PO qhs
Atrovent INH 2.5mLq6h PRN SOB
Levoxyl 100mcg PO qam
Hydrea 500mg PO qday
Heparin 5000units SQ qday
ASA EC 81mg PO qday
Lasix 40mg PO qday
Oscal 250+D 500mg po TID
Allopurinol 100mg PO Qday
Zocor 20mg PO qhs
Thiamine 50mg PO qday
Fosamax 70mg PO qday
Lido 5% patch qam to lower back
Bisacodyl 10mg PR PRN constipation
FeSO4 325mg PO BID
Lactinex 2 tabs PO BID
MVI
Vitamin C 500mg PO BID
Insulin NPH 12 units qam, 8units qhs + sliding scale

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T:99r   P:126   BP:181/90  R:36   O2:98% on 5L
Gen: elderly female, breathing rapidly and shallowly, otherwise
in NAD
HEENT: NCAT, PERRLA, EOMI, +proptosis, +exotropia, MMM
Neck: no bruit, JVP to level of superior thyroid cartilage
CV: tachy, irreg rhythm, no m/g/r
Pulm: crackles B from bases to 1/2 up, diffuse rhonchi
Abd: distended with hypoactive bowel sounds; tender only to deep
palpation at LLQ
Ext: 1+ pitting edema BLE to knees, but not grossly edematous
Neuro:A&O to self, place, year; however, did not recognize
examiner on return to exam room after 5 minute absence.
Guiaic: neg

FAMILY HISTORY: No h/o clotting disorders.

SOCIAL HISTORY: Since falling about a year ago the patient has been in and out
of [**Hospital1 112**]. She is now living at [**Hospital3 95406**]. She was widowed 2 years ago.No alcohol and no smoking.
Her son is a urologist at [**Hospital6 **]. She has three
grandchildren. 

### Response:
{"Acute vascular insufficiency of intestine,Congestive heart failure, unspecified,Atrial fibrillation,Accidental puncture or laceration during a procedure, not elsewhere classified,Perforation of intestine,Urinary tract infection, site not specified,Acute kidney failure with lesion of tubular necrosis,Paralytic ileus,Polycythemia vera,Peritoneal adhesions (postoperative) (postinfection),Intestinal infection due to Clostridium difficile,Benign neoplasm of ovary,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Unspecified acquired hypothyroidism,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Personal history of venous thrombosis and embolism"}
