CHIEF COMPLAINT: abdominal pain

PRESENT ILLNESS: Mr. [**Known lastname 25087**] is a gentleman with rectal cancer
originally treated in the beginning of [**2116-11-11**] with
combined modality 5-FU, leucovorin, and radiation therapy with
good response.  He was well until [**2121-7-11**] when his CEA
began
to rise.  Workup revealed a left lower lobe nodule and a right
upper lobe mass.

MEDICAL HISTORY: rectosigmoid CA s/p resection [**2116**] and chemo/XRT
HTN
hyperlipidemia
VATS- RUL/LLL nodule - cervical meiastinoscopy with LN biopsy
revealed no evidence of malignancy, then s/p VATS RUL

MEDICATION ON ADMISSION: Zofran, Compazine, Percocet, prn ativan, Prozac,
HCTZ. Oxycontin, Oxycodone, Colace, Dexamethasone 4/2/4,
Priolsec

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On discharge-
T 96.4 P 93 BP 93/66 RR16 98%4L
Gen- weak white male, looks older than stated age, NAD
HEENT- NCAT, EOMI
Pulm- CTAB. no W,R. soft exp rhonchi on L.
CV- RRR. no M,R,G
Abd- flat, soft, +BS, colostomy with bag, midline incision
staples loosely with no erythema or induration
GU- foley in place
Ext- 2+ LE and UE edema. petechiae on UE's and LE's.

FAMILY HISTORY: Father died of cirrhosis at the age of 49. One
sibling with paranoid schizophrenia. One grandparent died of TB.

SOCIAL HISTORY: Seven to ten pack year history, discontinued in
the [**2086**]. He has had exposure to asbestos working in a shipyard
Other postoperative infection,Peritoneal abscess,Abscess of intestine,Secondary malignant neoplasm of brain and spinal cord,Secondary malignant neoplasm of lung,Acute respiratory failure,Hyposmolality and/or hyponatremia,Diverticulitis of colon (without mention of hemorrhage),Personal history of malignant neoplasm of large intestine,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Personal history of contact with and (suspected) exposure to asbestos,Peritoneal adhesions (postoperative) (postinfection),Constipation, unspecified,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Accidents occurring in other specified places,Anticoagulants causing adverse effects in therapeutic use,Streptococcus infection in conditions classified elsewhere and of unspecified site, other streptococcus,Other iatrogenic hypotension,Anemia of other chronic disease
Other postop infection,Peritoneal abscess,Intestinal abscess,Sec mal neo brain/spine,Secondary malig neo lung,Acute respiratry failure,Hyposmolality,Dvrtcli colon w/o hmrhg,Hx of colonic malignancy,Hypertension NOS,Hyperlipidemia NEC/NOS,Hx-contct/expos asbestos,Peritoneal adhesions,Constipation NOS,Abn react-anastom/graft,Accident in place NEC,Adv eff anticoagulants,Other streptococcus,Iatrogenc hypotnsion NEC,Anemia-other chronic dis
Admission Date:  [**2122-8-18**]              Discharge Date:   [**2122-9-5**]

Date of Birth:  [**2067-3-30**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 17683**]
Chief Complaint:
abdominal pain

Major Surgical or Invasive Procedure:
PROCEDURE:
1.  Exploratory laparotomy, diverting end colostomy, left-
    sided.
2.  Irrigation of pelvic abscess, placement of drains in
    pelvic abscess.
3.  Intubation


History of Present Illness:
Mr. [**Known lastname 25087**] is a gentleman with rectal cancer
originally treated in the beginning of [**2116-11-11**] with
combined modality 5-FU, leucovorin, and radiation therapy with
good response.  He was well until [**2121-7-11**] when his CEA
began
to rise.  Workup revealed a left lower lobe nodule and a right
upper lobe mass.

He underwent a VATS resection of the right upper lobe on
[**2121-12-10**] and the pathology revealed a metastatic tumor from a
colonic origin.  Mediastinal lymph node sampling was negative.
He then underwent a left lower lobe wedge resection on [**2122-1-22**]
of the left lower lobe nodule and this was also consistent with
a
colonic metastasis.  He began tx with FOLFOX + Avastin.  He
required a 20% dose reduction of 5FU bolus and CI due to n/v and
abdominal cramping.  He completed 3 cycles of this, last dose on
[**2122-6-4**].

During his course he developed neck pains and headaches and was
found to have a rising CEA.  A restaging CT was performed on
[**2122-6-15**] and uncovered a PE in a small branch of the LLL pulmonary
artery.  To evaluate his headache prior to anticoagulation, and
MRI was performed on [**2122-6-16**] found a brain metastasis on the
right
occiptal lobe, and dural enhancement in the L brain.

His PE was managed with an IVC filter given the brain
metastasis.
He underwent resection of his brain metastasis on [**2122-6-19**] with
Dr.
[**Last Name (STitle) **].  Additionally, an upper extremity ultrasound on [**2122-6-22**]
documented the presence of a LIJ thrombus with extension to the
subclavian.

He began whole brain XRT.  This was complicated by
forgetfullness, low grade fevers, and persistent headache.  His
steroids were tapered.  He was admitted twice to [**Hospital3 417**]
hospital for evaluation of dehydration, hypotension, and fever,
without any source identified.  He contninued to lose weight and
be weak with occasional headache.  His steroids were increased
with improvement of his headaches, and no further fevers.

He was noted to be hyponatremic at the end of [**Month (only) 205**], along with
elevated liver enzymes.  His phenytoin was being tapered off.
Liver US was unremarkable, and LFTs trended down after cessation
of phenytoin.  A repeat MRI on [**2122-8-13**] was negative.  He was
advised increase PO intake with gatorade for his hyponatremia.

He developed difficulty with constipation, and reported having
small incompletely evacuating bowel movements since the end of
[**Month (only) 205**].  Laxatives were escalated, but he continued to have
difficulty.  His home health aide reported he was self
rectalizing to assist with his bowel movements.  Suppositories
were advised, but he continued to have difficulty.  He developed
worsening abdominal pain and constipation and was referred to
his
local ED, where he went on [**2122-8-17**].  There he was disimpacted.
He
was evaluated by surgery and underwent CT scan which
demonstrated
an anastamotic perforation and abcess with fluid collection.  He
was transferred to [**Hospital1 18**] for further management.

He notes that for the last several weeks he has been having
constipation with cramping.  This weekend (3dPTA) he began to
experience significantly worsened diffuse abdominal pain, which
has persisted through his OSH hospitalization.  He has had
nausea
since his chemotherapy, not recently worsened.  He has not noted
any fevers.


Past Medical History:
rectosigmoid CA s/p resection [**2116**] and chemo/XRT
HTN
hyperlipidemia
VATS- RUL/LLL nodule - cervical meiastinoscopy with LN biopsy
revealed no evidence of malignancy, then s/p VATS RUL

Social History:
Seven to ten pack year history, discontinued in
the [**2086**]. He has had exposure to asbestos working in a shipyard

from [**2090**] to [**2095**]. He uses alcohol occasionally and socially.
He denies any exposure to uranium, nickel, cadmium, or radon.
Lives with wife and 2 [**Name2 (NI) 25084**] 17/19.


Family History:
Father died of cirrhosis at the age of 49. One
sibling with paranoid schizophrenia. One grandparent died of TB.


One grandparent had a stroke. One grandparent had an MI.

Physical Exam:
On discharge-
T 96.4 P 93 BP 93/66 RR16 98%4L
Gen- weak white male, looks older than stated age, NAD
HEENT- NCAT, EOMI
Pulm- CTAB. no W,R. soft exp rhonchi on L.
CV- RRR. no M,R,G
Abd- flat, soft, +BS, colostomy with bag, midline incision
staples loosely with no erythema or induration
GU- foley in place
Ext- 2+ LE and UE edema. petechiae on UE's and LE's.

Pertinent Results:
[**2122-8-31**] 06:55AM BLOOD WBC-17.9* RBC-3.37* Hgb-10.5* Hct-30.7*
MCV-91 MCH-31.1 MCHC-34.1 RDW-19.6* Plt Ct-59*
[**2122-9-2**] 09:21PM BLOOD Plt Ct-72*
[**2122-8-30**] 07:07AM BLOOD PT-13.6* PTT-23.4 INR(PT)-1.2*
[**2122-8-28**] 06:34PM BLOOD Fibrino-220
[**2122-8-25**] 05:06PM BLOOD FDP-10-40
[**2122-8-25**] 05:06PM BLOOD Ret Aut-1.4
[**2122-8-31**] 06:55AM BLOOD Glucose-109* UreaN-29* Creat-0.8 Na-133
K-4.2 Cl-100 HCO3-24 AnGap-13
[**2122-8-30**] 07:07AM BLOOD ALT-71* AST-48* LD(LDH)-469* AlkPhos-246*
Amylase-79 TotBili-1.1
[**2122-8-30**] 07:07AM BLOOD Lipase-45
[**2122-8-20**] 03:03AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2122-8-31**] 06:55AM BLOOD Calcium-7.1* Phos-3.1 Mg-1.8
[**2122-8-30**] 07:07AM BLOOD Albumin-2.3* Calcium-7.2* Phos-2.8 Mg-1.9
[**2122-8-28**] 06:34PM BLOOD calTIBC-111* VitB12-[**2043**]* Folate-GREATER
TH Ferritn-1870* TRF-85*
[**2122-8-25**] 05:06PM BLOOD Hapto-248*
[**2122-8-19**] 01:45PM BLOOD TSH-0.85
[**2122-8-19**] 08:58AM BLOOD Cortsol-18.8
[**2122-8-25**] 03:38AM BLOOD Lactate-1.8
[**2122-8-26**] 02:51AM BLOOD freeCa-1.13
[**2122-8-29**] 03:23PM BLOOD SEROTONIN RELEASE ANTIBODY-PND

Brief Hospital Course:
Pt accepted from OSH.  He was started on amp/levo/flagyl,
dexamethasone and made NPO.  CT showed large amount of free
intraperitoneal air, large abscess at level of rectosigmoid
anastomosis, severe rectal wall thickening, most likely
post-radiation, but intramural abscess extension is also
possible, additional second collection to the left of bladder
dome, and IVC filter in place with thrombus about filter arms.
He was taken to surgery emergently for exp lap. They found
evidence of some pus in the abdomen. There was no evidence of
gross studding or gross soilage high up in the abdomen. Deep in
the pelvis, there was a large amount of pus. There was some
fecal contamination contained deep in the pelvis. There was
obvious air and stool leaking out of a small perforation quite
deep in the pelvis. It was unclear whether this was
diverticulitis or at the anastomosis.

Postop, he was in respiratory distress and was intubated in the
ICU.  He continued to do poorly in the ICU with lactic acidosis
and resp failure.  At most acute, base deficit was -20.  Pt was
extubated on [**8-25**].  Tubefeeding was started on [**8-22**].  TPN was
given for 3 days [**Date range (1) 25088**].  Amp was stopped on [**8-22**] and vanco
started.  On [**8-24**] he was transfused 2 u PRBCs for anemia.
Procrit was started.  He was transferred to the floor on [**8-30**].
Abx's were dc'd on [**9-1**].

On [**8-20**] it was noted that plt count was falling.  At lowest it
was 59.  Dx of heparin induced thrombocytopenia was made.  All
heparin was dc'd and at dc plt count was 71.

At dc pt is stable and tolerating full diet.  He is sating well
on O2 via NC.  He can get OOB to chair with assist.  Anemia has
been difficult to follow due to difficulty accessing blood.
Thrombocytopenia is improving.  Pt continues to have metastatic
colon ca.  There are no signs of infection.  Pt is coherent
neurologically.  The colostomy is passing gas and stool.  Pt is
off antibiotics and on a steroid taper.  Stable to transfer to
rehab for further PT/OT and hopeful eventual transfer home.

Medications on Admission:
Zofran, Compazine, Percocet, prn ativan, Prozac,
HCTZ. Oxycontin, Oxycodone, Colace, Dexamethasone 4/2/4,
Priolsec

Discharge Medications:
1. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
Disp:*180 Capsule(s)* Refills:*2*
2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*250 ML(s)* Refills:*2*
3. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1)  Injection
QMOWEFR (Monday -Wednesday-Friday) for 1 months.
Disp:*qs * Refills:*3*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Dexamethasone 1 mg Tablet Sig: Two (2) Tablet PO twice a day:
2 mg [**Hospital1 **] for 2 days, then 2 mg once a day and 1 mg once a day x
3 days, then 1 mg [**Hospital1 **] x 3 days, the 1 mg qday x 3 days, then
off.
Disp:*27 Tablet(s)* Refills:*0*
6. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
Disp:*60 Capsule(s)* Refills:*2*
8. Albuterol Sulfate 0.083 % Solution Sig: [**1-12**]  Inhalation Q6H
(every 6 hours).
Disp:*qs * Refills:*2*
9. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72HR(s)* Refills:*2*
10. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4
to 6 hours) as needed for pain.
Disp:*360 Tablet(s)* Refills:*0*
11. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for sleep or nausea.
Disp:*30 Tablet(s)* Refills:*2*
12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical  TID
(3 times a day).
Disp:*qs * Refills:*2*
13. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-12**]
Drops Ophthalmic  PRN (as needed) as needed for dry eyes.
Disp:*qs * Refills:*2*
14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 700**] - [**Location (un) 701**]

Discharge Diagnosis:
metastatic colon cancer with perferated viscus


Discharge Condition:
stable


Discharge Instructions:
Code status: Do not resuscitate (DNR/DNI)
  Comments: Per Attending discussion with wife: no pressors, no
compressions, no shocking. Do not re-intubate. (ammended [**8-25**]
per discussion with family after patient extubation)

Medications:
  Artificial Tears 1-2 DROP OU PRN dry eyes  [**9-4**] @ 1605 View
  Reglan 5-10 mg po q 6-8 h prn nausea
  Miconazole Powder 2% 1 Appl TP TID
  Dexamethasone 2 mg PO Q PM, 2 mg PO Q NOON for 2 more days,
then decrease to 2 mg q NOON and 1 mg q PM for 3 days, then 1 mg
[**Hospital1 **] x 3days, then 1 mg qday x 3 days, then dc.
  Furosemide 40 mg po BID
  Lorazepam 0.5 mg PO Q8H:PRN sleep or nausea
  OxycodONE (Immediate Release)  10 mg PO Q4-6H:PRN pain
please hold for sedation, RR<10
  Fentanyl Patch 25 mcg/hr TP Q72H
  Albuterol 0.083% Neb Soln 1 NEB IH Q6H
  Docusate Sodium 100 mg PO BID:PRN
  traZODONE HCl 50 mg PO HS:PRN
  Hydrochlorothiazide 25 mg PO DAILY
  Pantoprazole 40 mg PO Q24H  [**8-29**] @ 1643 View
  Epoetin Alfa 10,000 UNIT SC QMOWEFR Start: HS
10,000 given M, W, F
  Oxycodone-Acetaminophen Elixir [**5-20**] ml PO Q4-6H:PRN pain
please hold for sedation, RR<10  [**8-28**] @ 0939 View
  Fluoxetine HCl 40 mg PO DAILY

IVF- no IV

Nutrition- regular diet, allergic to grapes

Resp- O2 via NC as needed to keep O2 > 92%
  chest pt q4hrs strictly
  Precautions: Aspiration

Ostomy care- bag last changed on [**9-4**]

Wound care-
  Incision- Wet to dry dressing changes [**Hospital1 **]
  Fingersticks- none

Activity- as tolerated, out of bed with assist

Lines and drains-
  Closed suction drain 2 bulb suction, empty q4h, keep on
suction
  Foley to gravity, last changed [**8-28**]

Vital signs: q4
  o2 Sats: with vitals
  Weight: qd
  Monitor urine output: q4h
  Call HO if: T>101.4 ; HR <60 or >110 ; SBP <90 or >160 ; DBP
<60
  or >90 ; RR <10 or >22 ; O2 <93

DO NOT GIVE PT HEPARIN

Followup Instructions:
Hem Onc Appt Dr [**First Name (STitle) **] [**Hospital1 18**] [**Hospital Ward Name 23**] Building [**2122-9-8**] at 9 am

Call Dr[**Name (NI) 22019**] office to schedule a follow up appt. ([**Telephone/Fax (1) 25089**]

[**2122-11-5**]  10:00a   [**Last Name (LF) 1533**],[**First Name3 (LF) **] [**Doctor First Name 25090**]
  MULTI-SPECIALTY THORACIC UNIT-CC9
[**2122-11-5**]  09:30a   XCT (TCC) [**Apartment Address(1) **]
  RADIOLOGY
[**2122-9-8**]  09:00a   [**Last Name (LF) **],[**First Name3 (LF) **] P.
  HEMATOLOGY/ONCOLOGY-CC9
[**2122-9-8**]  09:00a   [**Doctor First Name **],HEM/ONC
  HEMATOLOGY/ONCOLOGY-CC9


                             [**Name6 (MD) 843**] [**Name8 (MD) 844**] MD [**MD Number(1) 845**]

Completed by:[**2122-9-4**]
{'Other postoperative infection,Peritoneal abscess,Abscess of intestine,Secondary malignant neoplasm of brain and spinal cord,Secondary malignant neoplasm of lung,Acute respiratory failure,Hyposmolality and/or hyponatremia,Diverticulitis of colon (without mention of hemorrhage),Personal history of malignant neoplasm of large intestine,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Personal history of contact with and (suspected) exposure to asbestos,Peritoneal adhesions (postoperative) (postinfection),Constipation, unspecified,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Accidents occurring in other specified places,Anticoagulants causing adverse effects in therapeutic use,Streptococcus infection in conditions classified elsewhere and of unspecified site, other streptococcus,Other iatrogenic hypotension,Anemia of other chronic disease'}


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: Mr. [**Known lastname 25087**] is a gentleman with rectal cancer
originally treated in the beginning of [**2116-11-11**] with
combined modality 5-FU, leucovorin, and radiation therapy with
good response.  He was well until [**2121-7-11**] when his CEA
began
to rise.  Workup revealed a left lower lobe nodule and a right
upper lobe mass.

MEDICAL HISTORY: rectosigmoid CA s/p resection [**2116**] and chemo/XRT
HTN
hyperlipidemia
VATS- RUL/LLL nodule - cervical meiastinoscopy with LN biopsy
revealed no evidence of malignancy, then s/p VATS RUL

MEDICATION ON ADMISSION: Zofran, Compazine, Percocet, prn ativan, Prozac,
HCTZ. Oxycontin, Oxycodone, Colace, Dexamethasone 4/2/4,
Priolsec

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On discharge-
T 96.4 P 93 BP 93/66 RR16 98%4L
Gen- weak white male, looks older than stated age, NAD
HEENT- NCAT, EOMI
Pulm- CTAB. no W,R. soft exp rhonchi on L.
CV- RRR. no M,R,G
Abd- flat, soft, +BS, colostomy with bag, midline incision
staples loosely with no erythema or induration
GU- foley in place
Ext- 2+ LE and UE edema. petechiae on UE's and LE's.

FAMILY HISTORY: Father died of cirrhosis at the age of 49. One
sibling with paranoid schizophrenia. One grandparent died of TB.

SOCIAL HISTORY: Seven to ten pack year history, discontinued in
the [**2086**]. He has had exposure to asbestos working in a shipyard 

### Response:
{'Other postoperative infection,Peritoneal abscess,Abscess of intestine,Secondary malignant neoplasm of brain and spinal cord,Secondary malignant neoplasm of lung,Acute respiratory failure,Hyposmolality and/or hyponatremia,Diverticulitis of colon (without mention of hemorrhage),Personal history of malignant neoplasm of large intestine,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Personal history of contact with and (suspected) exposure to asbestos,Peritoneal adhesions (postoperative) (postinfection),Constipation, unspecified,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Accidents occurring in other specified places,Anticoagulants causing adverse effects in therapeutic use,Streptococcus infection in conditions classified elsewhere and of unspecified site, other streptococcus,Other iatrogenic hypotension,Anemia of other chronic disease'}
