CHIEF COMPLAINT: ilesotomy takedown

PRESENT ILLNESS: The patient is an 82-year-old
female with stage IIA (T3, N0, M0) cecal carcinoma status
post right hemicolectomy and end ileostomy on [**2158-12-8**] by
Dr. [**Last Name (STitle) 853**] who presented with worsening of ileostomy
retraction, stenosis and skin breakdown.  She was seen by
stoma nurses at home who expressed concern that there was
nothing to be done to further prevent leakage and undermining
of her stoma.  She denied abdominal pain, nausea, vomiting,
had just a pulling feeling on her skin near her ostomy and
was still having ostomy output 8 times in 24 hours.  After
review of the risks and benefits with the patient regarding
an ileostomy closure, she gave her consent and she was
brought to the operating room.

MEDICAL HISTORY: PE in [**2147**]
Polymyalgia rheumatica
Chronic abdominal pain of presently unclear etiology
PVD
[**Name (NI) 2091**] with [**Name (NI) 5348**] Cr 1.3 in [**11/2158**]
Hypertension
Hypothyroidism
Hypercholesterolemia
GERD
Osteoarthritis
Glaucoma
Chronic abdominal pain
H/o diverticulitis treated with antibiotics
stage IIA (T3, N0, M0) cecal carcinoma
.
SURGICAL HISTORY:
right hemicolectomy and end ileostomy on [**2158-12-8**]
L fem-[**Doctor Last Name **] bypass [**2147**] at [**Hospital1 336**]
tubal ligation
hysterectomy
back surgery
hemorrhoid surgery
cataracts b/l

MEDICATION ON ADMISSION: Amlodipine 5mg daily, atenolol 50mg daily, levothyroxine 25 mcg
daily, pantoprazole 40mg daily, prednisone 5mg every other day,
simvastatin 20mg daily, MVI, ASA 81mg daily

ALLERGIES: morphine / Penicillins / Cipro / adhesive tape

PHYSICAL EXAM: Preoperative visit PE on [**2159-1-26**]:

FAMILY HISTORY: Denies family history of IBD or chronic abdominal pain. Mother
had borderline DM and died of a heart attack. Father with heart
disease, 1 son with heart disease. Denies family history of
vascular disease.

SOCIAL HISTORY: Lives in her own apartment in NH. Independent in her ADL's. Has
2 sons and 1 daughter. Denies tobacco use, EtOH consumption, and
illicits
Other colostomy and enterostomy complication,Acute kidney failure, unspecified,Other postoperative infection,Acute posthemorrhagic anemia,Other chronic pulmonary heart diseases,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Personal history of pulmonary embolism,Polymyalgia rheumatica,Chronic kidney disease, unspecified,Unspecified acquired hypothyroidism,Peripheral vascular disease, unspecified,Personal history of malignant neoplasm of large intestine,Pure hypercholesterolemia,Esophageal reflux,Unspecified glaucoma,Other chronic pain,Peritoneal adhesions (postoperative) (postinfection),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,Other specified disorders of skin,Long-term (current) use of steroids
Colstmy/enteros comp NEC,Acute kidney failure NOS,Other postop infection,Ac posthemorrhag anemia,Chr pulmon heart dis NEC,Hy kid NOS w cr kid I-IV,Enterococcus group d,Hx pulmonary embolism,Polymyalgia rheumatica,Chronic kidney dis NOS,Hypothyroidism NOS,Periph vascular dis NOS,Hx of colonic malignancy,Pure hypercholesterolem,Esophageal reflux,Glaucoma NOS,Chronic pain NEC,Peritoneal adhesions,Abn react-anastom/graft,Skin disorders NEC,Long-term use steroids
Admission Date:  [**2159-2-27**]              Discharge Date:   [**2159-3-10**]

Date of Birth:  [**2076-4-1**]             Sex:   F

Service: SURGERY

Allergies:
morphine / Penicillins / Cipro / adhesive tape

Attending:[**First Name3 (LF) 371**]
Chief Complaint:
ilesotomy takedown

Major Surgical or Invasive Procedure:
[**2159-2-27**] A ileostomy closure with lysis of adhesions and
ileocolonic anastomosis
[**2159-3-6**] Placement of PICC line


History of Present Illness:
The patient is an 82-year-old
female with stage IIA (T3, N0, M0) cecal carcinoma status
post right hemicolectomy and end ileostomy on [**2158-12-8**] by
Dr. [**Last Name (STitle) 853**] who presented with worsening of ileostomy
retraction, stenosis and skin breakdown.  She was seen by
stoma nurses at home who expressed concern that there was
nothing to be done to further prevent leakage and undermining
of her stoma.  She denied abdominal pain, nausea, vomiting,
had just a pulling feeling on her skin near her ostomy and
was still having ostomy output 8 times in 24 hours.  After
review of the risks and benefits with the patient regarding
an ileostomy closure, she gave her consent and she was
brought to the operating room.


Past Medical History:
PE in [**2147**]
Polymyalgia rheumatica
Chronic abdominal pain of presently unclear etiology
PVD
[**Name (NI) 2091**] with [**Name (NI) 5348**] Cr 1.3 in [**11/2158**]
Hypertension
Hypothyroidism
Hypercholesterolemia
GERD
Osteoarthritis
Glaucoma
Chronic abdominal pain
H/o diverticulitis treated with antibiotics
stage IIA (T3, N0, M0) cecal carcinoma
.
SURGICAL HISTORY:
right hemicolectomy and end ileostomy on [**2158-12-8**]
L fem-[**Doctor Last Name **] bypass [**2147**] at [**Hospital1 336**]
tubal ligation
hysterectomy
back surgery
hemorrhoid surgery
cataracts b/l

Social History:
Lives in her own apartment in NH. Independent in her ADL's. Has
2 sons and 1 daughter. Denies tobacco use, EtOH consumption, and
illicits

Family History:
Denies family history of IBD or chronic abdominal pain. Mother
had borderline DM and died of a heart attack. Father with heart
disease, 1 son with heart disease. Denies family history of
vascular disease.

Physical Exam:
Preoperative visit PE on [**2159-1-26**]:

Vitals: T: 97.2; HR: 66; BP: 140/76; RR: 12; Sat: 100% RA
GEN: A&O, NAD
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
ostomy retracted with some erythema on skin inferiorly,
+gas/stool in bag
Ext: No LE edema, LE warm and well perfused

Physical Exam on discharge:

Vitals: T: 97.8; HR: 80; BP: 176/60; RR: 20; Sat: 97% RA
GEN: A&O, NAD
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
vertical midline incision with some fibrinous exudate at base
being packed with dry dressings, ostomy over transverse incision
where prior ileostomy was, drainage continues to be low ouput
and no skin breakdown
Ext: Mild LE edema, LE warm and well perfused


Pertinent Results:
[**2159-2-27**] 01:56PM   WBC-18.4*# RBC-4.15* HGB-10.8* HCT-32.6*
MCV-79* MCH-26.1* MCHC-33.2 RDW-15.5
[**2159-2-27**] 01:56PM   PLT COUNT-347
[**2159-2-27**] 09:31AM   PT-10.8 PTT-23.8* INR(PT)-1.0
[**2159-2-27**] 01:56PM   GLUCOSE-139* UREA N-57* CREAT-1.7* SODIUM-140
POTASSIUM-5.3* CHLORIDE-103 TOTAL CO2-24 ANION GAP-18
[**2159-2-27**] 01:56PM   CALCIUM-8.7 PHOSPHATE-5.9*# MAGNESIUM-1.7

[**2159-2-27**] ECG:
Sinus rhythm. There is a late transition which is probably
normal. There are small R waves in the inferior leads consistent
with possible infarction.
Compared to the previous tracing of [**2158-12-7**] ST-T wave changes
are no longer present and inferior R waves are smaller.

[**2159-2-28**] ECHO:
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
normal (LVEF>55%). The right ventricular cavity is dilated with
normal free wall contractility. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
structurally normal. Mild (1+) mitral regurgitation is seen.
Moderate [2+] tricuspid regurgitation is seen. There is severe
pulmonary artery systolic hypertension. There is no pericardial
effusion.

[**2159-3-4**]
CT abd and pelvis:
1. Status post recent ileostomy takedown with right lateral
abdominal wound and underlying subcutaneous fluid collection,
which could be a postoperative seroma, given timeframe.

2. Right hemiabdominal enterocolonic anastomosis without
definite evidence of leak. However, oral contrast has not yet
reached the anastomosis, limiting assessment. Consider delayed
exam. Small amount of associated
pneumoperitoneum and fluid are likely postoperative.

3. Small fat-containing incisional hernia.

[**2159-3-5**]
CT abd and pelvis:
1. No extraluminal oral contrast identified; however, there is
increased
extraluminal gas compared to next preceding study suggesting an
anteriorly
located bowel wall leak given the intraluminal air-fluid level
seen at the
anastomosis and continuation of extraluminal gas with small
bowel loop.
Surrounding inflammatory changes evident though no focal fluid
collection
identified.
2. Stable trace perihepatic ascites.
3. Stable small right pleural effusion with compression
atelectasis.

[**2159-3-8**]
CXR
AP single view of the chest has been obtained with patient in
semi-upright position. Comparison is made with the next
preceding similar
study of [**2159-3-6**]. The left-sided PICC line has been
pulled back by a few centimeters and is now seen to terminate
just below the level of the
carina. This implies a pull-back by approximately 5 cm. The
present
termination point corresponds to the mid portion of the SVC and
excludes the possibility of mechanical contact with cardiac
structures. No other new cardiopulmonary vascular abnormalities
are identified.


Brief Hospital Course:
The patient was taken to the operating room electively for
ileostomy takedown and subsequently admitted to the surgical
floor. Intra-operatively extensive lysis of adhesions was
performed to take down the Hartmans. She tolerated the procedure
well, was extubated and brought to the PACU in stable condition.
In the PACU her UOP was noted to be marginally low and she was
sent to the floor NPO and with IVF. She was started on
Clindamycin post operatively.

On POD 1 she was transferred to the ICU with Acute Kidney
injury. Pre renal according with FENA, creatinine 1.9 from 1.3
[**Year (4 digits) 5348**]. Patient was given IVF resuscitation with crystalloids
and Albumin. U/o increased to 30-40 cc/h. Creatinine remained
stable. She had an ECHO performed that showed EF >55% but severe
pulmonary HTN. At this time she was on PCA for pain control and
her abdominal incision dressings were dry. She was restarted on
steroids, which she had been taking every other day, at her home
dose. On POD 2 and 3 she continued to have marginal but improved
UOP and was given boluses intermittently and 1 unit of pRBCs for
hct 22.3. Her respiratory status remained stable on exam and by
CXR and she was transferred back to the floor on POD2. She was
advanced in her diet and was switched to PO medications. On POD
4 her wound developed some erythema and a few staples were
removed and swab was done and small amount of fluid expressed.
This swab was sent for micro and eventually grew Proteus and
Enterococci. At this time the clindamycin was stopped and she
was started on Vancomycin and cefpodoxime. Through POD 4 into 5
she had an acute increase in oxygen requirement that responded
well to nebulizer treatment but in this setting her wound was
noted to have more induration and most of the remaining staples
were removed. The fascia was intact on exam but more murky fluid
was expressed and the wound was packed. At this point her
antibiotics were changed to Vancomycin and Ceftriaxone. She had
a CT scan done on POD 5 that showed no evidence of contrast
extravasation at the anastamosis however there was extraluminal
air near the anastamosis  that could represent a leak. She was
placed on IV medications and was made NPO in this setting. An
ostomy appliance was placed over the old ileostomy site
incision, which had the higher output compared to the midline
incision. A PICC line was placed on POD 6 and patient was
started on TPN and kept NPO. By POD8 the fistula output began to
decrease significantly. The ostomy nurse [**First Name (Titles) **] [**Last Name (Titles) 4221**] and
appropriate wound care supplies were provided. TID dry dressing
changes continued to her surgical wound site and IV vancomycin
and ceftriaxone continued for a total 7 day course to be
completed [**2159-3-10**]. She went to rehab with ostomy appliance over
fistula site for skin protection and dry antimicrobial packing
in midline surgical incision.

Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible. Physical therapy was
[**Month/Day/Year 4221**] to evaluate mobility who recommended rehab when
medically cleared. Ambulating was encouraged throughout her
hospital stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs.  The patient was tolerating a regular
diet, ambulating with assistance, and making adequate urine via
foley catheter. Her pain was well controlled.  She is being
discharged to an extended care facility to continue her recovery
and physical therapy.


Medications on Admission:
Amlodipine 5mg daily, atenolol 50mg daily, levothyroxine 25 mcg
daily, pantoprazole 40mg daily, prednisone 5mg every other day,
simvastatin 20mg daily, MVI, ASA 81mg daily


Discharge Medications:
1. insulin regular human 100 unit/mL Solution Sig: One (1) inj
Injection ASDIR (AS DIRECTED): Per attached insulin sliding
scale.
2. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
5. methylprednisolone sodium succ 1,000 mg Recon Soln Sig: Two
(2) mg Intravenous DAILY (Daily).
6. levothyroxine 200 mcg Recon Soln Sig: 12.5 mcg Intravenous
DAILY (Daily).
7. acetaminophen 1,000 mg/100 mL (10 mg/mL) Solution Sig: One
Hundred (100) mL Intravenous Q 8H (Every 8 Hours).
8. pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
9. metoprolol tartrate 5 mg/5 mL Solution Sig: Five (5) mL
Intravenous Q6H (every 6 hours).
10. ceftriaxone in dextrose,iso-os 1 gram/50 mL Piggyback Sig:
Fifty (50) mL Intravenous Q24H (every 24 hours) for 1 doses:
Last dose of course to be completed in PM of [**2159-3-10**].
11. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
12. hydromorphone (PF) 1 mg/mL Syringe Sig: 0.125-0.25 mg
Injection Q3H (every 3 hours) as needed for breakthrough pain.
13. sodium chloride 0.9 % 0.9 % Parenteral Solution Sig: Three
(3) ML Intravenous DAILY (Daily) as needed for line flush.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 1293**] - [**Location (un) 8957**]

Discharge Diagnosis:
1. Ileostomy stricture
2. Enterocutaneous fistula
3. Acute kidney injury
4. Acute blood loss anemia
5. Surgical wound infection


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
You were admitted to the hospital to have your ileostomy
reversed. Postoperatively you developed an enterocutaneous
fistula. This is a common complication postoperatively that
occurs when there is communication between your bowel and your
skin. Because of this, you should not eat or drink anything
until your follow up appointment and you will receive nutrition
through your PICC line.

You are now being discharged to rehab to continue your recovery
from this procedure.

ACTIVITY:

Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your [**Location (un) 5059**] at your next visit.
Don't lift more than [**10-1**] lbs for 6 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.

YOUR BOWELS:
Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your [**Month/Year (2) 5059**].

PAIN [**Month/Year (2) **]:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your [**Name2 (NI) 5059**].
You will receive a prescription from your [**Name2 (NI) 5059**] for pain
medicine to take by mouth. It is important to take this medicine
as directied. Do not take it more frequently than prescribed. Do
not take more medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the folloiwng, please contact your
[**Name2 (NI) 5059**]:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain


Followup Instructions:
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 853**], MD
When: THURSDAY [**2159-3-22**] at 2:15 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 90770**], MD
Specialty: Primary Care
Address: [**Street Address(2) **], STE#403, [**Hospital1 **],[**Numeric Identifier 66038**]
Phone: [**Telephone/Fax (1) 69547**]
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.



Completed by:[**2159-3-10**]
{'Other colostomy and enterostomy complication,Acute kidney failure, unspecified,Other postoperative infection,Acute posthemorrhagic anemia,Other chronic pulmonary heart diseases,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Personal history of pulmonary embolism,Polymyalgia rheumatica,Chronic kidney disease, unspecified,Unspecified acquired hypothyroidism,Peripheral vascular disease, unspecified,Personal history of malignant neoplasm of large intestine,Pure hypercholesterolemia,Esophageal reflux,Unspecified glaucoma,Other chronic pain,Peritoneal adhesions (postoperative) (postinfection),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,Other specified disorders of skin,Long-term (current) use of steroids'}


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: ilesotomy takedown

PRESENT ILLNESS: The patient is an 82-year-old
female with stage IIA (T3, N0, M0) cecal carcinoma status
post right hemicolectomy and end ileostomy on [**2158-12-8**] by
Dr. [**Last Name (STitle) 853**] who presented with worsening of ileostomy
retraction, stenosis and skin breakdown.  She was seen by
stoma nurses at home who expressed concern that there was
nothing to be done to further prevent leakage and undermining
of her stoma.  She denied abdominal pain, nausea, vomiting,
had just a pulling feeling on her skin near her ostomy and
was still having ostomy output 8 times in 24 hours.  After
review of the risks and benefits with the patient regarding
an ileostomy closure, she gave her consent and she was
brought to the operating room.

MEDICAL HISTORY: PE in [**2147**]
Polymyalgia rheumatica
Chronic abdominal pain of presently unclear etiology
PVD
[**Name (NI) 2091**] with [**Name (NI) 5348**] Cr 1.3 in [**11/2158**]
Hypertension
Hypothyroidism
Hypercholesterolemia
GERD
Osteoarthritis
Glaucoma
Chronic abdominal pain
H/o diverticulitis treated with antibiotics
stage IIA (T3, N0, M0) cecal carcinoma
.
SURGICAL HISTORY:
right hemicolectomy and end ileostomy on [**2158-12-8**]
L fem-[**Doctor Last Name **] bypass [**2147**] at [**Hospital1 336**]
tubal ligation
hysterectomy
back surgery
hemorrhoid surgery
cataracts b/l

MEDICATION ON ADMISSION: Amlodipine 5mg daily, atenolol 50mg daily, levothyroxine 25 mcg
daily, pantoprazole 40mg daily, prednisone 5mg every other day,
simvastatin 20mg daily, MVI, ASA 81mg daily

ALLERGIES: morphine / Penicillins / Cipro / adhesive tape

PHYSICAL EXAM: Preoperative visit PE on [**2159-1-26**]:

FAMILY HISTORY: Denies family history of IBD or chronic abdominal pain. Mother
had borderline DM and died of a heart attack. Father with heart
disease, 1 son with heart disease. Denies family history of
vascular disease.

SOCIAL HISTORY: Lives in her own apartment in NH. Independent in her ADL's. Has
2 sons and 1 daughter. Denies tobacco use, EtOH consumption, and
illicits 

### Response:
{'Other colostomy and enterostomy complication,Acute kidney failure, unspecified,Other postoperative infection,Acute posthemorrhagic anemia,Other chronic pulmonary heart diseases,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Personal history of pulmonary embolism,Polymyalgia rheumatica,Chronic kidney disease, unspecified,Unspecified acquired hypothyroidism,Peripheral vascular disease, unspecified,Personal history of malignant neoplasm of large intestine,Pure hypercholesterolemia,Esophageal reflux,Unspecified glaucoma,Other chronic pain,Peritoneal adhesions (postoperative) (postinfection),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,Other specified disorders of skin,Long-term (current) use of steroids'}
