CHIEF COMPLAINT: anuria s/p colovesical fistual takedown

PRESENT ILLNESS: 62 year old male with PMHx CAD s/p CABG x4 in [**2175**] with normal
EF, low grade bladder CA, diverticulitis c/b colovesical fistula
w/ recurrent UTIs who presents s/p takedown of fistula with
primary anastamosis and diverting ileostomy.  Patient had a
cystography which was concerning for colovesical fistula which
was followed by a retrograde fistulogram which confirmed the
diagnosis.  He presented today for takedown of the fistula.
Prior to the procedure, ureteral stents were placed to allow for
palpation of the ureters during procedure.  Urine output during
the procedure was noted to be ~30cc/hour intra op, which
decreased to the patient being anuric since 1800.  He was
resuscitated with 7L of crystalloid and 1 L of albumin and got
lasix 20mg IV x1 with no urinary output.  A renal u/s was done
post procedure which showed no evidence of hydronephrosis or
urine in the bladder. The patient was in his usual state of
health prior to the procedure. He denied recent illness,
although he did have one episode of hematuria on Tuesday that
cleared with his next void.  He otherwise denied urinary
changes.

MEDICAL HISTORY: noninsulin dependent diabetes mellitus, hyperlipidemia, obesity,
hypertension, sleep apnea on CPAP at home, h/o bladder cancer,
gastroesophageal reflux disease, gout, recurrent urinary tract
infections

MEDICATION ON ADMISSION: Metformin 500mg PO BID, Metoprolol succinate 25mg PO 2 tablets
[**Hospital1 **], Pravastatin 80mg daily, Ranitidine 150mg PO daily, Aspirin
81mg PO daily

ALLERGIES: Augmentin

PHYSICAL EXAM: ON ADMISSION:

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Lives with: Wife-[**Name (NI) **], Occupation: Salesman, Tobacco: smokes
half pack of cigarettes per day x 40yrs, quit 3 months ago,
ETOH: 3 drinks per week
Diverticulitis of colon (without mention of hemorrhage),Acute kidney failure with lesion of tubular necrosis,Abscess of intestine,Intestinovesical fistula,Other postoperative infection,Peritoneal abscess,Urinary tract infection, site not specified,Hyposmolality and/or hyponatremia,Urinary complications, not elsewhere classified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Obstructive sleep apnea (adult)(pediatric),Esophageal reflux,Gout, unspecified,Coronary atherosclerosis of unspecified type of vessel, native or graft,Personal history of malignant neoplasm of bladder,Aortocoronary bypass status
Dvrtcli colon w/o hmrhg,Ac kidny fail, tubr necr,Intestinal abscess,Intestinovesical fistula,Other postop infection,Peritoneal abscess,Urin tract infection NOS,Hyposmolality,Surg compl-urinary tract,DMII wo cmp nt st uncntr,Hyperlipidemia NEC/NOS,Hypertension NOS,Obstructive sleep apnea,Esophageal reflux,Gout NOS,Cor ath unsp vsl ntv/gft,Hx of bladder malignancy,Aortocoronary bypass
Admission Date:  [**2176-12-12**]              Discharge Date:   [**2176-12-29**]

Date of Birth:  [**2114-7-9**]             Sex:   M

Service: SURGERY

Allergies:
Augmentin

Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
anuria s/p colovesical fistual takedown


Major Surgical or Invasive Procedure:
s/p takedown of fistula with primary anastamosis and diverting
ileostomy, hemodiaylsis catheter placement and subsequent
removal

History of Present Illness:
62 year old male with PMHx CAD s/p CABG x4 in [**2175**] with normal
EF, low grade bladder CA, diverticulitis c/b colovesical fistula
w/ recurrent UTIs who presents s/p takedown of fistula with
primary anastamosis and diverting ileostomy.  Patient had a
cystography which was concerning for colovesical fistula which
was followed by a retrograde fistulogram which confirmed the
diagnosis.  He presented today for takedown of the fistula.
Prior to the procedure, ureteral stents were placed to allow for
palpation of the ureters during procedure.  Urine output during
the procedure was noted to be ~30cc/hour intra op, which
decreased to the patient being anuric since 1800.  He was
resuscitated with 7L of crystalloid and 1 L of albumin and got
lasix 20mg IV x1 with no urinary output.  A renal u/s was done
post procedure which showed no evidence of hydronephrosis or
urine in the bladder. The patient was in his usual state of
health prior to the procedure. He denied recent illness,
although he did have one episode of hematuria on Tuesday that
cleared with his next void.  He otherwise denied urinary
changes.


Past Medical History:
noninsulin dependent diabetes mellitus, hyperlipidemia, obesity,
hypertension, sleep apnea on CPAP at home, h/o bladder cancer,
gastroesophageal reflux disease, gout, recurrent urinary tract
infections


Social History:
Lives with: Wife-[**Name (NI) **], Occupation: Salesman, Tobacco: smokes
half pack of cigarettes per day x 40yrs, quit 3 months ago,
ETOH: 3 drinks per week


Family History:
non-contributory


Physical Exam:
ON ADMISSION:

GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, dry oral mucosa, op without
lesions, no supraclavicular or cervical lymphadenopathy, no jvd,
no carotid bruits, no thyromegaly or thyroid nodules
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. No pass-pointing on
finger to nose. 2+DTR's-patellar and biceps


Pertinent Results:
[**2176-12-12**] 10:30PM   WBC-6.7 RBC-3.80* HGB-11.2* HCT-32.8* MCV-86
MCH-29.5 MCHC-34.2 RDW-15.2

[**2176-12-12**] 10:30PM   PLT COUNT-138*

[**2176-12-12**] 09:44PM   GLUCOSE-148* UREA N-24* CREAT-2.4* SODIUM-142
POTASSIUM-4.9 CHLORIDE-106 TOTAL CO2-26 ANION GAP-15

[**2176-12-12**] 09:44PM   CALCIUM-8.0* PHOSPHATE-4.5 MAGNESIUM-1.8

[**2176-12-12**] 05:34PM URINE  HOURS-RANDOM CREAT-135 SODIUM-80
POTASSIUM-61
CHLORIDE-85

[**2176-12-12**] 02:10PM   GLUCOSE-171* UREA N-22* CREAT-1.4* SODIUM-141
POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-24 ANION GAP-14

[**2176-12-12**] 02:10PM   CALCIUM-8.7 PHOSPHATE-4.1 MAGNESIUM-2.1

[**2176-12-12**] 02:10PM   HCT-41.6

[**2176-12-14**] 04:51PM BLOOD Glucose-129* UreaN-59* Creat-8.6*# Na-136
K-4.9 Cl-98 HCO3-24 AnGap-19

[**2176-12-15**] 07:06PM BLOOD UreaN-65* Creat-9.1* Na-134 K-8.1* Cl-96
HCO3-21* AnGap-25*

[**2176-12-18**] 09:20AM BLOOD Glucose-165* UreaN-62* Creat-8.0*# Na-133
K-4.0 Cl-88* HCO3-27 AnGap-22*

IMAGING:
[**2176-12-12**] RENAL ULTRASOUND: No evidence of hydronephrosis.
Findings were discussed with the surgery team including [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] at the time of exam completion.

[**2176-12-18**] RENAL PERFUSION STUDY WITH NUCLEAR MEDICINE: Prompt and
symmetric renal perfusion, without tracer excretion into the
collecting system, compatible with bilateral acute tubular
necrosis.




Brief Hospital Course:
62 y/o male w/ PMHx sig for CAD, diverticulitis c/b colovesical
fistula with recurrent UTIs who presented for takedown of
fistula.  The patient underwent sigmoidectomy with primary
anastamosis with diverting loop ileostomy. Immediately the
patient had been noted to have poor urine output
intra-opertively and in the immediate post-op period was anuric.
Intermittent HD in consultation with renal service resulted in
return of kidney function prior to discharge.

NEURO/PAIN: The patient had initially been receiving pain
medication via an epidural catheter infusion and was
transitioned to a Dilaudid PCA by POD#2. His pain medication was
transitioned to Tylenol and PO narcotics on POD#5. He remained
neurologically intact with excellent pain control.

CARDIOVASCULAR: The patient remained hemodynamically stable in
the post-op period, after his episodic hypotension
intra-operatively. His vitals were continuously monitored in the
ICU immediately post-op until he was deemed stable for floor
transfer on POD#5. Cardiac enzymes on [**12-14**] were sent to rule
out hypoperfusion and global ischemic insult to the kidneys due
to post-op coronary demand ischemia. His troponins were
negative. He remained hemodynamically stable for the remainder
of his hospital course.

RESPIRATORY: He was successfully extubated post-op and was
maintained on continuous oxygen saturation monitoring in the ICU
and on floor transfer given his documented history of
obstructive sleep apnea. He had no desaturation periods and was
offered CPAP at night but continually refused this treatment
even after discussion with the respiratory staff. He had no
evidence of cough, and was encouraged to utilize incentive
spirometry during his stay. Incentive spirometry, early
ambulation were encouraged. DVT/PE prophylaxis including
pneumatic compression stockings and SQH were administered.

FEN/GI: The patient was maintained NPO in the immediate post-op
period with a nasogastric tube in place. The NGT had residuals
that were low by POD#4 and was removed without issue on POD#5.
The patient was then advanced from sips to clears and then to a
renal consistency/diabetic diet on POD#6. IV fluids were avoided
given his renal issues and concern for volume overload. The
patient's ostomy was producing flatus by POD#2 and by POD#3
liquid green stool output was forming. By POD#5 the patient had
a healthy amount of liquid green stool output with variable
flatus. His stoma was healthy and pink. His midline abdominal
incision was monitored closely. On HOD#8 the patient was
tolerating a diabetic consistency diet and IV fluids were
discontinued. Given some persistance of hiccups a KUB had been
completed on HOD#7 which showed no evidence of obstruction, and
thus his diet was continued. A non-contrast abdominal CT scan
was performed on HOD#8 which showed expected post-operative
changes and no acute intraabdominal process.  Pt's ostomy output
was controlled with loperamide and psyllium supplements which
were titrated toward a goal of <1200cc per day. He was
discharged with loperamide and psyllium supplements to achieve
adequate ostomy output.

ENDOCRINE: The patient was known to be diabetic on admission.
His blood glucose was closely monitored and a sliding insulin
scale was maintained for adequate glucose control. The patient's
home Metformin was discontinued given his anuria and creatinine
elevation.

RENAL: The post-operative anuria was attributed to
post-operative ATN secondary to hypovolemia during the procedure
likely exacerbated by bowel prep prior to surgery. A short
period of hypotension was documented intra-op. The patient
received nearly 10L of crystalloid for post-op fluid
resuscitation. An ultrasound post-op and CT did not demonstrate
hydronephrosis or obstruction. The CT on [**12-13**] of the
abdomen/pelvis did note a moderate amount of edema and stranding
within the perinephric fa--likely post-surgical. The nephrology
service was consulted given the dramatic presentation of post-op
anuria and renal failure. His creatinine had trended from 1.4
post-op on [**12-12**] to 8.6 on [**12-14**]. Renal recommended Q12 hour
electrolyte monitoring, postassium monitoring, cessation of
fluid volume and on POD#4 hemodiaylsis was initiated given
symptoms of uremia (nausea and volume overload) along with
azotemia. A PICC line was placed for access and a more permanent
HD tunnel catheter was placed on [**12-18**] for outpatient dialysis
considerations. By POD#6 he had only produced 15 mL of
concentrated urine output since post-op. A renal perfusion scan
was completed on [**12-18**] which showed that the patient had
adequate renal perfusion, but inadequate clearance and thus
bilateral acute tubular necrosis was confirmed. The patient was
continued on hemodialysis on T/R/Sat regimen and closely
followed by the renal consultation service.  Medications were
dosed appropriately and renal function gradually returned
between POD#7 and #9 with last HD POD#10 and removal of HD
catheter POD#11. Upon discharge, his urine output had maintained
in the 1-2L/day range and he had no longer required
catheterization or hemodialysis.

HEME/ID: The patient remained hemodynamically stable in the
post-op period. His post-op hematocrit remained stable in the
33-44% range over his hospital stay. He showed no evidence of
bleeding. His WBC was 6.7 post-op and he remained without
leukocytosis in the post-op period. He did develop some evidence
of inferior abdominal incision erythema which was closely
monitored on HOD#[**5-27**]. He remained afebrile during his hospital
course. Wound cultures were drawn intra-op given fluid
collections near to the diverticulum given the colovesicular
fistula. The wound cultures grew E. coli and he was treated with
Unasyn IV for a 24-hour period. ID consulation was obtained with
Unasyn discontinued and Vancomycin and Meropenem started, which
was narrowed to Meropenem after speciation/sensitivities. PO
Fluconazole was also started for yeast speciating from two urine
cultures. A 7-day Meropenem course was completed prior to
discharge. Patient is to be discharged on PO Fluconazole for
completion of antibiotic course as outpatient.

PPX: Sequential compression boots and heparin subcutaneously was
maintained to prevent the risk of DVT/PE. The patient was
encouraged to ambulate twice daily, and utilize incentive
spirometry during his stay.



Medications on Admission:
Metformin 500mg PO BID, Metoprolol succinate 25mg PO 2 tablets
[**Hospital1 **], Pravastatin 80mg daily, Ranitidine 150mg PO daily, Aspirin
81mg PO daily


Discharge Medications:


1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 30 days.
Disp:*30 Tablet(s)* Refills:*0*
5. loperamide 1 mg/5 mL Liquid Sig: One (1)  PO QID (4 times a
day): may adjust dosing for target ostomy output <1200cc/day.
Disp:*500 ml* Refills:*2*
6. trazodone 50 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as
needed for Insomnia.
7. psyllium     Packet Sig: One (1) Packet PO TID (3 times a
day) as needed for high ostomy output.
Disp:*30 Packet(s)* Refills:*3*
8. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).


Discharge Disposition:
Home With Service

Facility:
All Care VNA of Greater [**Location (un) **]

Discharge Diagnosis:
Sigmoid Diverticulitis
Colovesicular Fistula
Acute Renal Failure
Wound infection


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
Please call your doctor or nurse practitioner if you experience
the following:

*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down 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 in your
ostomy bag.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.

General Discharge Instructions:
* Please resume all regular home medications, unless
specifically advised not to take a particular medication.  Also,
please take any new medications as prescribed.
* Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-29**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
* Avoid driving or operating heavy machinery while taking pain
medications.
* Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
* Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
* Avoid swimming and baths until your follow-up appointment.
* You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
* You have steri-strips, they will fall off on their own. Please
remove any remaining strips 7-10 days after surgery.

Ostomy Instructions:
* Goal output no greater that 1200 cc within 24-hour period and
no less than 500 cc in a 24-hour period.
* You have been discharged on Immodium and a psyllium wafer and
may adjust the dose as necessary to maintain this target output.
You should not exceed more than 8 mg PO daily of immodium. If
you are experiencing thicker ostomy output and the volume is
low, discontinue the psyllium wafer first, then titrate down the
loperamide.
* Please call the office if you have any questions or concerns.

Followup Instructions:
Please have follow-up labs drawn at your PCP's office on [**2175-12-28**].


Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1207**], MD Phone:[**Telephone/Fax (1) 4775**] Date/Time:
[**2176-12-30**] 9:30

Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1207**], MD Phone:[**Telephone/Fax (1) 4775**] Date/Time:
[**2177-1-1**] 4:00

Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 274**] Date/Time:
[**2177-1-20**] 2:00

Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 721**] Date/Time:
[**2177-1-9**] 1:30





Admission Date:  [**2177-1-1**]              Discharge Date:   [**2177-1-11**]

Date of Birth:  [**2114-7-9**]             Sex:   M

Service: SURGERY

Allergies:
Augmentin

Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
fevers, UTI


Major Surgical or Invasive Procedure:
IR drainage intrabdominal abscess, [**2177-1-8**]


History of Present Illness:
This is a 62 year-old male with a cardiac history and low-grade
bladder cancer who had a colovesicular fistula after a bout of
diverticulitis and subsequently experienced multiple recurrent
UTIs who was s/p sigmoid colectomy, diverting loop ileostomy and
cystoscopy with ureteral stent placement on [**2176-12-12**].  Of note,
post-operatively, he experienced ATN (since resolved) and was
briefly on multiple antibiotics for positive blood cultures
(please refer to official HPI by Dr. [**First Name (STitle) **].

He returned on this admission with fevers, mild abdominal
discomfort, dysuria and increasing output from his ostomy.


Past Medical History:
noninsulin dependent diabetes mellitus, hyperlipidemia, obesity,
hypertension, sleep apnea on CPAP at home, h/o bladder cancer,
gastroesophageal reflux disease, gout, recurrent urinary tract
infections


Social History:
Lives with: Wife-[**Name (NI) **], Occupation: Salesman, Tobacco: smokes
half pack of cigarettes per day x 40yrs, quit 3 months ago,
ETOH: 3 drinks per week


Family History:
non-contributory


Brief Hospital Course:
Mr. [**Known lastname 15719**] was admitted to the colorectal surgery service under
Dr. [**Last Name (STitle) 1120**] on [**2177-1-1**] with plans for IVF resuscitation,
monitoring fevers as well as ostomy and urine output with blood
and urine cultures.  The infectious disease service was
consulted and recommended continuing meropenem for E.Coli UTI
(empirically at first from prior admission cultures but
ultimately [**1-1**] urine culture grew E.Coli meropenem sensitive).

On HD 2 the superior aspect of his midline abdominal wound
appeared to be draining brownish fluid; it was opened partially
at the bedside and continued to drain.  He was started on
octreotide for concern of an enterocutaneous fistula.  He was
made NPO and started on TPN.  He was sent for a pouchogram to
assess his simgoid anastamosis for leak and was negative.  The
wound and its output were monitored for the next few days and
with continued drainage he was taken for a CT Abdomen on [**2177-1-7**]
which showed a loculated fluid collection in the abdomen near
his midline abdominal wound and no evidence of an EC fistula.
Octreotide was discontinued and he was taken for insertion of a
drain into the collection by Interventional Radiology on [**2177-1-8**]
with subsequent successful placement of a drain.  200 cc of
purulent fluid was removed immediately; drain output was
monitored for the remainder of his stay and decreased each day
until the drain was removed on day of discharge, [**2177-1-11**].

His diet was subsequently restarted (regular) after drain
placement, which he tolerated without issue and TPN was weaned.

From an ID perspective, his urine culture from [**1-1**], wound swab
from [**2177-1-2**] as well as abcess culture from [**1-8**] grew Ecoli
sensitive to meropenem.  Blood cultures were negative.  He was
kept on meropenem during his hospitalization and discharged, per
ID recommendations, on a total 2 week course of ertapenem (to be
dc'd on [**2177-1-22**]).

He was discharged on [**2177-1-11**] ambulating, tolerating diet and
with limited pain taking minimal pain medications.  The drain
was removed prior to discharge.  He was instructed to continue
the ertapenem until [**2177-1-22**] with plans to follow up with Dr.
[**Last Name (STitle) 1120**] on [**2177-1-29**] and for a possible takedown of ileostomy on
[**2177-1-31**].



[**2177-1-9**] drain output decreasing
[**2177-1-8**] IR drainage, octreotide dc'd
[**2177-1-7**] octreotide [**Hospital1 **] to daily; CT abd/pelvis shows fluid
collection
[**2177-1-6**] dressing changes TID, Hct 22.8, 2 units PRBC
transfusion
[**2177-1-6**] [**1-2**] wound cx final: ecoli - [**Last Name (un) 2830**]-sensitive
[**2177-1-5**] NPO, TPN w/o fats; Trigs 294, con't octreotide,
dressing changed [**Hospital1 **]
[**2177-1-2**] EC-fistula? at midline incision, opened, octreotide
started, NPO
[**2177-1-1**] transfered from [**Location (un) 620**] w/ UTI, fever, dehydration/high
ostomy output
[**2177-1-1**] d/c Fluconazole, monitor ostomy output, ID recs,
Regular diet


Discharge Medications:
1. ertapenem 1 gram Recon Soln Sig: One (1) Recon Soln Injection
daily () as needed for E.coli for 14 days: to be administered by
IV infusion company.
Disp:*14 Recon Soln(s)* Refills:*0*
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.


Discharge Disposition:
Home With Service

Facility:
All Care VNA of Greater [**Location (un) **]

Discharge Diagnosis:
Intrabdominal Abscess


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down 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.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
.
General Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication.  Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.  Avoid lifting
weights greater than [**4-29**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water.  Gently pat the area dry.

Monitoring Ostomy output/Prevention of Dehydration:
*Keep well hydrated.
*Replace fluid loss from ostomy daily.
*Avoid only drinking plain water. Include Gatorade and/or other
vitamin drinks to replace fluid.
*Try to maintain ostomy output between 1000mL to 1500mL per day.

*If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with
each episode of loose stool. Do not exceed 16mg/24 hours.

*Continue packing your midline incision with wet-to-dry
dressings
*You will remain on IV antibiotics until [**2177-1-22**]

Followup Instructions:
[**2177-1-22**]   Discontinue antibiotics
[**2177-1-29**]   F/U with Dr. [**Last Name (STitle) 1120**]
[**2177-1-31**]  Ileostomy takedown

Please call ([**Telephone/Fax (1) 3378**] to schedule follow-up appt with Dr.
[**Last Name (STitle) 1120**] for [**2177-1-29**] and to schedule your surgery for [**2177-1-31**].



Completed by:[**2177-1-12**]
{'Diverticulitis of colon (without mention of hemorrhage),Acute kidney failure with lesion of tubular necrosis,Abscess of intestine,Intestinovesical fistula,Other postoperative infection,Peritoneal abscess,Urinary tract infection, site not specified,Hyposmolality and/or hyponatremia,Urinary complications, not elsewhere classified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Obstructive sleep apnea (adult)(pediatric),Esophageal reflux,Gout, unspecified,Coronary atherosclerosis of unspecified type of vessel, native or graft,Personal history of malignant neoplasm of bladder,Aortocoronary bypass status'}


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: anuria s/p colovesical fistual takedown

PRESENT ILLNESS: 62 year old male with PMHx CAD s/p CABG x4 in [**2175**] with normal
EF, low grade bladder CA, diverticulitis c/b colovesical fistula
w/ recurrent UTIs who presents s/p takedown of fistula with
primary anastamosis and diverting ileostomy.  Patient had a
cystography which was concerning for colovesical fistula which
was followed by a retrograde fistulogram which confirmed the
diagnosis.  He presented today for takedown of the fistula.
Prior to the procedure, ureteral stents were placed to allow for
palpation of the ureters during procedure.  Urine output during
the procedure was noted to be ~30cc/hour intra op, which
decreased to the patient being anuric since 1800.  He was
resuscitated with 7L of crystalloid and 1 L of albumin and got
lasix 20mg IV x1 with no urinary output.  A renal u/s was done
post procedure which showed no evidence of hydronephrosis or
urine in the bladder. The patient was in his usual state of
health prior to the procedure. He denied recent illness,
although he did have one episode of hematuria on Tuesday that
cleared with his next void.  He otherwise denied urinary
changes.

MEDICAL HISTORY: noninsulin dependent diabetes mellitus, hyperlipidemia, obesity,
hypertension, sleep apnea on CPAP at home, h/o bladder cancer,
gastroesophageal reflux disease, gout, recurrent urinary tract
infections

MEDICATION ON ADMISSION: Metformin 500mg PO BID, Metoprolol succinate 25mg PO 2 tablets
[**Hospital1 **], Pravastatin 80mg daily, Ranitidine 150mg PO daily, Aspirin
81mg PO daily

ALLERGIES: Augmentin

PHYSICAL EXAM: ON ADMISSION:

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Lives with: Wife-[**Name (NI) **], Occupation: Salesman, Tobacco: smokes
half pack of cigarettes per day x 40yrs, quit 3 months ago,
ETOH: 3 drinks per week 

### Response:
{'Diverticulitis of colon (without mention of hemorrhage),Acute kidney failure with lesion of tubular necrosis,Abscess of intestine,Intestinovesical fistula,Other postoperative infection,Peritoneal abscess,Urinary tract infection, site not specified,Hyposmolality and/or hyponatremia,Urinary complications, not elsewhere classified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Obstructive sleep apnea (adult)(pediatric),Esophageal reflux,Gout, unspecified,Coronary atherosclerosis of unspecified type of vessel, native or graft,Personal history of malignant neoplasm of bladder,Aortocoronary bypass status'}
