CHIEF COMPLAINT: Left Hydonephrosis; Ventral hernia; Sigmoid stricture

PRESENT ILLNESS: 67F with h/o obstructing sigmoid mass of indeterminant pathology
s/p chemo/rads and resection of mass with transverse colostomy
([**9-20**]).  Since this time she has been relatively stable.  She
has developed a ventral hernia at the site of her old diverting
colostomy.  Routine CT scan on [**4-21**] showed new onset left
hydronephrosis.  Presented for left ureteral stent placement
(which was unsuccessful) and elective resection of strictured
sigmoid.

MEDICAL HISTORY: Obstructing Rectosigmoid Mass
Emphysema

MEDICATION ON ADMISSION: Metoprolol 25mg [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Admission PE- [**2164-5-14**]

FAMILY HISTORY: Mother died in late 70s of CVA
Father died in mid 60s of "hiatal hernia" (?strangulated hernia)

SOCIAL HISTORY: +ETOH (~2/day)
+tobacco (50+ pk/yr history)
No recreational drugs
Other postoperative infection,Other retroperitoneal abscess,Hydronephrosis,Other emphysema,Fistula of intestine, excluding rectum and anus,Hemorrhage into bladder wall,Acute respiratory failure,Peritoneal adhesions (postoperative) (postinfection),Stricture or kinking of ureter,Personal history of irradiation, presenting hazards to health,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Incisional hernia without mention of obstruction or gangrene,Tobacco use disorder,Personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus,Attention to colostomy,Unspecified essential hypertension
Other postop infection,Retroperiton abscess NEC,Hydronephrosis,Emphysema NEC,Intestinal fistula,Bladder wall hemorrhage,Acute respiratry failure,Peritoneal adhesions,Stricture of ureter,Hx of irradiation,Abn react-surg proc NEC,Incisional hernia,Tobacco use disorder,Hx-rectal & anal malign,Atten to colostomy,Hypertension NOS
Admission Date:  [**2164-5-14**]              Discharge Date:   [**2164-7-6**]

Date of Birth:  [**2097-1-6**]             Sex:   F

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 4111**]
Chief Complaint:
Left Hydonephrosis; Ventral hernia; Sigmoid stricture

Major Surgical or Invasive Procedure:
Cystoscopy, left retrograde pyelogram, attempted
left stent placement.

Exploratory laparotomy, lysis of adhesions (3
hours), rectosigmoid resection and coloproctostomy,
mobilization of the splenic flexure, repair of ventral
hernia, post colostomy.


History of Present Illness:
67F with h/o obstructing sigmoid mass of indeterminant pathology
s/p chemo/rads and resection of mass with transverse colostomy
([**9-20**]).  Since this time she has been relatively stable.  She
has developed a ventral hernia at the site of her old diverting
colostomy.  Routine CT scan on [**4-21**] showed new onset left
hydronephrosis.  Presented for left ureteral stent placement
(which was unsuccessful) and elective resection of strictured
sigmoid.

Past Medical History:
Obstructing Rectosigmoid Mass
Emphysema

PSH:
Colostomy/[**Doctor Last Name **]/Jejunostomy Tube [**2163-5-19**]
Open Cholecystectomy

Social History:
+ETOH (~2/day)
+tobacco (50+ pk/yr history)
No recreational drugs


Family History:
Mother died in late 70s of CVA
Father died in mid 60s of "hiatal hernia" (?strangulated hernia)

Physical Exam:
Admission PE- [**2164-5-14**]

96.5  84  102/58  18  97%RA

Gen: alert and in NAD. OX3
Heent: PERRL. Neck supple. OP clear
CV: RRR no m/g/r
Resp: CTAB. good inspiratory effort
Abd: soft, ND, NT (+)transverse colostomy with loose brown
stool. +left side ventral hernia, soft. +BS
Ext: MAE. no c/c/e

Pertinent Results:
PROCEDURE:  Cystoscopy, left retrograde pyelogram, attempted
left stent placement.

ASSISTANT:  [**First Name4 (NamePattern1) 11894**] [**Last Name (NamePattern1) **], MD.

COMPLICATIONS.:  None.

ANESTHESIA:  General.

INDICATIONS:  The patient is a 67-year-old woman with a
recent CT scan in [**Location (un) 620**] showing a chronically obstructed
left kidney. There is a possible calculus along the route of
the left distal ureter, however, this is beyond the level of
obstruction.

PROCEDURE:  The patient was prepped and draped in lithotomy
position. A #22 French cystoscope was inserted into the
urethra which was normal. The bladder mucosa appeared
slightly atrophic, and the ureteral orifices were, however,
normal size and slightly laterally positioned.

A #8 French tapered catheter was gently inserted into the
left distal ureteral orifice and 5 cc of contrast dye was
injected which revealed a distal ureter with complete
retrograde obstruction. Beyond the level of obstruction,
was a very faint calcification, roughly 5-
8 mm in diameter, possibly consistent with the calcification
seen on CT scan. A straight sensor wire was attempted to be
placed beyond the strictured area but was unable. We then
moved to an angled Glidewire and multiple attempts at passing
the Glidewire beyond the area of stricture were unsuccessful.
At this point the decision was made to abort the stent
placement rather than continued attempts at the wire
placement or ureteroscopy without wire access which can result
in
ureteral rupture.

The bladder was emptied and the patient was transferred to
the PACU stable.

PLAN:  The patient will likely require a left percutaneous
nephrostomy tube and possible antegrade wire access which may
allow retrograde access to the stricture and possibly the
stone.

                        [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 66700**]

PROCEDURE:  Exploratory laparotomy, lysis of adhesions (3
hours), rectosigmoid resection and coloproctostomy,
mobilization of the splenic flexure, repair of ventral
hernia, post colostomy.

INDICATIONS:  This patient had either diverticulitis or an
obstructing carcinoma of the rectum which we could never get
close enough to do a valid biopsy. She underwent radiation
which remedied whatever the lesion was. We never found any
carcinoma in the specimen and she did have evidence of
diverticular disease. She underwent resection and then a
protective colostomy because of the fact that the anastomosis
never seemed to heal and indeed the most recent barium enema
revealed that she did not have adequate healing and as a
matter of fact had several leaks, probably disruptive of the
anastomosis either because of tension, which I had doubted,
or because of the previous radiation. After preparation the
following procedure was carried out.

PROCEDURE IN DETAIL:  Under satisfactory general anesthesia
the patient was placed supine and prepped and draped in the
usual manner. We opened up the left paramedian incision and
were able to free-up of lysis of adhesions in the pelvis
which were extensive and which required extensive revision
starting with the ligament Treitz taking down the previous
feeding jejunostomy, but in fact we were able to get the
entire pelvis freed up without any difficulty. Upon entering
the pelvis there were a number of adhesions that were quite
dense. These were taken down. We actually were able to take
down the small bowel. There was only one area where there was
ballooning out of the serosa which was later repaired with
interrupted 5-0 Prolene and we were then able to go to work
on the previous rectosigmoid which required rectosigmoid
resection in order to get an adequate connection with the
anastomosis on the bottom. There was a stricture at the
previous anastomosis. Initial attempt at irrigation did not
pass any fluid into the pelvis, only later when we mobilized
the colon and had a hole in it was there any irrigation that
came through. We mobilized the small bowel extensively in a
number of areas that were adherent to the pelvis. There was
an abscess which was then drained and irrigated with
gentamicin. We then cultured it as well prior to irrigating
with gentamicin. Finally after mobilizing the splenic
flexure, a 2-layer silk anastomosis was carried out with some
difficulty but finally a good anastomosis was obtained and
reinforced with the appendices epiploica.

In the meantime trying to mobilize the rectum I believe we
injured a branch of the internal iliac and we lost about 750
cc, controlling this with 5-0 Prolene; 2 units were given.

After this and the anastomosis we then changed gowns and
gloves for closure, irrigated and then checked for hemostasis
in the left upper quadrant, as well as around in the pelvis.
A closure of the hernia was done internally first with
approximating the fascia from within with interrupted 0
Vicryl sutures and then closing the peritoneum under it with
a #1 Vicryl suture. The wound was closed in layers. We
decided not to do a feeding jejunostomy because there was no
anastomosis between the mouth and the transverse colostomy.
The wound was closed in layers with #1 chromic catgut on the
peritoneum. Taking the rectus, which previously had been
separated and sewing it over the midline, #1 Vicryl on the
fascia, 3-0 Vicryl on the subcutaneous tissue and 4-0
Monocryl subcuticular closure. Two sponge counts and needle
counts were reported as correct by the nurse in charge. The
patient tolerated the procedure well. Estimated blood loss
was 750 cc. Urine output was scanty at about 60 cc for the
entire case but it picked up as soon as we took her out of
Trendelenburg. She may need some more volume and we did keep
her dry. It should be pointed out that we looked at the area
of the left ureter and indeed it looked like it was stenotic
right at the area with a large ureter above and may have been
radiated.

SECOND ASSISTANT:  [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D.

                        [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 26005**]


Brief Hospital Course:
[**Known firstname 1743**] [**Known lastname 54371**] underwent cystoscopy, left retrograde
pyelogram, and attempted
left stent placement. After the procedure she was admitted to
the surgery service under the care of Dr. [**Last Name (STitle) 957**]. The following
day she underwent exploratory laparotomy, lysis of adhesions,
rectosigmoid resection and coloproctostomy,
mobilization of the splenic flexure, and repair of ventral
hernia.  She tolerated the procedure well and was returned to
the floor after recovery in the PACU. Postoperatively she was
afebrile.  Hct was stable at 30.  Urine output was marginal, but
WNL. Pain was well controlled via epidural. At POD 2 she began
to mobilize fluid.  She was tachycardic and had periods of O2
desaturation. ECG was WNL. Troponin was negative. Chest xray
showed bibasilar atelectasis and small pleural effusions.  Lasix
was provided. At POD 4 she had return of bowel function. Diet
was advanced.  She remained tachycardic despite beta blockade.
She was afebrile. WBC remained elevated at 19.9. AT POD 6 she
was made NPO due to nausea and +gastric distention per KUB. PICC
line was placed and TPN started. NGT was placed. Cardiology was
consulted for persistent tachycardia. She was transferred to the
ICU. Repeat ECG, cardiac enzymes, and echo were WNL. TSH was
WNL. Lactate was 2.1.  A moderate amount of clear-amber fluid
was found draining from her rectum and was +creatinine at 32.
CT cystogram and CT urogram were completed which showed large
left retroperitoneal uroma which appeared to leak from distal
left ureter.  Significant right hydronephrosis was noted. CT
scan of abdomen/pelvis/chest showed moderate bilateral pleural
effusions and bibasilar atelectasis; abdominal and pelvic
ascites and focal fluid collections in the left abdominal and
pelvic retroperitoneal regions; and active extravasation of
contrast suspicious for ureteral injury.  There was no evidence
of pulmonary embolism.  There was no evidence of communication
of the fluid collections and the bowel. Fluconazole/Flagyl were
added to the abx regimen. Later in the evening she was intubated
for respiratory distress.  At POD 9 she underwent percutaneous
drain placement in the retroperitoneal fluid collection. A left
nephrostomy tube was placed with antegrade nephrostogram showing
probable transected left ureter with free extravasation of
contrast into the pelvis.  At POD 10 she remained intubated. She
was transfused for a Hct of 24.5. Abdominal drain began to
appear bilious. Fluid was +Amylase. At POD 11 she was extubated.
She was hemodynamically stable. WBC count was 20.5 from 27.   At
POD 14 she was febrile to 101.7.  Peritoneal fluid was negative
for growth.  Blood and urine cultures were sent. CXR showed
bibasilar pleural effusions and linear opacities. She was
hemodynamically stable. WBC count was 14.7 At POD 15 a repeat CT
scan was completed showing continued abdominal fluid collection.
The pigtail catheter was exchanged. The scan did not reveal a
communication between the collection and bowel.  At POD 16 she
was afebrile and doing well. WBC count was down to 9.9.  She
continued to have a moderate amount of biliious drainage from
the pigtail drain. At POD 29 she was transferred to the floor.
She was receiving CBI for hematuria. Nephrostomy continued to
drain clear urine. Urine cytology was sent which was negative
for malignant cells. At POD 31 an interval CT scan was performed
to evaluate abdominal fluid collection, as drain output had
greatly decreased.  The scan showed no new fluid collection with
marked resolution of drained collection. The urinary catheter
was discontinued. At POD 36 she was afebrile and doing well. The
hematuria was much improved since removal of the catheter.  She
had no problems with voiding independently.  The pigtail
catheter drainage was decreased to ~50ml per day with increased
ostomy output. She remained NPO with TPN for nutritional
support. At POD 44 the fistula output had dropped off
significantly to about 40ml per day.  A repeat CT scan showed no
residual fluid in the area of the pigtail catheter.  Her diet
was advanced to clear liquids. By HD 51 she was tolerating a
regular diet, but was not eating adequate calories per calorie
count. Megace was started. TPN was continued and cycled over
night.  The pigtail continued with low output.  Nephrostomy
remained in place and draining adequately.  She was afebrile and
ambulatory. WBC was  12.6, but repeat CT scan showed no new
fluid collection and no interval change in the drain site. A
PICC line was placed and the CVL was removed. On [**7-6**] she was
discharged home.  A PICC line was placed prior to discharge for
TPN, as she was not taking in adequate calories.  The pigtail
and nephrostomy tubes remained.  She was to follow up with Dr.
[**Last Name (STitle) 957**] in clinic in [**1-17**] weeks.

Medications on Admission:
Metoprolol 25mg [**Hospital1 **]

Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Ferrous Sulfate 300 mg/5 mL Liquid Sig: Five (5) ml PO DAILY
(Daily).
Disp:*qs * Refills:*0*
3. Megestrol 40 mg/mL Suspension Sig: Ten (10) ml PO Q24H (every
24 hours).
Disp:*qs * Refills:*0*
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:*0*
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO three
times a day.
Disp:*90 Tablet(s)* Refills:*0*
6. Sodium Chloride 0.9%  Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
7. Pigtail Flush
Normal Saline 0.9% 10ml syringe.  Flush pigtail abdominal drain
with 10ml NS daily.

Disp: 40
Refills: 0
8. PICC Line Care
PICC line care per protocol. Monitor for signs of infection or
misplacement.


Discharge Disposition:
Home With Service

Facility:
[**Hospital1 1474**] VNA

Discharge Diagnosis:
Sigmoid Stricture
Hydronephrosis
Ureteral injury s/p attempted stent placement
Post-op urinoma
Post-op abdominal fluid collection
Enteric Fistula w/ drain
Post-op Pneumonia
Post-op Anemia


Discharge Condition:
Stable


Discharge Instructions:
Please return or contact for:
* [**Hospital1 **] (>101 F) or chills
* Nausea or vomiting
* Abdominal Pain
* Increased output of pigtail drain
* Decreased or no output from ostomy
* Misplacement of drains
* Increased redness or drainage from around tube sites
* Chest pain or shortness of breath
* Any other concerns

No showering or tub baths with drains in place.  No lifting over
10 pounds or abdominal stretching exercises for 4 weeks.

Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 957**] in clinic in 2 weeks. Please
call for an appointment. The number is [**Telephone/Fax (1) 2359**].  You may
also call this number for any questions or concerns.



Completed by:[**2164-7-8**]
{'Other postoperative infection,Other retroperitoneal abscess,Hydronephrosis,Other emphysema,Fistula of intestine, excluding rectum and anus,Hemorrhage into bladder wall,Acute respiratory failure,Peritoneal adhesions (postoperative) (postinfection),Stricture or kinking of ureter,Personal history of irradiation, presenting hazards to health,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Incisional hernia without mention of obstruction or gangrene,Tobacco use disorder,Personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus,Attention to colostomy,Unspecified essential hypertension'}


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: Left Hydonephrosis; Ventral hernia; Sigmoid stricture

PRESENT ILLNESS: 67F with h/o obstructing sigmoid mass of indeterminant pathology
s/p chemo/rads and resection of mass with transverse colostomy
([**9-20**]).  Since this time she has been relatively stable.  She
has developed a ventral hernia at the site of her old diverting
colostomy.  Routine CT scan on [**4-21**] showed new onset left
hydronephrosis.  Presented for left ureteral stent placement
(which was unsuccessful) and elective resection of strictured
sigmoid.

MEDICAL HISTORY: Obstructing Rectosigmoid Mass
Emphysema

MEDICATION ON ADMISSION: Metoprolol 25mg [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Admission PE- [**2164-5-14**]

FAMILY HISTORY: Mother died in late 70s of CVA
Father died in mid 60s of "hiatal hernia" (?strangulated hernia)

SOCIAL HISTORY: +ETOH (~2/day)
+tobacco (50+ pk/yr history)
No recreational drugs 

### Response:
{'Other postoperative infection,Other retroperitoneal abscess,Hydronephrosis,Other emphysema,Fistula of intestine, excluding rectum and anus,Hemorrhage into bladder wall,Acute respiratory failure,Peritoneal adhesions (postoperative) (postinfection),Stricture or kinking of ureter,Personal history of irradiation, presenting hazards to health,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Incisional hernia without mention of obstruction or gangrene,Tobacco use disorder,Personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus,Attention to colostomy,Unspecified essential hypertension'}
