CHIEF COMPLAINT: symptomatic rectal prolapse

PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old gentleman with a
history of metastatic hepatocellular carcinoma who had a
markedly symptomatic rectal prolapse. He had difficult time
sleeping, and he was incompetent of stool prior to surgery.
He was scheduled for surgery last year, but  with this was
delayed. He responded to chemotherapy regimen for his
hepatocellular carcinoma, and he requested a rectal prolapse
surgery. Risks and benefit of that surgery were discussed in
detail. He understood that death was a risk. He signed a
surgical consent, held his chemotherapeutic regimen for 6
weeks and was offered surgery following that.

MEDICAL HISTORY: PMH: Met HCC, heart murmur, DM, HTN, neuropathy, hiatal hernia,
mild AS/MR, LVH.
PSHx:  Liver rxn & ablation, partial gastrectomy & splenectomy
for GIB, T&A.

MEDICATION ON ADMISSION: Nexavar (sorafenib)2 tabs qam, 1 qpm, metop 25 mg'', vit D 400',
vit B50 complex 1'', MVI', erythromycin drops 0.5% OU qd,
loperamide 2'', ranitidine 150'', phenytoin 200', HCTZ 25',
glipizide 5'.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: AFebrile, VSS
gen: NAD, resting comfortably in bed
CV: RRR
Pulm: bibasilar crackles, no respiratory distress
Abd: soft, NT, large ventral hernia, well healed scar
Ext: 2+ edema b/l LE extremities
no c/c

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: Widower
Involved in many groups: Masons, other social clubs
Rectal prolapse,Malignant neoplasm of liver, primary,Pulmonary collapse,Unspecified pleural effusion,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Unspecified essential hypertension,Diarrhea,Esophageal reflux,Diaphragmatic hernia without mention of obstruction or gangrene,Anemia, unspecified
Rectal prolapse,Mal neo liver, primary,Pulmonary collapse,Pleural effusion NOS,DMII neuro nt st uncntrl,Neuropathy in diabetes,Hypertension NOS,Diarrhea,Esophageal reflux,Diaphragmatic hernia,Anemia NOS
Admission Date:  [**2143-3-1**]              Discharge Date:   [**2143-3-11**]


Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
symptomatic rectal prolapse

Major Surgical or Invasive Procedure:
perineal proctectomy for rectal prolapse


History of Present Illness:
The patient is a [**Age over 90 **]-year-old gentleman with a
history of metastatic hepatocellular carcinoma who had a
markedly symptomatic rectal prolapse. He had difficult time
sleeping, and he was incompetent of stool prior to surgery.
He was scheduled for surgery last year, but  with this was
delayed. He responded to chemotherapy regimen for his
hepatocellular carcinoma, and he requested a rectal prolapse
surgery. Risks and benefit of that surgery were discussed in
detail. He understood that death was a risk. He signed a
surgical consent, held his chemotherapeutic regimen for 6
weeks and was offered surgery following that.


Past Medical History:
PMH: Met HCC, heart murmur, DM, HTN, neuropathy, hiatal hernia,
mild AS/MR, LVH.
PSHx:  Liver rxn & ablation, partial gastrectomy & splenectomy
for GIB, T&A.


Social History:
Widower
Involved in many groups: Masons, other social clubs

Family History:
 noncontributory

Physical Exam:
AFebrile, VSS
gen: NAD, resting comfortably in bed
CV: RRR
Pulm: bibasilar crackles, no respiratory distress
Abd: soft, NT, large ventral hernia, well healed scar
Ext: 2+ edema b/l LE extremities
no c/c

Pertinent Results:
[**2143-3-2**] 02:28AM BLOOD WBC-17.6*# RBC-3.46* Hgb-9.3* Hct-29.8*
MCV-86 MCH-26.8* MCHC-31.2 RDW-17.6* Plt Ct-435
[**2143-3-2**] 08:36PM BLOOD WBC-15.3* RBC-3.80* Hgb-10.4* Hct-33.2*
MCV-87 MCH-27.3 MCHC-31.3 RDW-16.4* Plt Ct-415
[**2143-3-3**] 11:20AM BLOOD WBC-12.5* RBC-3.37* Hgb-9.2* Hct-29.9*
MCV-89 MCH-27.4 MCHC-30.8* RDW-16.6* Plt Ct-378
[**2143-3-4**] 04:04AM BLOOD WBC-14.7* RBC-3.83* Hgb-10.8* Hct-33.3*
MCV-87 MCH-28.1 MCHC-32.3 RDW-16.3* Plt Ct-386
[**2143-3-5**] 05:15AM BLOOD WBC-13.0* RBC-3.60* Hgb-9.8* Hct-31.2*
MCV-87 MCH-27.2 MCHC-31.4 RDW-16.5* Plt Ct-413
[**2143-3-6**] 06:10AM BLOOD WBC-16.7* RBC-3.81* Hgb-10.3* Hct-32.8*
MCV-86 MCH-27.1 MCHC-31.5 RDW-17.5* Plt Ct-426
[**2143-3-2**] 08:36PM BLOOD ALT-195* AST-487* AlkPhos-973*
TotBili-0.5
[**2143-3-4**] 04:04AM BLOOD ALT-98* AST-261* LD(LDH)-177 AlkPhos-947*
Amylase-65 TotBili-0.5
[**2143-3-5**] 10:15AM BLOOD CK-MB-NotDone cTropnT-<0.01

[**3-2**] CXR: FINDINGS: Metallic clips project over the middle upper
abdomen. The lung volumes are low. The size of the cardiac
silhouette is borderline. There is slight enlargement of the
azygos vein. There also is subtle peribronchial cuffing and
perihilar haziness, combined with moderate retrocardiac
atelectasis. Overall, these findings could be suggestive of
moderate fluid overload. There is blunting of the left
costophrenic angle, possibly caused by minimal pleural effusion.
The right costophrenic angle shows no evidence of pleural
effusion. There are no parenchymal opacities suggestive of
pneumonia. Moderate calcification of the aortic wall at the
level of the aortic arch.

[**3-3**] CXR: FINDINGS: As compared to the previous examination,
there is newly appeared blunting of the right costophrenic
angle, suggestive of newly appeared mild pleural effusion.
Otherwise, the radiograph is unchanged. There are metallic clips
projecting over the middle upper abdomen. There still is slight
enlargement of the azygos vein. Combined with subtle
peribronchial cuffing and perihilar haziness, these findings are
suggestive of moderate fluid overload. No focal parenchymal
opacities suggestive of pneumonia. Moderate calcification of the
aortic wall at the level of the aortic arch.
[**3-4**] CXR: IMPRESSION: Minimal improvement in moderate degree of
pulmonary edema. Small bilateral pleural effusions

[**3-5**] CXR: FINDINGS: In comparison with the study of [**3-4**], the
pulmonary vascularity is essentially within normal limits, as is
the size of the cardiac silhouette.

[**3-7**] CXR: COMPARISON: [**2143-3-5**]. As compared to the
previous examination, there is a subtle increase in bilateral
suprabasal atelectasis. There are no signs suggestive of
overhydration, no evidence of pleural effusion and no focal
parenchymal opacities suggestive of pneumonia.


Brief Hospital Course:
The patient was admitted to the surgery service for post
operative evaluation and treatment.

Neuro: The patient received Dilaudid and Tylenol with good
effect and adequate pain control. When tolerating oral intake,
immediately post operatively, the patient was transitioned to
oral pain medications.

CV:  The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored. On [**3-5**], the patient had
an episode of nausea and emesis, and an ECG was obtained, which
did show some ectopy/irregular rhythm, and ST changes for which
cardiac enzymes were cycles, and were negative.


Pulmonary:  The patient was stable initially from a pulmonary
standpoint; vital signs were routinely monitored.  Good
pulmonary toilet, early ambulation and incentive spirometry were
encouraged throughout this hospitalization.  The patient was put
on Levofloxacin on [**3-6**] as he continued to have increased sputum
(often green) and a rising white blood count post operatively.
His white blood count decreased with the addition of
levofloxacin.

GI/GU/FEN:

Post operatively, the patient's diet was advanced, which was
tolerated well.  Mr. [**Known lastname 10378**] did have some coughing during eating
initially, however passed a bed side swallow evaluation; he was,
however, put on aspiration precautions.

The patient began experiencing some diarrhea post operatively,
which was sent for c. diff and was negative; he was put on
Flagyl for presumed c. diff, and should continue the medication
until [**3-15**].  He was also put on cholestyramine, and metamucil
(and stool softeners were held) for diarrhea.  The patient had
occasional small amounts of blood from the rectum/surgical site.
 His hematocrit was closely monitored, however, and the blleding
was not significant.

The patient's intake and output were closely monitored, and IVF
were adjusted when necessary.  The patient's electrolytes were
routinely followed during this hospitalization, and repleted
when appropriate.



ID: The patient's white blood count and fever curves were
closely watched for signs of infection. He was put on Flagyl for
presumed c.diff (though he was c. diff negative x 3), and
levofloxacin for a respiratory tract infection.



Endocrine:  The patient's blood sugar was monitored throughout
this stay; insulin dosing was adjusted accordingly.



Hematology/Oncology:  The patient's complete blood count was
examined routinely; 2 units of packed red blood cell
transfusions were required during this stay.  He continues to
have a small amount of bleeding from the rectum, which is normal
post operatively, especially in his case, as he has had much
erosion to the area.  His hematocrit should continue to be
checked periodically following discharge, and has been routinely
checked throughout this hospitalization.

The patient's sorafenib should be held for six weeks following
surgery, and was held during this hospitalization.

Prophylaxis:  The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.



At the time of discharge, the patient was doing well, afebrile
with stable vital signs.  The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled.


Medications on Admission:
Nexavar (sorafenib)2 tabs qam, 1 qpm, metop 25 mg'', vit D 400',
vit B50 complex 1'', MVI', erythromycin drops 0.5% OU qd,
loperamide 2'', ranitidine 150'', phenytoin 200', HCTZ 25',
glipizide 5'.


Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed: Hold for diarrhea, loose stools.
2. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO BID (2 times a day): Hold for diarrhea, loose stools.
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
5. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule
PO DAILY (Daily).
6. Hexavitamin     Tablet Sig: One (1) Cap PO DAILY (Daily).
7. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED): Per sliding scale.
8. Glipizide 5 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1)
Tab,Sust Rel Osmotic Push 24hr PO DAILY (Daily).
9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed: Hold for sedation, RR<12.
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
11. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID
(3 times a day) as needed for oral thrush.
12. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Powder in
Packet Sig: One (1) Powder in Packet PO TID (3 times a day).
13. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. B Complex Vitamins     Capsule Sig: One (1) Tablet PO DAILY
(Daily).
15. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
16. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
17. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1)  Inhalation every 6-8 hours as needed.
18. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours).
19. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO BID (2 times a day).
20. Sodium Chloride 0.9%  Flush 3 mL IV DAILY:PRN
Peripheral IV - Inspect site every shift
21. Sodium Chloride 0.9%  Flush 3 mL IV DAILY:PRN
Peripheral IV - Inspect site every shift
22. Ondansetron 4 mg IV Q8H:PRN
23. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day): COntinue until [**2143-3-15**].
24. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) as needed for repiratory infection: COntinue
until [**2143-3-15**].
25. Psyllium 1.7 g Wafer Sig: One (1) Wafer PO BID (2 times a
day) as needed for loose stools.
26. Cholestyramine-Sucrose 4 gram Packet Sig: One (1) Packet PO
twice a day as needed for diarrhea.
27. Ondansetron 4 mg IV Q8H:PRN


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]

Discharge Diagnosis:
perineal proctectomy for rectal prolapse


Discharge Condition:
stable


Discharge Instructions:
Incision Care:  Keep clean and dry.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.

.
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in 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.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or

back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.

* Do not drive or operate heavy machinery while taking any
narcotic pain medication.  You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to ambulate several times per day.

* No heavy ([**9-25**]  lbs) until your follow up appointment.


Followup Instructions:
Please follow up with Dr. [**First Name (STitle) 2819**] in [**12-12**] weeks; call his office at
([**Telephone/Fax (1) 6347**] to schedule an appointment
{'Rectal prolapse,Malignant neoplasm of liver, primary,Pulmonary collapse,Unspecified pleural effusion,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Unspecified essential hypertension,Diarrhea,Esophageal reflux,Diaphragmatic hernia without mention of obstruction or gangrene,Anemia, unspecified'}


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: symptomatic rectal prolapse

PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old gentleman with a
history of metastatic hepatocellular carcinoma who had a
markedly symptomatic rectal prolapse. He had difficult time
sleeping, and he was incompetent of stool prior to surgery.
He was scheduled for surgery last year, but  with this was
delayed. He responded to chemotherapy regimen for his
hepatocellular carcinoma, and he requested a rectal prolapse
surgery. Risks and benefit of that surgery were discussed in
detail. He understood that death was a risk. He signed a
surgical consent, held his chemotherapeutic regimen for 6
weeks and was offered surgery following that.

MEDICAL HISTORY: PMH: Met HCC, heart murmur, DM, HTN, neuropathy, hiatal hernia,
mild AS/MR, LVH.
PSHx:  Liver rxn & ablation, partial gastrectomy & splenectomy
for GIB, T&A.

MEDICATION ON ADMISSION: Nexavar (sorafenib)2 tabs qam, 1 qpm, metop 25 mg'', vit D 400',
vit B50 complex 1'', MVI', erythromycin drops 0.5% OU qd,
loperamide 2'', ranitidine 150'', phenytoin 200', HCTZ 25',
glipizide 5'.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: AFebrile, VSS
gen: NAD, resting comfortably in bed
CV: RRR
Pulm: bibasilar crackles, no respiratory distress
Abd: soft, NT, large ventral hernia, well healed scar
Ext: 2+ edema b/l LE extremities
no c/c

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: Widower
Involved in many groups: Masons, other social clubs 

### Response:
{'Rectal prolapse,Malignant neoplasm of liver, primary,Pulmonary collapse,Unspecified pleural effusion,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Unspecified essential hypertension,Diarrhea,Esophageal reflux,Diaphragmatic hernia without mention of obstruction or gangrene,Anemia, unspecified'}
