CHIEF COMPLAINT: Vomiting
Diarrhea
Colon Cancer

PRESENT ILLNESS: 66F with locally advanced rectosigmoid adenocarcinoma s/p
diverty colostomy and feeding jejunostomy [**5-21**]; s/p CT guided
abscess drainage [**2163-8-22**].  She just finished a course of
cemoradiation on [**2163-8-2**] (Capecitabine).  Of note from her
previous hspitalization, the abscess drain was prematurely
removed and she was discharged home on Augmentin x 7 days.  She
was schedule dto be admitted for resection of her rectal cancer,
but presents two days early with mild abdominal pain around
ostomy and peri-ostomy hernia with vomiting and increased ostomy
output x 1 day.

MEDICAL HISTORY: Obstructing Rectosigmoid Mass
Emphysema

MEDICATION ON ADMISSION: Megace 40mg QID
Metoprolol 25mg 1.5 [**Hospital1 **]
ASA 81mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Admission Physical Exam: [**2163-10-7**]

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 specified intestinal obstruction,Other retroperitoneal abscess,Fistula of intestine, excluding rectum and anus,Other emphysema,Dehydration,Peritoneal adhesions (postoperative) (postinfection),Diverticulitis of colon (without mention of hemorrhage),Loss of weight,Late effect of radiation,Radiological procedure and radiotherapy as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Personal history of malignant neoplasm of large intestine,Tobacco use disorder,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site
Intestinal obstruct NEC,Retroperiton abscess NEC,Intestinal fistula,Emphysema NEC,Dehydration,Peritoneal adhesions,Dvrtcli colon w/o hmrhg,Abnormal loss of weight,Late effect of radiation,Abn react-radiotherapy,Hx of colonic malignancy,Tobacco use disorder,Mth sus Stph aur els/NOS
Admission Date:  [**2163-10-7**]              Discharge Date:   [**2163-10-21**]

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:
Vomiting
Diarrhea
Colon Cancer

Major Surgical or Invasive Procedure:
Exploratory lap, lysis of adhesions (3 hours),
resection of fistula, and closure of the enterotomy, low
anterior resection and colorectostomy, coloproctostomy,
takedown of colostomy, transverse colostomy and frozen
section biopsy

History of Present Illness:
66F with locally advanced rectosigmoid adenocarcinoma s/p
diverty colostomy and feeding jejunostomy [**5-21**]; s/p CT guided
abscess drainage [**2163-8-22**].  She just finished a course of
cemoradiation on [**2163-8-2**] (Capecitabine).  Of note from her
previous hspitalization, the abscess drain was prematurely
removed and she was discharged home on Augmentin x 7 days.  She
was schedule dto be admitted for resection of her rectal cancer,
but presents two days early with mild abdominal pain around
ostomy and peri-ostomy hernia with vomiting and increased ostomy
output x 1 day.

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 Physical Exam: [**2163-10-7**]

98.2  114  88/60  20  99%RA

Neuro:  AxOx3, NAD
HEENT: PERRL, EOMI
CVS: RRR, no m/c/r
Resp: CTAB, no w/r/r
Abd: soft/distended/tenderness to percussion around ostomy site
and peri-ostomy hernia/NABS
Ext: no c/c/e

Pertinent Results:
Admission Labs:

[**2163-10-7**] 02:00PM BLOOD WBC-21.7*# RBC-4.47 Hgb-12.9# Hct-40.7
MCV-91 MCH-28.8 MCHC-31.6 RDW-17.6* Plt Ct-851*
[**2163-10-7**] 02:00PM BLOOD Neuts-85* Bands-8* Lymphs-3* Monos-2
Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2163-10-7**] 02:00PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-1+ Polychr-OCCASIONAL Ovalocy-1+
Target-OCCASIONAL Schisto-1+ Burr-2+
[**2163-10-7**] 02:00PM BLOOD Plt Ct-851*
[**2163-10-7**] 10:00PM BLOOD PT-11.8 PTT-24.3 INR(PT)-1.0
[**2163-10-7**] 02:00PM BLOOD Glucose-131* UreaN-30* Creat-0.8 Na-136
K-4.7 Cl-98 HCO3-21* AnGap-22*
[**2163-10-7**] 02:00PM BLOOD ALT-10 AST-27 AlkPhos-79 Amylase-29
TotBili-0.4
[**2163-10-8**] 06:40AM BLOOD Calcium-8.1* Phos-3.0 Mg-1.3*
[**2163-10-7**] 02:00PM BLOOD Albumin-4.2 Calcium-10.2 Mg-1.9
[**2163-10-7**] 05:40PM BLOOD Lactate-1.8

Discharge Labs:

[**2163-10-20**] 05:07AM BLOOD WBC-15.0* RBC-3.36* Hgb-10.1* Hct-29.8*
MCV-89 MCH-30.1 MCHC-33.9 RDW-16.8* Plt Ct-707*
[**2163-10-20**] 05:07AM BLOOD Glucose-109* UreaN-13 Creat-0.4 Na-137
K-4.7 Cl-103 HCO3-27 AnGap-12
[**2163-10-20**] 05:07AM BLOOD Calcium-8.7 Phos-3.9 Mg-2.0

----------NUTRITION LABS----------
Date-----Alb-----Fe-----TIBC-----[**Last Name (un) **]-----TRF
*[**10-7**]-----4.4
*[**10-10**]-----2.8-----26-----[**Telephone/Fax (3) 66698**]
*[**10-17**]-----2.9-----38-----172-----280-----132

CT OF THE ABDOMEN WITH IV CONTRAST:

There are new diffuse, but patchy, tree- in-[**Male First Name (un) 239**] and ground-glass
opacities in the right middle, right lower, and left lower lobes
with sparing of the lingula, most consistent with pneumonia.

The liver appears normal. The patient is status post
cholecystectomy. There are splenic arterial calcifications. The
pancreas, adrenal glands and kidneys are within normal limits.
The stomach appears normal. There is a jejunostomy tube
overlying the left upper quadrant in suitable position. Enteric
contrast has been administered via that tube for this study.

There is marked dilatation of the proximal small bowel, to a
greater extent than on the prior study. A segment of jejunum in
the left upper quadrant measures 4 cm in diameter. More distally
there are several segments of irregular narrowing, accompanied
by wall thickening of the small bowel. These abnormal segments
are mostly within or immediately above the pelvis, particularly
near the residual rectum.

More distally the terminal ileum is normal in caliber. Contrast
passes freely into the cecum. The proximal residual colon is
only mildly distended, and more distally, is almost collapsed
near the colostomy site. Although contrast passes freely
throughout, the appearance of proximal small bowel dilatation,
worse than before, suggests either a low- grade obstruction,
perhaps related to segments of abnormally thickened distal small
bowel, or an ileus.

There are multiple enlarged retroperitoneal and mesenteric lymph
nodes, which are unchanged. As none of these is over 12 cm in
shortest dimension, however, these may be reactive, but
metastatic disease is also possible. There are vascular
calcifications in the aorta with mild distal fusiform dilatation
up to 2.9 cm at the aortic bifurcation. There is no free air.

CT OF THE PELVIS WITH IV CONTRAST: There is a persistent
collection of fluid in the presacral space of intermediate
density with a smooth enhancing wall. It is only somewhat
smaller than before and measures 1.9 x 2.5 cm in axial
dimensions. The collection contains air, which suggests a
fistulous connection to adjacent bowel or may be due to abscess
formation.

The rectal stump also contains air and fluid. More proximally
the residual rectum is markedly thickened throughout, suggesting
persistent tumor. There is also enteric contrast which has
passed into the residual rectum, which outlines the convex
contour of an apparent endoluminal mass more distally. There is
no pelvic or inguinal lymphadenopathy or free fluid.

BONE WINDOWS: There are no suspicious lytic or blastic lesions.

IMPRESSION:
1. Increased dilatation of the proximal small bowel, with areas
of narrowing and wall thickening in the more distal small bowel.
This appearance may relate to radiation change or involvement
with tumor. Proximal dilatation may be due to an ileus or
low-grade obstruction, although contrast passes freely
throughout.
2. Residual rectum with an overall similar appearance, including
marked thickening and apparently an endoluminal mass. The
residual rectum contains contrast proximally, implying a
fistulous connection to the small bowel. There is also air and
fluid more distally.
3. Persistent presacral fluid collection with enhancing rim. The
presence of air within the collection also suggests fistulous
connection to adjacent bowel, or may be due to abscess
formation.
4. Mild lymphadenopathy, which could be either metastatic or
reactive.

Operative Note:

PREOPERATIVE DIAGNOSIS:  Carcinoma of the rectosigmoid with a
question of an enterorectal fistula.

POSTOPERATIVE DIAGNOSIS:  Enterorectal fistula, question
carcinoma of the rectosigmoid.

INDICATIONS:  The patient presented with massive weight loss
and total obstruction of her rectum which may have been due
to a pelvic abscess which was not seen early on. We could not
get a histologic diagnosis and at the first operation I did
not think that I could extirpate the rectum very well, and so
we did an end sigmoid colostomy and treated her with
radiation and chemotherapy. We then brought her back. She had
2 recurrent pelvic abscess which we believed probably was the
result of an enterorectal fistula. At the time of surgery, we
were able to take down the enterorectal fistula and close the
enterotomy and then do a low anterior resection, takedown the
colostomy and resect it and then do an anastomosis and then
because of the situation with the previous radiation then do
a protected colostomy. The following procedure was carried
out.

OPERATIONS:  Exploratory lap, lysis of adhesions (3 hours),
resection of fistula, and closure of the enterotomy, low
anterior resection and colorectostomy, coloproctostomy,
takedown of colostomy, transverse colostomy and frozen
section biopsy.

ASSISTANT:  Dr. [**Last Name (STitle) 66699**]
[**Name (STitle) **] [**Name8 (MD) **], MD (RES)
Dr [**Last Name (STitle) **].

PROCEDURE:  Under satisfactory general anesthesia, the
patient was placed supine and prepped and draped in the usual
manner. We excised the old incision and actually carried this
higher on the abdominal wall, entering the abdomen cleanly.
The liver had no disease. There were a number of adhesions.
The principal adhesion, however, was to a loop of bowel which
went down on the right side to the rectum and clearly was an
enterorectal fistula. This was taken down and the opening in
the small bowel was closed in 2 layers with 4-0 silk
transversely and interrupted 4-0 Prolene. Attention was then
turned to lysing all of the adhesions in the small bowel
until we actually had a totally free small bowel and this was
carried out without difficulty.

We then started dissecting the rectum which we did by
grasping the rectum with 3-0 silk sutures, getting behind it,
freeing it up from the left ureter which was clearly seen and
was intact and there was no hematuria and then gradually
working our way down and doing a total mesenteric excision,
getting below the entrance of the fistula into the rectum and
then finally well below the sacral curve. Irrigation of the
rectum revealed that it was entirely open at this point up
into the point of the obstruction which the area of radiation
at the bottom of which was the enterorectal fistula, the most
distal. After we saw that we could get a reasonable length of
rectum up to do the anastomosis, we took down the colostomy
which had a pericolostomy hernia and then transected it with
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3224**] stapler and then anastomosed it with 2 layers of 4-0
silk, initially by using the rectum as a handle, but then
dealing with the front and taking it off and then getting a
very nice 2-layer 4-0 silk interrupted anastomosis.

We then irrigated the pelvis copiously. We were happy with
the anastomosis. The rectal tube had been removed and we then
changed gowns and gloves and closed the site of the colostomy
which had a pericolostomy hernia and then prepared the
transverse colostomy by getting a quarter inch Penrose drain
under the transverse colon. We then changed gowns and gloves
to closure kit and closed the peritoneum, put the Penrose
drain which had a tie around it in the peritoneum, irrigated
the peritoneum, checked for the nasogastric tube, checked for
bleeding which there was very little and then closed the
peritoneum with #1 chromic catgut. The paramedian incision
was then closed as a lateral paramedian incision taking the
freed up muscle and placing it in the midline and then #1
Vicryl on the fascia. After the fascia was closed, we then
made a transverse incision over the right rectus, split the
rectus and then brought up a loop of colon through the
previous identified colon through and put a bridge
underneath. This was subsequently matured at the end of the
procedure by dividing the anterior wall. The closure was
completed. We had previously closed the area of the colostomy
with #1 Vicryl. The subcutaneous tissue of the incision was
closed with 3-0 Vicryl and with 4-0 Monocryl and the same
with the area of the previous transverse colostomy.

Estimated blood loss was 600 cc. The patient tolerated the
procedure well. She was slightly acidotic so she was left on
the ventilator. Two sponge counts, needle counts and
instrument counts were reported as correct by the nursing in
charge. The patient tolerated the procedure well and was
returned to the PACU and will likely go to the ICU.


Brief Hospital Course:
[**Known firstname 1743**] [**Known lastname 54371**] presented to the emergency department at [**Hospital1 18**]
on [**2163-10-7**]. Her WBC was found to be elevated at 21.7.  An
abdominal/pelvic CT scan showed increased dilatation of the
proximal small bowel, with areas of narrowing and wall
thickening in the more distal small bowel; residual rectum with
intraluminal mass; implied fistulous connection from residual
rectum to the small bowel; persistent presacral fluid collection
with enhancing rim; and mild lymphadenopathy (see pertinent
results). A chest xray was obtained which was negative for acute
process or effusion(see pertinent results).

She was admitted to the surgery service under the care of Dr.
[**Last Name (STitle) 957**] for questionable obstructive process and presacral fluid
collection.  She was placed NPO; tube feeds were held; and a
foley catheter was inserted. Vancomycin/Levofloxacin/Flagyl were
started for empiric coverage. At HD 2 a PICC line was placed;
TPN was started.  Her j-tube was placed to gravity.  She was
taken to interventional radiology for CT-guided aspiration of
the presacral fluid collection which revealed 30-40ml of
purulent, then serosanguinous drainage.  A pigtail catheter was
placed.  A sample of the drainage was sent for culture.

At HD 5 her abdomen remained distended with question of
continued obstructive process. She denied pain or vomiting. She
remained NPO and continued  nutrition via TPN.  At HD 6
Hibiclens washes and Neomycin/Erythromycin were provided.  On HD
7 she was taken to the operating room where she underwent an
exploratory lap, lysis of adhesions, resection of fistula, and
closure of the enterotomy, low anterior resection and
colorectostomy, coloproctostomy,takedown of colostomy,
transverse colostomy and frozen section biopsy. She tolerated
the procedure well. Estimated blood loss was 600ml and she
received 2 units of PRBCs and 500ml albumin.  She remained
intubated after surgery and was taken to the ICU for further
care.

By POD 1 the presacral fluid culture grew staph aureus
susceptible to Vancomycin and her Levo/Flagyl were discontinued.
 Blood cultures from the emergency department were negative.
She was doing well.  Urine output and vital signs were stable.
She was extubated without complication.

At POD 3 narcotic pain control was weaned and she was receiving
tylenol with good control. Her colostomy was functioning well
with good output. 1/2 strength tube feeds were started and TPN
was continued. Her WBC count was elevated at 20.2 and a repeat
abscess culture was sent from the pigtail. Vancomycin was
continued. Levofloxacin/Flagyl were restarted. Her diet was
advanced to sips, and she was deemed stable for transfer to the
floor.

On POD 4, she was transferred to a regular floor.  She continued
to be afebrile.  Her tube feeds were advanced to 30cc/hr and her
TPN was continued.  She ctoninued to has gas and stool from her
ostomy an her pigtail continued to drain 25 cc of serosanguinous
fluid.  She was continued on her vancomycin.

On POD 5, she continued to be afebrile and stable.  Her tube
feeds were advanced to 40 cc/hr, which she tolerated well.  She
was advanced to sips and her TPN was continued.  Her antibiotics
were continued and her pigtail continued to have minimal output.

On POD 6, she continued to do well and be afebrile.  She was
advanced to a soft diet and her TF were advanced to 50 cc/hr
cycled overnight.    Her pigtail continued to have minimal
output of 10cc and her TPN was discontinued. Her metoprolol was
increased for an elevated heart rate.

On POD 7, she was deemed stable for discharge home.  She
remained afebrile and her tube feeds advanced to 70 cc/hr cycled
overnight with non-generic imodium.

On POD 8, she continued to do well, tolerating a soft diet.  Her
pigtail was discontinued.  She was discharged home with nursing
services for her tube feeds and IV antibiotics.

Medications on Admission:
Megace 40mg QID
Metoprolol 25mg 1.5 [**Hospital1 **]
ASA 81mg daily

Discharge Medications:
1. Ampicillin Sodium 1 g Piggyback Sig: One (1)  Intravenous
every six (6) hours for 7 days.
Disp:*4 4* Refills:*24*
2. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
One (1)  Intravenous  every eight (8) hours for 7 days.
Disp:*3 3* Refills:*18*
3. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
4. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Disp:*180 Tablet(s)* Refills:*2*
5. Acetaminophen 160 mg/5 mL Solution Sig: Twenty (20) ml PO Q
8H (Every 8 Hours) for 10 days: Please flush down J-tube.
Disp:*QS QS* Refills:*0*
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
Disp:*30 Tablet, Chewable(s)* Refills:*2*
7. Imodium A-D 1 mg/5 mL Liquid Sig: Two (2) mg PO twice a day:
Give 10ml liquid down J-tube twice daily.
Disp:*qs qs* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Location (un) **] home therapies

Discharge Diagnosis:
Enterorectal fistula, question carcinoma of the rectosigmoid.


Discharge Condition:
Stable


Discharge Instructions:
Please call your doctor [**First Name (Titles) **] [**Last Name (Titles) **] greater than 101.5,
nausea/vomiting, inability to eat, wound
redness/warmth/swelling/foul smelling drainage, abdominal pain
not controlled by pain medications or any other concerns.

Please take medications as prescribed.

Please follow-up as directed.

No heavy lifting (anything that makes you strain) for 4-6 weeks
or until directed otherwise.  Please leave water proof dressing
on until follow-up with Dr. [**Last Name (STitle) 957**].

Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 957**] in [**1-17**] weeks.  Please call his
office at ([**Telephone/Fax (1) 376**] to schedule an appointment.



Completed by:[**2163-10-24**]
{'Other specified intestinal obstruction,Other retroperitoneal abscess,Fistula of intestine, excluding rectum and anus,Other emphysema,Dehydration,Peritoneal adhesions (postoperative) (postinfection),Diverticulitis of colon (without mention of hemorrhage),Loss of weight,Late effect of radiation,Radiological procedure and radiotherapy as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Personal history of malignant neoplasm of large intestine,Tobacco use disorder,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site'}


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: Vomiting
Diarrhea
Colon Cancer

PRESENT ILLNESS: 66F with locally advanced rectosigmoid adenocarcinoma s/p
diverty colostomy and feeding jejunostomy [**5-21**]; s/p CT guided
abscess drainage [**2163-8-22**].  She just finished a course of
cemoradiation on [**2163-8-2**] (Capecitabine).  Of note from her
previous hspitalization, the abscess drain was prematurely
removed and she was discharged home on Augmentin x 7 days.  She
was schedule dto be admitted for resection of her rectal cancer,
but presents two days early with mild abdominal pain around
ostomy and peri-ostomy hernia with vomiting and increased ostomy
output x 1 day.

MEDICAL HISTORY: Obstructing Rectosigmoid Mass
Emphysema

MEDICATION ON ADMISSION: Megace 40mg QID
Metoprolol 25mg 1.5 [**Hospital1 **]
ASA 81mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Admission Physical Exam: [**2163-10-7**]

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 specified intestinal obstruction,Other retroperitoneal abscess,Fistula of intestine, excluding rectum and anus,Other emphysema,Dehydration,Peritoneal adhesions (postoperative) (postinfection),Diverticulitis of colon (without mention of hemorrhage),Loss of weight,Late effect of radiation,Radiological procedure and radiotherapy as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Personal history of malignant neoplasm of large intestine,Tobacco use disorder,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site'}
